Short-Term Treatment and Social Work Practice: An Integrative Perspective

Book by Goldstein Eda Noonan Maryellen

Chapter 1
Short-Term Treatment: An Overview
Mental health professionals in a variety of disciplines are using short-term methods in their practice more than ever before. Although brief treatment always has been part of the therapeutic repertoire, it received little positive attention in mental health circles until the 1940s. The first wave of interest in short-term and crisis intervention occurred during and just after World War II as a result of several concurrent developments: efforts to make traditional psychoanalytic psychotherapy more efficient, experiences with soldiers under battle conditions, attempts to help soldiers and their families when the former returned to civilian life, and work with the victims of disasters and those undergoing stressful life events. Despite the interest in short-term approaches, they were not widely assimilated into mainstream mental health services at that time.
Even after the revival of interest in brief treatment that occurred in the 1960s, it continued to be relegated to a second-class status in comparison to long-term treatment among psychodynamically oriented clinicians. Showing a prejudice in favor of so-called deeper and more intensive treatments, which were thought to be essential for the achievement of personality change, many psychotherapists viewed short-term intervention as shallow and superficial (Shechter, 1997; Wolberg, 1965).
THE RISE OF SHORT-TERM TREATMENT
Numerous factors have contributed to the diminished status and use of long-term treatment and the increased use of short-term and crisis intervention (Budman & Gurman, 1988; Parad & Parad, 1990b; Shechter, 1997). Beginning in the 1960s, optimism about the ability of mental health treatment to help people led to efforts to make treatment accessible to greater numbers of individuals at earlier points in the emergence of their difficulties and for help with problems in living, as well as severe emotional disorders. The short-lived community mental health movement, ushered in by the Community Mental Health Centers Act of 1963 during the Kennedy presidency, was heavily weighted toward emergency and brief treatment. Even psychodynamically oriented clinicians experimented with short-term treatment, and new interventive models proliferated, including those that were cognitive and behavioral.
Another contributing factor to the changing nature of treatment was the criticism of traditional forms of intervention on the part of numerous special populations who sought greater opportunities for self-expression, freedom from oppression, and respect for their diversity. Among these groups were those reflecting counterculture lifestyles, people of color, women, and gays and lesbians, who tended to perceive long-term, psychodynamically oriented treatment as a form of social control, a means of blaming the victim, and a way of labeling difference as pathological. Self-help, consciousness-raising, and rap groups, along with other types of alternative helping methods, gained popularity and eroded the dominance of more traditional therapies.
As mental health treatment became more available, individuals sought help for a host of concerns that previously would not have been thought to warrant treatment. Less motivated for long-term treatment, clients expected treatment to focus on more here-and-now, reality-oriented problems. Often they possessed more knowledge about treatment options and were more vocal in questioning the utility of seemingly ill-defined and open-ended approaches with unspecified goals.
The accumulation of findings from practice research also supported the use of short-term approaches since many studies failed to show that more open-ended treatments were superior to brief intervention (Koss & Shiang, 1994; Wells & Phelps, 1990). Moreover, the use of long-term treatment was associated with high dropout rates. For example, in one study, as many as 80 percent of patients in mental health clinics and family service agencies, who were offered more ongoing intervention, were seen for six or fewer sessions (Garfield, 1986). Thus, despite clinicians' stated preferences for long-term treatment, intervention turned out to be short term by default rather than by design (Budman & Gurman, 1988, pp. 6-7). Additionally, as Wells (1990, p. 13) notes, there is some evidence to show that even for those who actually received long-term treatment, improvement occurred early, with 75 percent of clients making considerable progress within six months.
The economic climate of the past several decades has been another major cause of the dramatic increase in the use of briefer forms of treatment. New, more cost-conscious and seemingly efficient forms of delivering mental health care have proliferated, and reimbursement for, allocation of, and accessibility to mental health services have been greatly curtailed and circumscribed. Social agencies and hospitals, which have been the mainstays of service delivery in their communities, have been forced to slash their budgets, rearrange their priorities, downsize their staffs, engage in reengineering their operations, and offer more short-term intervention, sometimes to the exclusion of other types of treatment. Practitioners in these settings, as well as those in private practice, are being forced to reexamine their customary and preferred ways of helping others.
For all the reasons cited, social workers, among other mental health providers, are using time-limited treatment with ever greater numbers of clients. Some practitioners are embracing this development enthusiastically, while others are resigning themselves to it out of necessity. On the positive side, short-term approaches may be highly responsive to what clients want and expect. Consumers seek or are mandated to seek help for a wide range of problems, many of which can be addressed appropriately by brief forms of intervention. For example, a young adult may enter treatment after the breakup of a relationship and may benefit from supportive work aimed at assisting him in dealing with issues of loss and blows to self-esteem. Similarly, a mother who seeks help in disciplining an acting-out youngster may be able to benefit from brief, educative work focused on parenting skills, and a truant adolescent boy may benefit more from a simple change in his school setting than from open-ended ongoing treatment of his personality problems.
Even if clients present with more complex treatment issues that might warrant a more open-ended approach, they may not want or be amenable to such intervention. Proceeding when the goals of the worker and client are divergent runs the risk of causing the client to withdraw from treatment. It is preferable to try to meet the client's expectations if possible, as illustrated in the following example.
Mrs. Pierce, a twice-divorced, recently remarried 40-year-old woman, came for help because of marital problems that were leading her to want to separate from her new husband. She recounted incidents in which he had ignored her needs and wishes and gave evidence of her concerns that he was seeing another woman. Although the worker accepted the client's view of her husband, she learned that Mrs. Pierce had a history of repetitive instances in which her suspiciousness of men's motives led her to distance herself from them and she thought that she was contributing to her unsuccessful relationships. Concerned that the client might leave her current husband, only to repeat her pattern again and again, the psychodynamically trained worker thought that it would be advisable for Mrs. Pierce to get help in understanding the origins of her long-standing feelings of distrust, her sense of inadequacy, and her fears of rejection so that she could modify her ways of perceiving and relating to her husband and other men. The client, however, expressed an interest only in getting help in summoning the courage to leave her spouse.
Recognizing that she could not involve the client in a more insight-oriented and modifying long-term treatment unless she saw its benefit, the worker explained the reasons behind her thinking that the client would benefit from looking into her characteristic relationship patterns. The client missed the next session. In the following meeting, in response to the worker's inquiry about her feelings after their last meeting, the client indicated that she was not going to return at all because she did not want to dwell on the past but she realized that the worker meant well and was probably right. She said that she did realize that she had made a mess of her marriages but needed help in extricating herself from her current relationship, adding that she felt too upset to deal with her other issues at the present time. The worker accepted the client's wishes to focus on her present concerns and abandoned her agenda.
Despite the rationale for briefer forms of intervention, many practitioners remain skeptical, if not overtly negative, about the proliferation of short-term methods. Although their opposition may reflect bias against brief intervention, many clinicians also believe that the current emphasis on short-term treatment is misguided and ill conceived as a result of philosophical, political, and economic reasons.
Whether viewed from a positive or negative perspective, the use of short-term approaches challenges practitioners to expand and change their attitudes about the nature of the treatment process, learn new interventive strategies, and address greater external demands for accountability.
SHORT-TERM TREATMENT MODELS IN MENTAL HEALTH PRACTICE
There are three main types of short-term treatment models that are being used extensively in mental health practice: (1) the psychodynamic model, (2) the crisis intervention model, and (3) the cognitive-behavioral model. The table on pp. 20-21 compares the major characteristics of these models.
The Psychodynamic Model
The short-term psychodynamic treatment model consists of a variety of approaches that modify some of the basic assumptions of traditional psychoanalytic theory and treatment and embody more contemporary psychodynamic theories. Short-term psychodynamic psychotherapy generally is used with clients who have circumscribed problems that are embedded in either mild or moderate long-standing conflicts and maladaptive personality traits and patterns. Although their goals are restorative and supportive in some instances, most time-limited psychodynamic models aim at selective personality change and resolution of underlying conflicts. They have clearly defined selection criteria that favor highly motivated and well-functioning clients who have circumscribed problems and tend to exclude a wide range of individuals whose difficulties are more severe, pervasive, and chronic.
Despite the fact that each of the psychodynamic short-term models to be discussed below has somewhat different origins, goals, foci, selection criteria, and practice principles, they share common assumptions and features:
Common Features of Psychodynamic Approaches
1. The belief that early childhood experiences are a major contributor to adult dysfunction
2. The view that presenting problems generally are embedded in long-standing personality conflicts and patterns
3. The use of selection criteria such as a history of adequate adjustment, problems of acute or recent onset, strong motivation, and ability to relate easily
4. A quick and focused assessment
5. Setting of treatment goals that include either selective or more global personality change
6. The early establishment of a working alliance
7. A focus on core conflicts or relational themes that are manifested in the client's history and the treatment relationship
8. The utilization of active techniques such as clarification, confrontation, and interpretation
9. The use of time limits that can be negotiated fiexibly in some instances
Although the classical psychoanalytic model has been associated traditionally with in-depth, long-term treatment aimed at restructuring the personality, many authors have commented on the short-term nature of Freud's early cases and the fact that initially psychoanalysis was not long term (Flegenheimer, 1982; Shechter, 1997; Stadter, 1996; Wolberg, 1980). Nevertheless, the techniques that are characteristic of Freudian psychoanalysis are geared to helping the patient undergo a controlled regression in which early memories and childhood experiences are explored. The patient's revival of important aspects of his or her relationships with significant others in early life in the treatment or transference to the analyst or therapist provides the basis for therapeutic work. The patient's distorted perceptions of the therapist can be analyzed and interpreted in order to help the patient gain insight into the nature of his or her problems and their roots. Traditionally, the analyst was to remain neutral, anonymous, and abstinent or nongratifying so as to maximize the patient's transference.
Interested in making psychoanalysis more efficient and available to a greater range of patients, Ferenczi and Rank (1925) were the first psychoanalysts to address the issue of time in the treatment process. Rank believed that setting and adhering to a time limit in treatment would prevent regression and force the patient to deal with reality. Ferenczi emphasized the importance of using active techniques, such as suggestion and direct advice, in order to maintain the client's level of functioning, help the patient focus on his or her difficulties, and foster motivation (Flegenheimer, 1982, p. 27). Ferenczi and Rank's views were radical for the time and were neither endorsed nor accepted by the psychoanalytic community. Their work fell into disrepute for some time.
Two decades later, Alexander and French (1946) published a pioneering book, Psychoanalytic Therapy, the first systematic presentation of short-term psychodynamic psychotherapy. As Koss and Shiang (1994, p. 665) point out, Alexander and French believed that psychoanalytic principles could be beneficial, irrespective of the length of treatment, and sought to adapt selective psychoanalytic techniques in order to "give rational aid to all those who show early signs of maladjustment" (1946, p. 341). Drawing on the earlier work of Ferenczi and Rank, they also questioned some of the basic assumptions of the traditional psychoanatytic approach: that depth of treatment was related to length; that brief treatment was temporary and superficial while the resuits of long-term treatment were stable and profound; and that it was necessary to prolong treatment in order to overcome the patient's resistance to change (Budman & Gurman, 1988, p. 2).
Alexander and French tried to avoid techniques that fostered regression and emphasized therapy over real-life experiences. Among the more directive and active techniques that they advocated were (1) the manipulation of the frequency of sessions in order to confront the patient's dependency on the therapist; (2) the utilization of temporary interruptions to determine the patient's reactions to termination; (3) emphasis on the patient's affective experience in the here and now, with attention to relevant historical material; (4) direct encouragement of the patient to face conflicts and problems and to put what he or she learned in therapy into practice; and (5) the therapist's assumption of a role that was diametrically opposed to the earlier parental roles in order to promote an emotionally corrective experience that would foster the patient's functioning and ability to engage in more satisfactory interpersonal relationships.
Like Ferenczi and Rank, Alexander and French were ahead of their time and provided the foundation for all later psychodynamic short-ter...