Mantosh J. Dewan, MD

What strategies can help you maximize the effectiveness of brief dynamic therapy? Here, Mantosh Dewan, MD, discusses 5 tenets that can help you and your patient get the most benefit from this form of therapy. He notes that if you follow these tenets in short-term therapy, your work in long-term therapy will also be sharper and more rewarding.

Dr Dewan addresses this topic at a symposium on psychodynamic therapy at the 

 in Philadelphia. Dr Dewan is SUNY Distinguished Service Professor, Upstate Medical University, Syracuse, NY.

Podcasts

In this podcast,  Dr Mantosh Dewan, discusses strategies to help you and your patient get the most benefit from this form of therapy.

Podcast: Brief Dynamic Therapy-5 Tenets to Maximize Effectiveness

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After reading this article, you will be familiar with:



 • The history of brief psychotherapy • Why there is a need for brief psychotherapy • The approaches of the various psychotherapies • The type of patient most suitable for brief psychotherapy.



Who will benefit from reading this article?


 Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.

Brief psychotherapy is not the name of a specific model or theory of treatment. Rather, it describes an approach that attempts to make psychotherapy as efficient and practically helpful as possible within a limited time frame. The aim of brief therapy is to speed up the process of change, amplify patient involvement, and foster more focused psychotherapy sessions. Over the years, several approaches to brief psychotherapy have evolved. Some advocate a handful of sessions; others involve more than 20 sessions (eg, psychodynamic therapy).

A growing body of empirical evidence highlights not only the fact that short-term psycho­therapy produces positive outcomes but also that the likelihood of success can be linked to certain patient and therapist characteristics. The value of brief psychotherapies for a variety of conditions has been well documented.

 Some may be surprised to learn that treatments of brief duration have roots in psychoanalysis, which is often portrayed as the model that requires the longest time in treatment. In Studies on Hysteria, Freud4 described 3 of his cases that only lasted between 1 and 9 weeks. Furthermore, his successful treatment of famed composer Gustav Mahler’s impotence in a single, 4-hour session is a demonstration of the value of focus and brevity.

 Other psychoanalysts, such as Ferenczi and Rank,

 also made deliberate attempts to abbreviate the length of psychotherapy. However, it was Alexander and French7 who most systematically moved analysts toward briefer therapies in their classic work Psychoanalytic Therapy: Principles and Applications.

These psychoanalysts were the first to promote the idea of therapists serving as active change agents and to suggest that patient experience, not insight, is a primary factor in achieving benefit. They specifically noted the importance of the therapist in facilitating what they termed the “corrective emotional experience.” Here patient re-exposure to painful early experiences was actively fostered by therapists who responded in a more supportive, accepting, and constructive manner than did significant figures from the patient’s past.

Subsequent research reviews by Fisher and Greenberg

 showed that Alexander and French were onto something important. It turns out that patient insights are not as central to change as many analysts assumed. Other prominent writers coming out of a psychoanalytic tradition (eg,  Davanloo, Luborsky, Malan, Mann, Sifneos) have similarly supported the value of abbreviated variations of psychoanalysis. Interpersonal psychotherapy, which was first manualized in 1983, focuses on relationship issues but, unlike psychodynamic treatments, it does not make the therapeutic relationship a central focus.

 Instead, it shortens treatment by concen­trating attention on role changes and the problems patients are having in their current relationships. Altering relationship expectations, examining patterns of communication with others, dealing with interpersonal crises, and using social supports are the main topics. In general, unlike short-term dynamic therapies, this approach down­plays connec­tions to the past and seeks symptom relief through more pragmatic interactions about how current relationships might be better handled.

The arrival of behavioral treatments in the 1950s also moved the literature to an appreciation of the possibilities of briefer treatments. Initially spearheaded by Skinner

 this work focused on the role of therapist as teacher and placed the emphasis on altering learned behavior patterns and developing new skills for coping with anxiety. The learning model was eventually melded with cognition by Ellis14 in his rational-emotive psychotherapy and ultimately developed by Beck and his followers into today’s cognitive therapy-a powerful, well-researched, respected, and manualized treatment.

 Cognitive therapy is active and  focused; it teaches patients to replace dysfunctional thought patterns with new, more adaptive ways of thinking. A tight treatment focus, an active therapist, and between-session assignments are designed to speed treatment progress.

Another line in the development of briefer psychotherapy treatment approaches emphasizes the role of the therapist as collaborative problem solv­er. In these so-called strategic therapies, exemplified by such writers as de Shazer,

 Erickson and Haley,18 and Walter and Peller,19 the therapist actively helps patients interrupt and redirect self-defeating, poorly chosen attempts to solve their current problems. Through such techniques as reframing problems and creating directed tasks, patients are moved toward new ways to act and ways to generate alternative behaviors from those that are maladaptive. The chief goals are to improve independent functioning and alleviate symptoms. It is assumed that future treatments may be needed to prevent relapse and maintain treatment gains.


 All the treatments outlined in this article are responsive to the need to provide more services in less time because of the high demand for mental health services and the limited, inadequate supply of therapists. Briefer psychotherapies are also dictated by the restrictions imposed by insurance companies and the tight economic resources that are common in clinics, hospitals, and counseling centers. By necessity, treatments have had to become swifter and more targeted.

In addition, psychotherapies have had to objectively demonstrate their benefits to compete in the marketplace of available services. Or as Green­berg

 has so concisely put it: “In the future there will be no income without outcome.” Indeed, brief psychotherapies have played an important role in demonstrating the worth of “talking cures” in an era of evidence-based practice. An avalanche of research has been spurred as a result of most psychotherapy now being conducted based on brief formats. In fact, since short-term approaches are the most studied, they account for most of the literature on psychotherapy outcomes.

All the approaches outlined above have been subjected to scientific scrutiny. The accumulated evidence from hundreds of studies and many meta-analyses leaves no doubt about the effectiveness of brief psychotherapy treatments.

Brief therapies have produced evidence of changes in brain function-just as medications do.

 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.

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.

 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 phases

• 	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.

 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.

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.

 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.

Also, we should mention the issue of stages of change so well described by Prochaska and Norcross.

 Patients enter treatment with wide variations in their readiness for change, which ranges from those who deny the need for change to those who are primed to make changes. Those who deny the need may require weeks of exploration before they are able to commit to taking actions suggested by a briefer approach.


 In some ways, briefer treatments may require a higher level of skill to rapidly identify central issues, accelerate the formation of a meaningful treatment relationship, inspire hope, and provide a framework in which patients will feel free to try new solutions for old problems. Benefits from psychotherapy may be greatly diminished if a therapist blindly adheres too strictly to a therapy manual.

 Successful psychotherapy, at its base, is an interpersonal encounter and not just a rote application of impersonal techniques to a passive recipient.

The importance of listening to patients is highlighted by Lambert and Archer.

 Patients’ prognosis was greatly improved when the therapist elicited feedback from patients about how therapy was progressing. Apparently, getting honest feedback promotes needed change in the therapeutic pro­cess. This enhances the treatment relationship, intensifies patient involvement in the process, and increases patient satisfaction. Research also indicates that treatment benefit is significantly related to qualities that competent therapists bring to the encounter. The more a clinician is perceived to be empathic, caring, open, and sincere, the better the outcome.

Over several decades, the empirical literature has documented that treatment has the power to harm as well as to help. It can make patients worse than they would have been without therapy. Of particular interest is the indication that specific therapist qualities can foster a decline. The concept of therapist pathogenesis is of note.

 Pathogenesis refers to the degree to which therapists allow their own needs to supercede those of the patients who are dependent on them. A series of studies with very disturbed patients underscores the relationship between the level of therapist path­ogenesis and negative treatment outcomes.


 In 2002, the Psychiatry Residency Review Committee (RRC) recognized a need to train psychiatrists in a series of core competencies. The RRC mandated that psychiatric residency programs include training in 5 different forms of psychotherapy, one of which is brief psychotherapy. This mandate has sparked added interest in learning about brief psychotherapy and has led to the publication of materials about how clinicians can get started in learning the basics of brief psychotherapy approaches.

While reading is a start, evidence suggests that the attainment of proficiency requires more. The need for carefully designed courses and the chance to develop skills through supervised practice experiences is crucial. In general, additional therapist training has been shown to correlate with greater improvement in patients’ symptoms and decreased rates of attrition and recidivism.

 Extended training opportunities must take into account not only the techniques of specific treatment models but the discovery that there are common factors that underlie and power all successful psychotherapy treatments.

1. Dewan MJ, Steenbarger BN, Greenberg RP, eds. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Washington, DC: American Psychiatric Press, Inc; 2004.
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Articles

Brief Psychotherapies: Potent Approaches to Treatment

Although the focus of some debate, a number of excellent studies comparing psychotherapy or medications alone versus combination therapy have reported two important findings. First, the combination of psychotherapy and medication is better than either treatment alone (primarily in severely ill or chronic patients) and second, biological symptoms (e.g., sleep disturbance, agitation) generally respond better to medications, whereas psychological and interpersonal deficits are more effectively treated by psychotherapy (Barlow et al., 2000; Dewan and Pies, 2001; Keller et al., 2000). This paper addresses several key issues that are important in making combined treatment work effectively. First, medications have powerful psychological meaning for both patients and therapists. Second, when indicated, combined treatment can be provided by a psychiatrist (integrated treatment) or a psychiatrist/psychopharmacologist plus a non-physician psychotherapist (split treatment). 

While I present data suggesting that integrated treatment by a psychiatrist is the treatment of choice on both theoretical and economic grounds, split treatment continues to be widely practiced. Psychotherapy by itself is a complex procedure that requires great skill and has the potential for both benefit and harm. Adding another modality (medication) and another partner (a prescribing physician) requires even greater sensitivity and skill on the part of the clinician.

When medications are used in addition to psychotherapy, it is important to emphasize that combined therapy does not mean that only half the usual attention needs to be paid to each modality. Medications (e.g., antidepressants, anxiolytics and sleeping medications) are sometimes prescribed long after they would have been discontinued if the patient had been treated with medication alone. Also reported are cases where primary care physicians (and some psychiatrists who primarily practice psychotherapy) add subtherapeutic amounts of medications to ongoing therapy due to their discomfort with psychopharmacological agents (Dewan, 1992). 

Every patient and therapist brings their own unique and personal attitudes toward medication. Therefore, therapists need to carefully assess their own reasons for considering medications and also look for the psychological reactions and meaning, both obvious and covert, that medications have for each patient.

Some patients derive a psychological benefit from being given medications since they consider it a caring, nurturing act that feeds their dependency needs or validates their suffering. Other patients see it as an imposition of external control or as a statement by the therapist that they are not strong enough to solve their problems by themselves, which may contribute to noncompliance. Offering medications to patients in denial of their illness means that they have to confront their worst nightmare and acknowledge that they are very sick. Some patients with bipolar disorder will take antipsychotic medications for a short time but refuse the long-term use of mood stabilizers because it forces them to recognize that they are suffering from a chronic illness (Dewan, 1992). 

Not offering medications is also interpreted in different ways. Some patients see it positively, feeling that the therapist "must be interested in me as a person and not just in my symptoms" or "I am competent enough to do it by myself." Angry and dependent patients may regard it negatively, as a withholding of support or prolongation of their agony. This is particularly potent since our culture vigorously promotes the false idea that a pill can fix everything. Other patients feel they are not being taken seriously, or are not considered sick enough, or even that the therapist thinks they are faking their symptoms. Some patients so overvalue their medication that they will carry around the unfilled prescription as a soothing, and often very effective, good luck charm or transitional object.

Psychotic patients may have unusual, idiosyncratic associations to the names of medications. One of my patients vehemently opposed taking Stelazine (trifluoperazine) ("I hate it! It reminds me of my sister Stella"), but graciously agreed to taking an equivalent drug, Mellaril (thioridazine) ("That's fine. It will make me mellow, right doc?") (Dewan, 1992). 

Therapists also have strong biases and reactions toward the use of medications. Sometimes therapists do not refer for medication evaluation because they erroneously believe that relief from medications will undermine psychotherapy or that medications are not needed because there is a psychological explanation for the symptoms. Some therapists oppose the use of benzodiazepines, believing them to be addicting. Thus, patients are deprived even when such medications could be enormously helpful and prescribed safely. The therapist's unrecognized feelings, be it fear, hate or sexual attraction toward a particular patient, may unfairly dictate the addition of medication as a way of distancing, controlling or even punishing the patient (Dewan, 1992).

Over the past decade, medicine in general and managed care organizations (MCOs) in particular have moved toward the primary care model. The aim is to provide primary, holistic care in which one doctor takes care of all the patient's needs. However, the only mental health care practitioner capable of providing comprehensive biopsychosocial care--the psychiatrist--is being replaced by a supposedly less costly but fragmented split treatment model. 

Using a theoretical model, I first challenged the widely held assumption that split treatment was less expensive than integrated treatment (Dewan, 1997). In a more elaborate study, I collected the 1998 payment schedule from seven large MCOs with a combined market share of 54% and 67.8 million covered lives (Dewan, 1999). Medicare, covering 36.9 million people, was also added. As can be seen in the Table, (Due to copyright restraints, we are not able to publish this table on the Internet. Please see our print publication.) there are both substantial cost and time savings with integrated treatment. Furthermore, "When time away from work or child care plus the expense of traveling are factored in, the cost benefit analysis favors integrated care from a psychiatrist even more." Even when a social worker was substituted for the psychologist, the cost for integrated treatment was only $16 higher (Dewan, 1999).

In an elegant study, Goldman et al. (1998) used an MCO's database to retrospectively evaluate 1,517 depressed patients followed for 18 months. It is revealing that, despite this MCO's stated aim of trying to "directly refer to psychiatrists for both psychotherapy and pharmacotherapy," only 191 patients (13%) were in integrated treatment. Patients in split treatment needed more psychotherapy sessions (21.2 versus 10.4), more medication visits (6.3 versus four), and more total outpatient care (26.2 versus 14.7 visits). Instead of split treatment leading to savings, it cost $518 more per patient ($1,854 versus $1,336). For all 1,326 patients in split treatment, the MCO paid an extra $686,868! The authors concluded: 

Splitting psychotherapy and pharmacotherapy is a practice and point of view that has in effect been legislated without evidence...This study contradicts the pervasively held belief that split treatment is more cost-effective.

In fact, these data indicate that integrated treatment provided by a psychiatrist is the preferred theoretical (biopsychosocial) and economic model. However, there are no studies comparing the therapeutic outcomes of integrated versus split treatment. There is an urgent need for studies in this area.

In 1980, the American Psychiatric Association attempted to clarify split treatment relationships and described three models. In the consultative model, the psychiatrist provides a limited consultation but no care. In the private practice collaborative model, responsibility is shared equally. However, in fact the psychiatrist carries the greater liability risk because they are deemed the head of the team by the legal system and have deeper pockets. In the supervisory model, most often seen in clinics, the psychiatrist is responsible for the initial diagnosis, formulation of the treatment plan, and for supervising, directing and monitoring all aspects of the therapist's work.
Collaboration between disciplines has many advantages for the patient and the collaborators. The patient receives greater amounts of time and expertise, which may lead to better adherence to medications. Collaboration provides an invaluable opportunity for professional and emotional support of each other on an ongoing basis, especially in times when the patient is in crisis or when treatment has a disastrous outcome such as a suicide.

Unfortunately, therapists and psychiatrists often do not take the additional time to interact regularly and instead work on parallel tracks. Further, interdisciplinary competition, whether conscious or not, allows for the undermining of each other's work or working at cross purposes and lends itself to splitting by the patient. To avoid failure, the therapist and the psychiatrist need to build a mutually trusting and respectful relationship, one that clearly recognizes the special and differing skills that each partner brings to the collaboration.

Meyer and Simon (1999) offered a model letter that a psychiatrist would send to a referring therapist that addresses the important elements each partner needs to know about the other: their qualifications, certification, liability coverage, experience, clinical orientation, who will provide what part of the treatment, how to contact each other after hours, vacation coverage (do not cover each other; get someone from your own discipline), how emergencies will be handled and confidentiality. The patient needs to know that all information will be shared between the collaborating partners and should sign appropriate releases at the outset.

Himle (2001) enumerated what each partner can expect from the other. It is expected that the psychiatrist will ask the therapist for a clinical report with a reason for referral and then interview the patient. If medications are recommended, the reasons and specific options will be discussed with the patient. Since patients have very personal reactions to medications, the specific medication is best chosen as a collaborative venture to improve adherence. How to take the medication, expected improvement and potential side effects are clearly described and perhaps even written down so that both the patient and therapist are aware of them. The schedule for follow-up appointments will be clearly spelled out. After the first or second appointment, the psychiatrist and therapist will communicate directly and agree on a treatment plan. Finally, the psychiatrist will support the psychosocial treatment plan, but not discuss psychotherapeutic issues with the patient. 

The therapist is expected to provide a written clinical summary with a reason for the referral, preferably followed by a brief phone call to the psychiatrist. The therapist will set the stage appropriately with the patient about the referral for medication consultation by describing the symptoms to be targeted and summarizing the research data that suggest medications are likely to be helpful. With psychotic patients, I emphasize medications as critical; with personality-disordered patients I present medications as a potentially useful adjunct to the more important work of psychotherapy; and with other patients, I present medications as an equal and often synergistic partner with ongoing psychotherapy. Patients need to be told explicitly that the consultation may or may not result in medication being prescribed. It is also important that the referral be for an open-ended consultation and not for a specific medication.

An important expectation of therapists is that they will promptly convey to the collaborating psychiatrist any clinical deterioration, suspected side effects or medical problems. This is critical, since the therapist will generally see the patient more frequently than the psychiatrist and is usually the best-informed member of the treatment team. It is important that therapists educate themselves as to the most common side effects of the frequently prescribed medications.

Finally, therapists are expected to fully support the medication regimen and are an important ally in improving adherence. If the therapist disagrees with or wants to change the medications, this discussion should take place directly with the physician and not through the patient. Similarly, specific questions from the patient about medications should be referred back to the prescribing physician.

The prevailing primary care model and the traditional biopsychosocial model allow psychiatrists to provide seamless, integrated combined treatment. In addition, for many conditions such as depression, integrated care is more cost-effective than split treatment. However, since split treatment continues to be widely practiced, it is important to pay particular attention to several aspects in order to make it work. The meaning of medications for both the patient and the therapist must be taken into account. Successful split treatment requires clarity of roles, respect for the many strengths that each profession brings to the enterprise and an appreciation of the powerful psychological dynamics of each. A thoughtful and sometimes energetic engagement is required by all partners in order to avoid potential pitfalls and benefit from the rich promise of medications and collaborative care.

American Psychiatric Association (1980), Guidelines for psychiatrists in consultative, supervisory or collaborative relationships with nonmedical therapists. Am J Psychiatry 137:1489-1491.
 

Barlow DH, Gorman JM, Shear MK, Woods SW (2000), Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. [Published errata JAMA 284(19):2450; 284(20):2597.] JAMA 283(19):2529-2536 [see comment].
 

Dewan MJ (1992), Adding medications to ongoing psychotherapy: indications and pitfalls. Am J Psychother 46(1):102-110. 
 

Dewan MJ (1997), Cost of care by a psychiatrist versus split treatment. NR295. Presented at the 150th Annual Meeting of the American Psychiatric Association. San Diego; May 20.
 

Dewan M (1999), Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry 156(2):324-326 [see comments]. 
 

Dewan MJ, Pies RW (2001), The Difficult-To-Treat Psychiatric Patient. Washington, D.C.: American Psychiatric Publishing Inc.Goldman W, McCulloch J, Cuffel B et al. (1998), Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Serv 49(4):477-482.
 

Himle JA (2001), Medication consultation: the nonphysician clinician's perspective. Psychiatric Annals 31(10):623-628.
 

Keller MB, McCullough JP, Klein DN et al. (2000), A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. [Published erratum 345(3):232.] N Engl J Med 342(20):1462-1470 [see comments].
 

Meyer DJ, Simon RI (1999), Split treatment: clarity between psychiatrists and psychotherapists (Part 2). Psychiatric Annals 29(6):327-332.

How can psychiatrists and psychotherapists optimize their collaboration and individual skills to facilitate treatment success?

Mantosh J. Dewan, MD

Articles

Podcast: Brief Dynamic Therapy-5 Tenets to Maximize Effectiveness

Brief Psychotherapies: Potent Approaches to Treatment

Making Combined Therapy Work