The Brief Therapies
Abstract and Keywords
Research and meta-analysis of research on psychotherapy outcome has consistently supported the use of therapy that is planned from the beginning to be brief. In recent years several brief therapy approaches have been developed, often by social workers, and found to be effective. This article provides an overview of the research supporting the use of brief therapy and describes the basics of the major approaches to brief therapy such as the task-centered approach, the psychodynamic approaches, interpersonal therapy, cognitive-behavioral therapy, emotion-focused therapy, the strength-based approaches, couples and family therapy, and group therapy. It closes with the discussion of several future trends in brief therapy.
Brief therapy (BT) “refers to a family of therapeutic interventions in which the practitioner deliberately limits both the goals and the duration of the contact” (Wells, 1994, p. 2). Though BT generally involves limiting the number of sessions of treatment, it is not necessarily defined by number of sessions or length of time. In addition, the sessions provided within the structure of BT do not necessarily have to be held on a weekly basis but rather can be spread out over a longer period of time with longer intervals between sessions (Steenbarger, Greenberg, & Dewan, 2012). The number of sessions can be as high as 45 but most of the time treatment involves only 10 to 20 sessions. There are several different approaches to BT and many of them have criteria for client selection: motivation to change, good ego strength, history of meaningful relationships, ability to focus on one issue for treatment, capacity for self-reflection, willingness to examine feelings and conflicts in relationships, and absence of psychosis or personality disorder. Most BT approaches have the following guidelines (Hoyt, 2011; Steenbarger et al., 2012): (1) Develop as quickly as possible a positive, collaborative therapeutic alliance; (2) identify a focus usually in the form of a concretely and specifically defined problem; (3) rapidly assess the client’s problem and level of functioning and de-emphasize using formal diagnosis; (4) emphasize the client’s present life and future (goals) rather than past experiences and memories; (5) focus on changing repetitive problematic patterns of client’s feeling, thinking, and/or behaving especially in significant relationships; (6) be active and keep the work centered on the client’s focus and continually provide structure to therapy; (7) believe in the client’s capacity to change and expect the client will change; (8) emphasize the client’s resilience, strengths, competencies, and resources; (9) mutually develop with the client between session tasks (homework); and (10) specify the number of sessions from the beginning work to make the most of each session. Most research on the effectiveness of different therapeutic approaches is conducted on brief therapies, and in frontline practice this is the experience of most clients (Lambert, 2013a).
Why Brief Therapy?
Research has found that even when time-unlimited therapy is the option of choice of the clinician and the client’s ability to pay for treatment is not an issue, most clients choose brief treatment with the mean number of sessions being between 5 to 8 with 70% of clients leaving therapy by the 10th session and 90% by the 25th session, which is considered to be the upper limit for brief therapy (Bohart & Wade, 2013; Messer, 2001; Olfson & Pincus, 1994). Also providing support for the use of brief therapy is the research on the dose-response effect of therapy. Studies have found that 50% of clients are able to make clinically significant change within 8 to 12 sessions and 75% by 14 to 25 sessions (Lambert, 2013b). These findings indicate that most clients want and can satisfactorily benefit from brief therapy.
Social Work and Brief Therapy
Though BT was not part of the language of social work practice in the early days of the profession, practice principles and philosophy were consistent with it. For example, it took a person-environment perspective, emphasized a problem-focus, social workers were to develop a collaborative relationship with clients, and both the worker and client were to take active roles (Richmond, 1917, 1922). Richmond frequently refers to the importance of working with client’s “assets,” “untapped resources,” and “possibilities,” which is consistent with today’s strengths and empowerment perspectives. In the 1930s and 1940s the functional approach to social case work was developed which emphasized the worker developing a mutual relationship with the client, working with client strengths, and setting time-limits (Robinson, 1930; Smalley, 1970). In the 1950s the functional approach was one of the major influences in the development of the problem-solving approach (PS) to practice (Perlman, 1957, 1970). The PS approach was very influential in the development of the task-centered (TC) approach to social work practice in the 1960s and 1970s (Reid & Shyne, 1969, Reid & Epstein, 1972). The TC approach was the first evidence-based model developed in social work and designed from its beginning to be brief. TC practice has been found to be effective with a wide variety of client problems and populations (Rzepnicki, McCracken, & Briggs, 2011). In the 1980s social workers developed two approaches to BT that emphasize working with clients’ strengths: solution-focused therapy (SFT; De Jong & Berg, 2013; de Shazer, Berg, Lipchik, Nunnally, Molnar, Gingerich, & Weiner-Davis, 1986) and narrative therapy (NT; Freeman, 2011; White & Epston, 1990). These approaches do not have selection criteria and have been used successfully with a wide variety of clients. Considerable research has been building in the process of establishing SFT as an evidence-based approach to treatment (Franklin, Trepper, Gingerich, & McCollum, 2012). Little research has been conducted examining the effectiveness of narrative therapy but in recent years that trend has begun to change (Erbes, Stillman, Wieling, Bera, & Leskela, 2014; Lopes, Goncalves, Machado, Sinai, Bento, & Salgado, 2014; Vromans & Schweitzer, 2011). The need for brief therapy in real world practice is as great as ever and social workers continue to be on the forefront of developing, refining, and providing it (Cochran & Field, 2013; Hair, Shortall, & Oldford, 2013).
What Are Other Major Approaches to Brief Therapy?
Meta-analyses of decades of outcome studies of various theoretical approaches to therapy have found that no one approach is more effective than any other (Wampold & Imel, 2015). What accounts for the effectiveness of the various approaches are the factors they have in common rather than any specific interventions unique to an approach (Wampold & Imel, 2015). However, according to Wampold and Imel (2015) there is no such thing as “common factors therapy,” rather the various specific approaches to therapy are the delivery mechanisms for the common factors. Therefore clinicians need to know and have expertise in some of the specific approaches to treatment.
Though social workers did not develop them there are a number of other theoretical approaches to BT that social workers use in practice and are evidence-based: psychodynamic therapy (Barber, Muran, McCarthy, & Keefe, 2013), which includes intensive short-term dynamic psychotherapy (ISTDP), short-term anxiety-provoking psychotherapy (STAPP), supportive-expressive psychoanalytic psychotherapy (SEPP), and time-limited dynamic psychotherapy (TLDP); interpersonal therapy (IPT) (Swartz, Grote, & Graham, 2014); and emotion-focused therapy (EFT; Greenberg, 2015). The upper limit of the length of treatment of these approaches is between 20 and 40 sessions; they also have clear selection criteria. Other BT approaches tend to have lower upper limits in duration (10-20 sessions) and not use selection criteria: The Mental Research Institute (MRI) approach (Watzlawick, Weakland, & Fisch, 1974; Rakowska, 2015; Rynes, Rohrbaugh, Lebsenshon-Chialvo, & Shoham, 2014); cognitive behavioral therapies (CBT; Hollon & Beck, 2013; McMain, Newman, Segal, & DeRubeis, 2015), which includes Cognitive Therapy, Rational Emotional Therapy, Cognitive-Behavioral Modification/Stress Inoculation training, Prolonged Exposure Therapy, Behavioral Activation, and Multi-Modal Therapy; single-session therapy (Gee, Mildred, Brann, & Taylor, 2015; Hoyt & Talmon, 2014); motivational interviewing (Arkowitz, Miller, & Rollnick, 2015); couples and family therapies (Heatherington, Friedlander, Diamond, Escdero, & Pinsoff, 2015; Sexton, Datchi, Evans, LaFollette, & Wright, 2013), which includes, for example, Brief Strategic Family Therapy (BSFT), Multi-systemic Therapy (MST), Multi-dimensional Family Therapy (MDFT), Functional Family Therapy (FFT), and Integrative Family and Systems Treatment (I-FAST); group therapies (Burlingame, Strauss, & Joyce, 2013), and eye movement desensitization and reprocess (EMDR; Shapiro & Laliotis, 2015).
Numerous approaches to brief therapy have been developed and found to be effective with a variety of clients and client presenting problems. BT is here to stay and social workers need to be skilled in at least one of the approaches to BT. Future trends appear to be: an increasing emphasis on the common factors in therapy (Drisko, 2013), focusing on client strengths (Jones-Smith, 2014; Padesky & Mooney, 2012), regularly monitoring client progress as feedback to the clinician (Boswell, Kraus, Miller, & Lambert, 2015), and systematically integrating approaches (Castonguay, Eubanks, Goldfried, Muran, & Lutz, 2015; Fraser, Grove, Lee, Greene, & Solovey, 2014; Greene & Lee, 2011; Selekman & Beyebach, 2013).
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