Brief therapies have produced evidence of changes in brain function—just as medications do.25,26 Moreover, in studies of depression treatments, benefits from brief therapies have been shown to exceed those from antidepressants in preventing relapse while producing fewer adverse effects.21,27
Differences and similarities among brief psychotherapies
There are several ways in which various brands of brief psychotherapy differ from or resemble each other. Among the dissimilarities are the length of treatment expected, the breadth of goals, the emphasis on here-and-now issues versus interweaving the past and the present, and the level of therapist directiveness. In general, the brief psychodynamic and interpersonal treatments are more extended, have broader goals, present more integration of past and present, and are less directive than the strategic- and solution-focused approaches. The cognitive and behavioral approaches lie between the other brands on these dimensions.
The similarities among the treatments may be of greater importance. The research literature, while acknowledging the benefits of psychotherapy, has had difficulty in proving that one type of therapy is superior to others, which suggests that common factors may be the most significant ingredients for producing change.24,28,29 Among the common ingredients across all psychotherapies are the facilitation of a strong alliance between therapist and patient, the attempt to create patient mastery experiences, the confrontation and resolving of problems, and the aim of instilling hope and positive expectations regarding the future. Although they may emphasize different techniques, each of the brief psychotherapy models progresses through a series of similar phases7:
• Engagement
• Discrepancy
• Consolidation
In the initial engagement phase, the therapist sets up a collaborative atmosphere, fosters accelerated alliance formation and, through exploration, establishes a focused framework and a set of goals. Patients are encouraged to view their problems from a variety of angles that make intuitive sense. This promotes more optimistic expectations of what may be accomplished.
In the discrepancy phase, novel experiences are created that move the patient toward new understanding of his or her discomforts while trying out additional ways of approaching problems. The aim is to promote new learning during a state of heightened emotion. Success with new behavior patterns leads to feelings of mastery over internal conflicts.
In the consolidation phase, the goal is to strengthen the changes that have been made. Patients are urged to continue to try out new behaviors that seem more successful than their old behaviors. This process is similar to what Freud labeled “working through.” This concept stresses that patients need to be repeatedly faced with examples of how past feelings and perceptions are unnecessarily distorting their reactions to current issues and interpersonal relationships.9 At this point, after noting significant changes, many short-term therapies might advocate reducing the frequency of sessions (while increasing treatment duration) to make sure that changes are internalized and that gains are maintained over time.
Patient selection criteria for brief therapy
As noted, short-term psychotherapies come in a variety of packages. Nonetheless, all approaches attempt to attain positive results in a relatively brief period. In fact, some of the approaches, such as interpersonal therapy, explicitly set the total number of sessions in a discussion with the patient at the beginning of treatment. p> But not all patients and diagnoses can be adequately handled in a significantly abbreviated time frame. Typically, a variety of factors need to be considered in making an assessment of suitability for a briefer treatment. There are several major issues to consider when deciding whether psychotherapy of less than 20 sessions is likely to be the best approach.1-3
Among the prime considerations is whether the problems described are long-standing or of recent vintage. Chronic problems are likely to be embedded in overlearned behavioral and emotional patterns that require longer treatment. A short-term approach is contraindicated if the initial presentation suggests more severe issues that are overwhelming and disabling to everyday functioning. A high level of severity will likely hamper the patient’s ability to engage actively in treatment efforts during sessions and in assignments between sessions.
Research indicates that psychotherapy works best when there is a good therapeutic alliance between the patient and the therapist.30,31 Anything that delays the formation of such an alliance will lengthen and slow down treatment progress. Therefore, it is less probable that patients with histories of poor interpersonal relationships will be able to easily adapt to the intensity of the therapy relationship and achieve rapid gains. Past traumas, such as abuse or rape, may also be expected to slow the progress of therapy. Here a patient’s lack of trust or sense of vulnerability may lead to resistance, hesitation about revealing too much, and caution about entering the treatment relationship.
Another signal that therapy may need to be lengthened is the level of the patient’s social supports. Those with few or nonexistent supports may seek the support in therapy that they are not receiving elsewhere, and they may be resistant to more precise and rapid goals for change that would attenuate the treatment relationship. Since brief treatments rely on focus, patients with multiple complex problems tend to be more difficult to treat than those who present with more easily targeted concerns, such as a phobia or a narrowly delineated marital problem.
