Dr Robert London

Placing Short-Term Psychotherapy First

Recently, I read about a survey showing that almost half the patients who begin psychotherapy quit—against their therapists' recommendations.

According to the article, some of the reasons for this high dropout rate are patients' unwillingness to open up about themselves, disagreement with the therapist about the nature of their problem, and a lack of confidence in the therapist. In addition, some patients do not think they are improving fast enough. Others have unrealistic expectations.

Regardless of the reasons, one fact is clear: Psychotherapy with a clear or negotiable end point has a much lower dropout rate than traditional, long-term therapy, which has a 50% or higher dropout rate (Harvard Mental Health Letter September 2005;4).

For the last three decades, I've been teaching that psychotherapy has a beginning, a middle, and an end, a theory consistent with the short-term psychotherapy program I ran at New York University Medical Center/Bellevue Hospital in New York. Jonathan D. Brodie, M.D., Ph.D.—the new chairman of the psychiatry department at NYU Medical Center—says that as a resident rotating through the program, he remembers my pointing out that therapy can be effective after 3–6 months, and that the same person can return years later for additional short-term work.

He further reminded me that psychotherapy should have a beginning, a middle, an end—an idea that clearly made an indelible mark on him. This is a critical point. And it is one that new patients should know from the start.

For far too long, traditional open-ended, no-end-in-sight psychotherapy providers have failed to implement the ideas for improvement mentioned in the Harvard newsletter. Chief among those views is to define what the psychotherapy aims to accomplish, with goals and time constraints.

Sometimes, traditional psychotherapists dismiss short-term therapy as shallow or as missing the “real” issues that surround emotional problems or maladaptive behaviors. These therapists abide by the “sword of Damocles” model of psychotherapy, warning patients that “if you stop now, you'll get worse.”

Part of the problem is that many psychiatrists and psychotherapists know little about how short-term therapies work. As a result, they don't realize how successful these therapies can be. The reality is that often the dropout rate is attributed to patient problems because that fits into the therapists' model—not the model needed by the patient for problem resolution. This is a cardinal error in talk psychotherapy.

When Outdated Models Prevail 

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For many reasons, therapists continue to use traditional psychotherapy, but primarily because these are the approaches with which they are most comfortable. Rarely in medicine has this been an acceptable rationale for patient care: I like the theories I've learned. I'll continue to use them. This attitude prevails despite advances in knowledge and techniques.

What makes traditional approaches even more problematic is that therapists seem unable to integrate the patient's psychiatric and economic needs. In contrast, that's what short-term therapists have done all along: Describe the process of psychotherapy, determine the problem, and negotiate a therapeutic plan for improvement with the patient's finances in mind.

Psychotherapy is a service that must be paid for, which means that patients who get it are essentially consumers. But I would guess that often the therapist fails to recognize the significance of cost to that consumer.

The ambivalence that pervades much of traditional therapeutic process is puzzling. For example, as the newsletter points out, most health care professionals remind patients of upcoming appointments. But psychotherapists avoid doing so—because they want to promote responsibility in patients or explore the meaning behind cancellations. It's interesting; I don't know many therapists willing to go a year without pay while they explore the inner meanings behind issues surrounding responsibility or avoidance. This is just one example of the flawed approach of traditional psychotherapy. Often, the focus should be on improving functioning through structured approaches, such as in cognitive-behavioral therapy and brief dynamic therapy.

Nothing is wrong with viewing therapy, in part, as a business relationship.

Payments, timeliness, and responsibility are a part of that relationship, as is a description of the process, with an end point. These kinds of issues are seldom the grist for traditional explorative/open-ended/no-end-in-sight talk psychotherapy. Of course, there is a place for long-term, explorative psychotherapy, but when is it best to use this approach? When short-term approaches fail, that's when.

Why Patients Say They Left 

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There are many stories from patients about why they left psychotherapy. In some cases, they wanted more from it than they were able to get; in others, they were unable to get the therapist to listen to and appreciate their real life issues.

One friend told me that she went into psychotherapy, as she put it, to fix some of the cracks and fissures in the foundation of her house. She believes that hearing herself talk for more than 2 years was helpful and that some of the therapeutic concepts seemed valid. But instead of fixing the cracks, the therapy focused not only on tearing down the house but the whole town as well. On the last visit, after weeks of wanting to put a hold on the care, this friend said she had to quit. She just didn't understand the therapist's approach. “The concept of having two parents who always adored me, paid for school, and continued to be two of my best friends failed to be relevant in the therapist's eyes,” said my friend, a successful professional. [The therapist] “needed to tear the house down. So I left.”

Another situation involves a patient I saw 6 years after he had “quit” talk therapy. His reason for leaving was straightforward: The patient's father had lost his job, his mother was ill, so he and his brother decided to pay their parents' mortgage. As a result of those financial pressures, weekly psychotherapy payments no longer fit his budget.

But the therapist, a traditionalist, strongly insisted that the patient revisit the anger he had toward both parents and, in light of that, take care of himself by remaining in therapy. In addition, the therapist would not consider reducing treatment to twice monthly. Instead, that therapist wanted to examine the patient's “rescue fantasies” on a more regular basis.

We all know that people do run from psychotherapy. But, in both of these cases, the therapists abandoned common sense as they pursued their singular “right way” to do psychotherapy.

Beyond the World of Action 

Clinical Psychiatry News - Volume 33, Issue 10, Page 28 (October 2005)

Many of my Toolbox columns have been directed at addressing emotional difficulties rooted in the world of action, such as problems revolving around obsessions, overeating, or smoking cessation. Certainly, in these cases, short-term approaches are applicable and the standard of care.

But short-term approaches are equally applicable to problems involving perspective, such as relationships, careers, and jobs. The cognitive methods aimed at thinking through problems, circumscribing them, and altering behavior to effect change is geared for the short term.

On the first visit, I offer patients a 3-month treatment plan. If after 3 months, the job is done, we stop. If the job is done in 6 weeks, we stop. Or we could extend for several 3-month periods. Clearly, this gives the patient a real sense of participation, an idea of the end point, and a good indication of what lies ahead. Demystification of the process begins on the first visit. This approach is similar to that advocated in the Harvard newsletter's research.

Today, we have many disorder-specific treatments that work, which incorporate the patient's motivation and willingness to move forward. Our job is to know how to tap into those strengths to help the patient progress. Short-term psychotherapies have a substantially lower dropout rate and appear to show excellent therapeutic results. So the questions become: Why are we not doing more of this treatment? How many training models—4-year psychiatric residency or psychology programs, not to mention various training institutes that teach psychotherapy—focus on the short-term, cognitive, or brief dynamic treatments?

The Accreditation Council for Graduate Medical Education has guidelines that make short-term psychotherapy a component of the residency curriculum training. But is that enough? Shouldn't a person who completes a 4-year training program in psychiatry be expert in these techniques in first-line care? Such training is particularly important because these techniques not only relate to many of the therapeutic needs facing society but also are educationally and economically sound.

Psychiatry residents and young psychiatrists are experts in psychopharmacology. Pharmaceutical companies, which now produce more site-specific medications with fewer side effects, have made great strides in care for our patients. But we also need to focus on teaching residents as much about short-term treatment as they learn about psychopharmacology.

We must reclaim the art of psychotherapy. One way to do this is to learn how to practice short-term approaches: The therapist circumscribes the problem and clearly defines the issues to the patient. In the process, both parties become better able to solve the problem in an efficient, cost-effective way. Furthermore, this shift in emphasis would be another step toward showing that parity in psychiatry is practicable and doable. Taking this approach is in the best interests of our patients—and our profession.

Let me know what you think about this important reality in talk psychotherapy, and I'll try to pass your thoughts along to my readers.

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