Book: Psychotherapy: A Very Short Introduction (Very Short Introductions)

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Early psychoanalytic treatments were often brief. Freud treated two of his most famous patients over a very short period: ‘Dora’ only for eleven weeks and the ‘Rat Man’ for eleven months. He saw the composers Bruno Walter and Gustav Mahler for only six and four session each. Some of his contemporaries attempted to develop shorter treatments as well as varying the analytic technique to make it more active.

Despite this, psychoanalysis demonstrated a remorseless lengthening. Further innovations, such as the development of the transference neurosis and regression, required extensive working through. The passive analytic stance increased the risk of dependence in longer therapies. Psychoanalytic training added a further pressure by requiring extensive personal analysis and lengthy training cases. Brief therapies are also more demanding to conduct, and their greater turnover of patients adds to professional uncertainty. Brief therapy came to be seen as second best or inferior.

In recent decades interest has grown in the development of shorter or time-limited psychotherapies. Originally initiated by psychoanalysts, this development has been accelerated by accumulating evidence for the effectiveness of time-limited therapies, especially CBT. It had regularly been observed how change occurs most often either in the early stages of therapy or when the end is in sight, but that focus can be lost in the middle stages. This also contributed to the drive for shorter therapies.

Cost-effectiveness pressures and the need to provide evidence-based treatments identified, for example, by NICE (National Institute for Clinical Excellence) in its guidelines for the UK’s health services, have coincided with demands from patients for shorter treatments. For many of us, therapists and patients alike, short-term therapies are now the treatments of choice, rather than a necessary compromise. The IAPT programme (Improving Access to Psychological Therapies) in the UK, which offers short-term, mainly CBT-based therapies, has consolidated this development. A number of time-limited psychotherapies have emerged with increasing evidence for their effectiveness but also with plenty of ‘sibling rivalry’. Let us start by outlining what they have in common.

Common features of brief psychotherapies

‘Psychotherapy should be as short as possible and only as long as the patient really needs it’ writes Angela Molnos. The aim of therapy is ‘to create a special place in which the past can appear in the here-and-now, a space in which past emotional conflicts are re-lived and understood with clarity, and in which new solutions to old problems are found’. Common factors include weekly, face-to-face sessions with a more active therapist, and with a clear focus on problem patterns as they present. Depending on whether the therapy is more psychodynamic or cognitive in nature, the use of transference will vary, as will the emphasis on problem solving. Dynamic approaches are more likely to pay attention to attachment and loss during the ending of the therapy. Therapies also vary in how much they follow a detailed manual outlining practice. CBT practitioners often value them, whereas brief psychodynamic therapists rarely rely on them.

The shortening in brief therapies is most noticeable in the early sessions. Patterns of thinking and feeling are identified and are challenged very early on. Problematic personal and interpersonal patterns do not require much digging to find—if we only look carefully, they are there in all our interactions. The therapist may notice how the person enters the room (striding in or shuffling, looking the therapist in the eye or avoiding her gaze, talking non-stop or having to be drawn out) and feed this back. Such habits reflect the person’s lived experience, and how this shows in the present provides food for thought. Observations like these lie at the core of the therapeutic process, and are returned to regularly.

To illustrate these points and give a flavour of brief or time-limited therapies, we describe three common, but distinct forms. IPT was devised specifically for depression. CAT is an integrative approach, combining cognitive understandings and techniques within a more analytic framework. SFT is an active approach, which engages people’s inbuilt ability to find solutions. As is devoted to CBT, it will not be included here.

We find that making a distinction between brief therapies and time-limited ones is helpful. Brief therapies usually last for one year or less but there is quite a degree of flexibility. In time-limited therapies the number of sessions or the length of therapy is explicitly determined at the outset. Most time-limited therapies are also brief but they do not necessarily have to be.

Interpersonal psychotherapy (IPT)

IPT was developed in the US in the 1980s by Myrna Weissman and John Markowitz, specifically for people with depressive illness. It has been shown to be very effective with patients who are either not helped by medication, or are unwilling to take it. The term ‘illness’ is used quite deliberately here. A central feature of IPT is explaining that the patient is suffering from a medical illness, thereby giving her temporary relief in the ‘sick role’. This reduces self-blame and guilt, and helps patients to accept that they are not at fault for feeling the way they do. It also confirms that this is a well- recognized and treatable condition, and thus helps to instil hope. IPT also includes psycho-education about the illness and its various treatments as part of the protocol.

Despite its very medical language IPT insists that mood and life situation—and especially relationships—are closely interrelated. Patients are helped to make links between life events and the onset of their depression. IPT has an explicit relationship focus, and the patient’s aims for therapy are usually linked to bringing about changes in their relationships. Therapy is based on common therapeutic factors such as developing a strong treatment alliance and emotional engagement, so that patients can feel understood and supported during a difficult phase in their lives. However, the therapy relationship is not explored in any detail as in psychodynamic therapy.

IPT links the emergence of depression to commonly occurring and disturbing life events. These are grouped as losses (or bereavement) such as the death of someone close, role transitions such as significant changes or life upheavals, or role disputes which are conflicts or struggles with important people. IPT goals are to reduce or remove depressive symptoms, to improve interpersonal functioning, and to resolve interpersonal problems. The therapist pays particular attention to how patients communicate their needs and feelings to others. They also help patients to repair their social supports, which are often lost in the withdrawal from contact so common in depression.

IPT is limited to between twelve and sixteen sessions, and is highly structured with a defined beginning, middle, and end. The therapist and patient start by conducting an interpersonal inventory. This lists in detail the important relationships in the patient’s life, such as with partners, parents, or children. They examine the emotional quality of these relationships with close attention to the feelings both within and between the people involved. They will explore patterns of interaction and communication, especially if conflicts are experienced. Does the other person, such as a partner, help the patient manage better or actually make the problem worse? The therapist will use all indications, in both verbal and non-verbal communication, to establish possible links between the relationships and the onset of symptoms. Together therapist and patient try to understand the ‘why now?’ while also identifying any underlying personal vulnerabilities or predispositions. The goal of the beginning phase is to create a joint formulation of the problem—what may have caused it as well as what keeps it going. A common pattern is a vicious cycle of depression leading to lowered self-esteem, resulting in social withdrawal, in turn leading to loneliness and increased depression. We all recognize what it is like to feel miserable, embarrassed, or ashamed and so not to want to trouble others. The result is that we don’t make that call to a friend or ask for help.

The work of the middle stage will depend on which of the three possible areas has been agreed in the beginning phase: losses, role transitions, or role disputes. With losses the therapist will help the patient describe in detail the actual death: what happened, whether it was expected or not, what the funeral was like, and any rituals involved. They will focus on any feelings, particularly when these were negative or ambivalent. Patients often need special help to think and talk about the loss and any associated difficult memories, about what they miss, and how to begin to move forward. For one patient this had become a seemingly overwhelming task, after the sudden death of her ‘perfect’ husband. He had been the one to take responsibility for comforting and supporting her in all aspects of life—practical, interpersonal, and emotional. Suddenly she was deprived of it all, with few psychological tools for managing the catastrophic fall-out. How could she even begin to admit to any angry or mixed feelings towards this paragon?

For role transitions, the therapy starts by identifying which spheres of life are affected. These can include work roles or social roles such as moving home or the children leaving, or they can be biological to do with health or ageing. What often matters most is whether the transition was planned, whether it was wanted or not, and whether it was accompanied by a loss of support. The therapist helps the patient recognize the feelings connected to the transition, particularly any sense of loss. The patient’s capacities and resources are not neglected—both internal and external strengths are identified. Opportunities arising from the change are sought which might require learning new skills or managing new challenges. Learning how to assert needs and preferences, or even taking risks, can be part of this process.

A communication analysis often has a central place in role disputes or conflicts. This carefully explores what the patient wishes for, and whether it is reasonable and realistic. Time is spent understanding what she wants to say, how she says it, how this comes across to others, and whether it is understood by them. A withdrawn woman, used to taking a back seat in the family, thought resentfully that others should be able to ‘read her mind’. She therefore failed to spell things out, or else she tended to say things in such a soft voice that they didn’t hear it or take it seriously. The therapist will help the patient make potential links with symptoms. Any mismatch between what the person had aimed for and the actual interpersonal outcome is carefully discussed. Different ways of communicating can be explored by brainstorming or role plays, always encouraging the patient to come up with ideas herself and try them out. Although IPT does not use homework as such, the patient might be encouraged to rehearse and practise things between sessions.

The end phase of therapy focuses on reviewing and consolidating any gains, and if necessary making contingency plans for the future. As the ending is a transition in itself, some of the skills learned earlier can be applied to it.

As with most therapies, the initial model has been refined by experience and research. Dynamic Interpersonal Therapy or DIT is a recent such development in the UK, which lasts for sixteen sessions. It is an approach to IPT which combines an interpersonal focus with a more psychoanalytic stance, following a clear manual through the different stages of therapy. It uses interpretations of unconscious feelings and reactions in combination with what is known as mentalization. This comprises techniques to enhance the patient’s capacity to reflect on her own states of mind, and through this to better understand what others might be feeling or thinking. By becoming more aware in this way she can improve her ability to understand and manage relationships.

Cognitive analytic therapy (CAT)

CAT was first developed in the 1980s in the UK by Dr Anthony Ryle, a general practitioner working with students in a university setting and later in adult mental health services. His initial aim was to create a common language for the psychotherapies. He was frustrated with psychoanalysis for its resistance to research, and with behaviour therapy for its reductionism. CAT takes psychiatric diagnoses and individual presenting problems seriously, but quickly moves to address the difficulties behind them. It focuses on the sense of self, often negative or fragmented, which is trapped by unhelpful relationship patterns.

CAT is a time-limited therapy, usually sixteen weekly sessions with one follow-up at three months. For more complex difficulties, this can be extended to twenty-four sessions with additional follow-ups. Like most brief therapies, CAT is an interactive model, based on collaboration and joint exploration. The model shares the analytical interest in exploring the early roots of interpersonal difficulties and the need for all of us to have a sense of our own story or narrative. It tries to understand how we have arrived at this point in our lives and what keeps us here, even—or especially—when the personal cost is high.

A joint reformulation of the patient’s narrative, and the core patterns emerging from it, is expressed in the form of a letter, derived from the discussions in the first few sessions. This is initially brought in draft form, written by the therapist, and read out aloud by her. A common reaction to hearing the letter is a sense of being validated, as if troubles have been witnessed or acknowledged. The letter summarizes the person’s life experiences and lays out the conclusions she has drawn from them. These conclusions are usually about her sense of personal value, about her relationships and how to deal with feelings and conflicts that emerge within them. The patient takes the draft letter away, rereads it, and brings it back with any amendments necessary to truly reflect their experiences. Once agreed, it becomes a shared basis for the remainder of the therapy and, indeed, for beyond therapy. Both parties can refer back to it at any time, and it helps them keep on track as therapy progresses. One patient took to keeping it in her bedside table and would read it to herself during times of stress, or to remind herself of how to act and think differently when falling back into old coping strategies.

A second function of the letter is to jointly identify a couple of main or target problems to focus the therapy on, plus unhelpful patterns or procedures stemming from attempts to solve these problems. Such procedures often end up as problems in their own right. A young woman brought back her letter with big, dirty footprints all over it, after leaving it on the staircase in her shared house. This spoke volumes of her tendency to let people ‘walk all over her’, while she attempted to fit in with everyone, in order to feel accepted and valued.

The main part of the therapy then involves exploring and understanding the various ways in which such unhelpful interpersonal patterns (known in CAT as reciprocal roles) manifest themselves. It includes paying attention to how the person treats herself, whether through self-neglect or overindulgence, or in more extreme self-harming ways. It will especially note when these patterns repeat themselves in the therapy relationship.

The patient and therapist together then look for exits or alternative ways of self-management and of interacting with others, and will use the therapy relationship or transference in this process. Change moments often come when a familiar interpersonal pattern is reactivated in a session, but accompanied by a new way of being or relating. This challenges the person’s familiar expectations and habits. A common example is to expect rejection or criticism after having been angry with the therapist in a session or after revealing what were believed to be shameful secrets.

The main difference from IPT lies in the way these patterns are outlined very explicitly in CAT, especially in the form of a diagram, which the therapist and patient draw up together (see ). This identifies the interpersonal patterns that most commonly occur in the patient’s life, including how these are linked. Such a visual representation helps her take a step back from the overall picture and develop what is called an observing eye (or ‘I’), aiming for a more integrated sense of self. With this overview she can start to join up the dots, see a fuller picture, and get a different perspective on herself. The diagram can also help the person recognize patterns or voices that have been handed down through the generations and help them find their own, authentic voice through dialogue with the therapist.

The diagram uses the person’s own words as much as possible, and the therapist will take care to build on their strengths and ‘push where it moves’. The aim is to enhance the patient’s (self-)reflective capacity and to gradually make the tools for this her own. Anthony Ryle wrote, ‘what the person can do with the therapist today, s/he will do on her own tomorrow’. As with CBT, the patient is helped to become aware of their thought and behaviour patterns and to devise homework tasks. These usually involve small steps to break unhelpful patterns such as beginning to say no to others or creating time for self-care.

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8. With the help of this CAT diagram the patient could see how her attempts to feel better about herself just led back to old, unhelpful patterns

Difficulties may emerge towards the end of therapy, often relating to past losses or unresolved separations. These will have been identified and anticipated in the early letter or in the diagram, which helps to address reactions to the ending, such as anger or sadness. The ending is also attended to by the patient and therapist each writing a goodbye letter. This is a letter to the other person, but also an opportunity to summarize the therapy. It covers what has been gained and learned, but also openly acknowledges missed opportunities, and realistically predicts challenges ahead. It is a chance to say a ‘fare well’ or an explicit ‘goodbye’, rather than repeat painful ‘byes’ of the past.

Solution-focused therapy (SFT)

SFT has links with Ericksonian thinking, and was developed by Steve de Shazer in the US during the 1970s. He noticed that clients seemed more energized when talking about solutions to their problems and how they would like their future to be, rather than analysing past difficulties. A central feature of the model is its non-pathologizing stance. It identifies healthy aspects of the person’s experience that can be used, and it underscores that they already have resources to draw on. Therapy becomes a process of mobilizing and building on these to resolve problems, always with an eye to the future. A refreshing change if you have felt mired in problems for a long time! The focus in SFT is on ‘competences rather than deficits, strengths rather than weaknesses, possibilities rather than limitations’. SFT can be very brief, often just three to six sessions.

SFT seeks solutions which ‘fit the client rather than the problem’. In this it is very like IPT and CAT, but it is more explicitly directed towards solutions for the future rather than linking with the past. SFT uses a number of specialized techniques referred to as skeleton keys. One is inviting people to become aware of exceptions, times when they succeeded in solving their problems. It also involves identifying and mobilizing the client’s personal and social resources, and imagining how they would like their future to be. This might include asking the miracle question discussed below, but mainly uses small, manageable steps when trying to change.

Personally relevant and realistic goals are generated. These are very concrete and require specific actions, rather than being vague formulations expressed in negative terms, such as wanting ‘not to feel depressed any more’. The aim is for ‘good enough’ or satisfactory outcomes, with agreed ways of recognizing when these are achieved. Links are made between outcomes and what clients have done differently, so that they can take credit for their own achievements. Problems are discussed openly, with the therapist taking their share of responsibility. The therapist might ask questions such as ‘What have I missed?’ or ‘What needs to happen today?’

SFT pays very close attention to the use of language. Questions are usually framed positively: ‘What are your best hopes for this session?’ ‘What are you already doing that is helpful?’ ‘How will you know that today has been helpful?’ This engages the person in examining their expectations and their own role in changing. Questions cover how the person will know when things are getting better or how many sessions are needed.

The miracle question, a striking SFT technique, goes something like this:

Imagine that while you are asleep tonight a miracle occurs, and when you wake the problem you have told me about has disappeared. You are now problem free. However, because you have been asleep you won’t know that the miracle has happened. What will you notice when you wake up that shows you things are different?

You are encouraged to ask yourself about the experience, again using positive language: ‘What will I be doing differently?’ ‘What will I be saying?’ ‘How will it affect my life?’ ‘How would I know that?’ ‘What will others notice and how will they describe it and react?’ ‘What else will be different?’ ‘And what else … ? And what else … ?’

An angry young student regularly sabotaged himself by missing course deadlines, getting into drunken fights, and generally underperforming, rather than stand up to his father and challenge what he saw as high family expectations. Via the ‘miracle’ he might allow himself to enjoy doing well. The therapy focuses on how this will manifest itself, not on wishful thinking. What will the person be doing and thinking differently, and what are they doing now that will move them towards this ‘miracle’ scenario? So our student might identify how he was speaking more openly to his parents, that he was getting support from his brother in this, that he had cut down on his drinking, and that it had made a difference to his girlfriend.

SFT therapy sessions use scaling. So in relation to the miracle question the therapist might say: ‘If on a scale of 1 to 10, 10 means you have already got there, and 0 means you haven’t even started, where would you say you are today?’ If the young man thinks that he is on a 3, he might review with the therapist what he did to get there, and what he needs to do to get to point 4 before next week. Scaling can be used at any time during or between sessions. One can rate where one was before, what one did to get from there to here, what are realistic hopes, what might sabotage change, and how to prevent this. SFT always uses positive questions, such as ‘What makes me hopeful that I will move up the extra two points?’

Much of the work in SFT takes place between sessions using tasking or homework assignments. These involve thinking about the change you desire and the actions needed to achieve it. It means trying out and practising new skills independently and in the contexts where they belong. Some homework simply involves observational tasks, such as noticing things that already work well or keeping notes of positive changes. These can then be combined with behavioural tasks—doing things differently, such as saying no rather than giving in. Similarly, cognitive tasks will provide alternatives to negative thinking habits, such as ‘Today I didn’t let my worry stop me from going to the shops on my own’ rather than ‘I will never get back to having an independent life’. Using rituals or metaphors that mark a new stage or symbolize the achievement of a task can boost morale and give a sense of achievement.

As in all time-limited or brief therapies, the ending of therapy will have been on the agenda right from the start. SFT differentiates explicitly between treatment goals and life goals. Without this any therapy can become overextended, invite dependency, and unwittingly undermine the self-confidence and self-reliance that has been built up. Unlike in CAT, SFT clients will determine when therapy should end, and SFT therapists find that most opt for a brief input. The ‘good enough’ outcome between ‘miracle’ and the status quo is identified early, and anticipated in detail, including how it will be recognized if and when it is achieved. It is then time to stop.

What these and other brief or time-limited therapies share is the sense that because time is at a premium, every session counts. Both parties have to make active use of the time available to them. A focus is created at a very early stage, and the patient or client plays an active role in addressing their difficulties, both within and between sessions. There is also an unspoken belief that once people begin to do things differently, those around them will respond differently, and therefore much of the working through will occur naturally within these relationships. Obstacles in this process can be anticipated in the therapy, and new alternatives practised. In this way, the therapy quickly starts to look towards the future and draws on the person’s own resources. This in itself reduces the risk of dependency with its potential to undermine confidence, and represents one of the major advantages of time-limited psychotherapy.

Previous: Chapter 3: Post-Freudians: moving towards the interpersonal
Next: Chapter 5: Counselling