by Ger Murphy
In this brief piece I want to address the issue of short-term psychotherapy, how we can see it, whether it can have real value, and if an integrative approach can be formulated that does justice to the practice.
In all areas of endeavor attempts are being made to increase efficiency and manage resources better, psychotherapy is no exception to this consideration. In a time of increased waiting lists and restricted budgets a pressure is arising to explore the question of shorter treatment, so as to allocate reduced funds in the most equitable way without compromising the effectiveness of the practice intervention. I want to consider some of the key questions involved in exploring the theme, offer a conceptual framework that may do justice to an integrative approach, and consider some practice issues and clinical considerations which arise.
My interest in this theme has arisen out of the work on short –term psychotherapy at the Institute of Creative Counselling and Psychotherapy over the past 5 years. During that time we have offered a service to patients of local South Dublin GP practices who are on the Medical Card scheme. The Institute has seen approximately 300 clients over this period for short-term work, offering 6 sessions, with a possibility of a further 6 sessions where it was seen as desirable. This work has allowed us to reflect on the possibility of offering a valid, useful, and ethically sound service to these clients who would not otherwise have been in a position to receive psychotherapy.
As we undertook this new work certain key questions arose. These included:
- Can short-term work be valuable and effective, or is it always to be seen as short-changing the client of a longer service?
- Can we be over-wedded to long-term work?
- Can a model of short term work be formulated that does not rely solely on the brief psychotherapy and cognitive psychotherapy approaches but integrates a focus on therapeutic relationship and an integration of the person, including a focus on the body and self relating?
- Are ‘deep’ and ‘brief’ mutually exclusive?
- Could we develop a model which was in tune with the Integrative Psychotherapy model developed at our Institute over the past 25 years (Ger Murphy 2008)
To explore these questions it is necessary to open ourselves to shifting our viewpoint and it is worth quoting two of the leaders in Brief Psychotherapy here:
“few things hamper therapists more than theories”`
Steve de Shazor (2003)
“There is nothing more dangerous than an idea….When it’s the only one you have”
Bill O Hanlon (2008)
- To look on six sessions of one to one psychotherapy as a six-hour possibility of real conversation, exploration and change can be different from seeing it as ‘only six sessions’ and focusing on the limitation of this.
- It is clear that such short-term work as I am speaking of here, will need to focus more on problem–solving than on character change as some long term psychotherapies would do. Here I am defining a problem as ‘more of the same of something which is not working’`
- Many clients may need long term work due to the level of early life trauma, and the embedded characterological difficulties that this may give rise to, and this calls for a thorough assessment where the client’s definition of the problem is given real value alongside the psychotherapist’s conception of the pathology in functioning.
We see here that it will be the client’s definition of what the problem is, that will matter. We need to see this as us helping the client with the problem they define and want to change. This will be the first focus in the engagement, i.e. to define the problem and then look at what solutions the client has been using to attempt to solve it up to now and how these might be strengthened or altered. Therefore this work will be more problem focused than longer term work.
- This brief work then will focus much more on description and solution and will eschew interpretation and explanation. It may matter less to the client why this problem came about and more how a solution can be found.
- In this circumstance the therapy will be as much concerned with discovering inventing and applying solutions to problems as with validating clients distress and pain, although appropriate time must be given to developing a compassionate relationship to form the basis for change.
- There can be a tension between being ‘solution–focused’ and client centered. When clients come with a history of psychic pain related to a problem they will need to be listened to deeply on this and yet ‘it is important not to listen too long to what has gone wrong’ as the story of the difficulty can be over absorbing and somewhat hypnotic, and we must assume that the client wants to develop a different future which they want our help in developing.
- Another tension can be experienced between ‘deep’ and ‘brief’. This can lead one to assume that there is a mutual exclusion between brief and deep which I believe may not be the case, from the experience on hand. This can be based on a belief that only problem-solving can be accomplished in a short time whereas I will suggest that in helping clients develop new or improved personal capacities ,we are offering possibilities of real and deep change. Ecker and Hulley (1996)
I would now like to introduce a model of short term work which can be of value to clients presenting with acute symptoms of anxiety and low mood. This model has been used over the past 5 years with clients referred by GP practices in South Dublin. It is a model which is possible to explain to clients and which can de-mystify psychotherapy for new clients who attend and can be useful in developing a speedy collaborative approach. This model which I describe as CPR (alluding to emergency medicine, and thus easily remembered) has three elements. These are:
- Capacity Building
These three elements can offer clients a cogent framework which they can use in addressing their need for increased emotional resilience and strength.
This refers to the development of four key capacities which, think strongly alter the inner life of the client, and can be offered in a clear way so as to allow the client to self-assess and highlight areas of potential development. These capacities can be seen as a having a technique base and are also concerned with inner object-relating (Gomez 1997)
1. Capacity for Self Awareness
This includes the ability to notice when one is activated emotionally in a regressive way, i.e. responding to present circumstances out of similarity to past events, including autonomic system arousal, preparedness for fight\flight\freeze the presence of catastrophic thinking, and body response changes, breathing etc.
2. Capacity to Self Soothe.
This includes the ability to bring oneself down from sympathetic nervous system arousal, using breathing, self-talk etc.
3. Capacity for Self-Forgiveness \Acceptance
This includes the capacity for self-compassion, the allowance of risk-taking and the possibility of mistake-making in the journey of growth. This can also include the development of a spiritual perspective on life.
4. Capacity to Self-Resource.
This includes the capacity to have an increased awareness of ones own needs and to strategically search for their fulfillment
This element emphasizes the need to develop a greater capacity to live in present moment awareness, to give time to developing this state through awareness practices between sessions and the importance of continuing a presence focused practice with mindfulness and\or body focused centering. This ability is closely related to the capacity for self-awareness outlined above, but has the additional focus on the necessity for an ongoing personal practice. This is based on the Buddhist notion from the Buddha’s Four Noble Truths, which I think is as relevant today which states that suffering arises from Desire and Aversion, being as they are, focused on past memories and future expectations (Sills (2009).
This area focuses on helping the client find on-going strategies for energy balance and release. These practices are often given in sessions and encouragement is given to clients finding appropriate ways for doing so on an ongoing basis. It has been seen that many clients when asked to focus on their relationship to the four major feeling areas of fear, sadness, anger and joy find the work with emotions to be a major complicating factor in their well-being. Particularly the management of fear in a healthy way is often lacking. To be able to engage with fear, neither through disassociation nor overwhelm, but with mindful intensity is often a key growth area for these clients. Specific strategies which can be considered include:
– Simple body awareness and body work
– Use of breath and grounding techniques
– Resourcing work – Ogden (2007) and Rotchchild (2005)
– Gestalt type dialogue work
– Physical disciplines, yoga,dance, exercise,diet
It is worth remembering how challenging this work is as acknowledged by
“therapy needs to consist of helping people to be in their bodies and to understand their bodily sensations. And this is not something that any of the traditional psychotherapies, that we have all been taught, help people to do very well”
Van der Kolk (1998)
It is important to assess well for this short term work and to have the capacity and resources to differentiate between service needs. Many clients can get benefit from short term work if their ego capacity is already of a relatively high level, their pre-morbid functioning was adequate and psychological-mindedness is present, i.e. they are sufficiently interested in their internal working and realize that the changes will need to be made within knowing, as the late Dr Michael Corry used to say, ‘Happiness is an inside job’
This work is not suitable for clients exhibiting a borderline personality disorder or those who have psychotic features. It has been seen to be useful for some who have had long term contact with the psychiatric system, where the belief in self-empowerment and the relevant capacity is evident. Clients who benefit from this approach need to be able to develop a partnership approach, and a clear working alliance, without the need for a developmentally-needed relationship (Clarkson 1997) involving strong transference and dependency where the psychotherapist has to act, for some time as an auxiliary ego in helping the client develop increased right brain functioning and self regulation (Shore 2005). A focus on problem-solving is useful in this work where a focus is placed on the doing of the problem, the viewing of the problem and the context of the problem. (O’Hanlon 2009). This approach is best used with clients who need assistance in managing current concerns in their internal life and who wish to reestablish stability of functioning. It can also be of benefit to clients who may need longer term work as a resource in stabilizing themselves in advance of such work
This approach and those like it that can challenge some of the tenets of practitioner’s approaches can be demanding. There is a call for the practitioner to manage the sessions differently, to structure the work and to challenge both themselves and their clients to work rapidly for change. Authority is used differently and more explicitly, and practitioners need to be able to inhabit all four quadrants of practice appropriate for the Integrative Psychotherapist (Murphy 2008). In this the therapist is able to operate both as a holding presence and a dynamic one who invites the client to engage in creative experimentation.
Of course short term psychotherapy has many limitations in that the degree of change is often more limited than in well done longer term work. Yet it has been the experience of work with a significant number of clients that significant change can take place in a short period of time and that this can be satisfying for the client. It is also of note that short term work can have a great deal of satisfaction for psychotherapists as it offers the opportunity to engage differently with more personal transparency and higher levels of activity than in other work. Therefore for reasons of best practice as well as distribution of scarce resources I believe that short term work can have much to offer the field of psychotherapy and that a measured discussion on its benefits and limitations is timely.
Ger Murphy is an accredited psychotherapist and trainer with IAHIP,he is Director of the Institute of Creative Counselling and Psychotherapy, he also is a founder of IAHIP, ICP and Inside Out journal. He can be contacted on firstname.lastname@example.org
Murphy, Ger (2008) Integrative Psychotherapy A Model, Published privately, www.iccp.ie/library
De Shazor, Steve (2003) www.brieftherapy.org
O’Hanlon, Bill (2008) www.brieftherapy.org
Ecker B,and Hulley L, (1996)Depth oriented Brief Therapy, Wiley Publishers
Gomez, Lavinia (1997) An Introduction to Object Relations: New York, Free Association Books
Sills, Franklyn (2009) Being and Becoming, The Psychodynamics, Buddhism, and the Origins of Selfhood: North Atlantic Books
Ogden, Pat.(2007) Pain Trauma and The Body A Sensori Motor Approach to Psychotherapy in Minton, Ogden, P. New York: Norton and Co
Rotchchild, Babette (2005) The Body Remembers: New York: Norton and Co
Van der Kolk, Bessel MD (1998) International Society of Traumatic Stress Studies
Clarkson, Petruska (1997) The Therapeutic Relationship: London: Open University Press
Shore,A.(Autumn 2005) Introduction to Including the body in Mainstream Psychotherapy: American Psychological Association Journal.