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Prerequisite Cognitive Adjustments
Three conceptual shifts need to be made by therapists trained in long term psychotherapy before they are able to comfortably and successfully undertake brief psychotherapy, a) From the start there must be a willing suspension of disbelief and cynicism about brief therapy. For example a quick positive response is not always a temporary "flight into health", b) Therapy must be conceptualized as a time limited enterprise, something that will end at a known planned date. This appears deceptively simple, but in practice it is actually a difficult cognitive change to make and one that has ramifications for all your treatment decisions, particularly your activity level as the therapist, c) The therapist must expect and accept that patients will return to therapy periodically across their life span. This is often an easier adjustment for people to psychotherapy, psycotherapy
Patient Evaluation & Selection
This is the art of finding the fight patient with the right problem for brief psychotherapy. First I recommend using a two session evaluation format for determining if a patient is appropriate for brief therapy. This format allows the clinician to conduct a complete psychiatric evaluation and assess the
Exclusion criteria, a short list. The brief therapy patient should not be; a) actively psychotic; b) abusing substances; or c) at significant risk for self harm. The presence of any of these conditions should rule out a patient for brief psychotherapy.
Inclusion criteria (not all are required). The potential candidate for brief therapy should; a) be in moderate emotional distress; b) want relief from his pain; c) be able to articulate a fairly specific cause or a circumscribed problem (or accept your specific formulation); d) have a history of at least one positive (mutual) interpersonal relationship; e) still be functioning in at least one area of life; and f) have the ability to commit to a
Developing a Focus
Developing a treatment focus is probably the most misunderstood aspect of brief therapy. Many writers talk about "the focus" in a circular and mysterious manner, as if the whole success of the treatment rests on finding THE one correct focus (Hall, Arnold, & Crosby, 1999). Rather what is needed is establishment of a focus that both the therapist and patient can agree upon and which fits the therapist's treatment approach. The main
Selecting Your Intervention Style
Eclectic brief therapy, is not doing "whatever works": rather it relies upon selecting a style of therapy which can effectively treat the patient and the agreed upon problem/focus. One of the ways in which the brief therapist keeps the treatment focused is by working consistently from within one style or orientation. In my opinion there are basically three styles or orientations from which to choose; psycho-dynamic, interpersonal, and cognitive. The intervention style you use will depend upon your own preference and the
The psychodynamic therapies (see Sifneos, i972; Malan, 1976; & Davanloo, 1980) are the more limited in application, being appropriate for only a small number of patients suffering from neurotic forms of depression (failure to grieve, fear of success & competition; & triangular conflicted love relationships) (Groves, 1992). These are demanding treatments for the therapist to undertake and require the patient to tolerate considerable affective arousal. The psychodynamic therapies rely upon vigorous (active) interpretation to link the past, present, and transference, showing little regard for the patient's defensive efforts (Burk, White, & Havens, 1979). The cognitive brief therapies (see Beck, 1979) aim at bring the patient's "automatic" (pre-conscious) thoughts into awareness and demonstrating how these
Phases of Planned Brief Therapy
Let us look at the traditional three phases of psychotherapy as they apply to brief treatment, a) The initial phase includes patient evaluation & selection, focus selection, and establishing your main orientation. This phase is usually accompanied by symptom reduction and a positive transference. The working relationship should quickly develop. b) Middle phase - the work gets more difficult. The patient becomes concerned about the time limit, issues of separation and aloneness come to the fore. The patient often feels worse and the therapist's faith in the treatment process is tested, c) Termination phase here the therapy usually settles back down. The patient accepts that treatment will end as planned and symptoms decrease. In addition to the treatment focus, post therapy plans and loss of the therapy relationship are