Dr Robert London

Short-Term Therapy: Let's Use it

Clinical Psychiatry News - Volume 31, Issue 9, Page 12 (September 2003)

Perceptions of psychotherapy among the lay public have been influenced by movies and television more than any other force. The films of Woody Allen, for example, portray therapy as an interminable strip mining of the psyche and as cash-guzzling emotional interrogations that meander (sometimes for decades), searching for the rare breakthrough.

This makes for good entertainment but bad treatment. In fact, it is the short-term psychotherapies that prove effective for many patients and should be so for more. The aim of therapy is clear—alleviating the pain and suffering of emotional disorders in the shortest possible time.

These short-term therapies, two of which are brief psychodynamic therapy (BPT) and cognitive-behavioral therapy (CBT), help patients observe their problems, thinking, and actions, thus enabling patients to alter them. Then, in turn, they can alter their behavior in a positive way—which includes using better coping skills.

CBT, for example, has been proven to work for many patients with anxiety disorders, adjustment disorders, some somatization disorders, and some personality disorders. Hypnosis and guided imagery can effectively treat chronic intractable pain problems, smoking cessation, and overeating, as well as DSM-IV anxiety disorders.

The goal is to get patients to start replacing negative, distorted, and generalized thoughts and to begin reprocessing those thoughts with alternative sets of perspectives on the same old problems.

It is critical to isolate the disorder on problems requiring treatment, being careful not to get lost in dogmatic conceptual models of mental functions and hypothesized inner turmoil and conflict. Short-term psychotherapy is oriented to reaching goals in days, weeks, or months—not years.

This requires an active approach on the part of the therapist—whether it's using BPT, where the focus is on working through specific intrapsychic conflicts; or CBT, where clear treatment protocols exist. When patients throw up certain barriers, we need to address those resistances head-on—rather than interpret them. I often tell my patients, “You've got this marvelous energy, but you've got to get out of reverse and get into drive.” And they get it.

Recently, I had a 32-year-old patient tell me, “My father always calls me when I'm busy.” Those kinds of generalized statements quickly led her to rage against the father, who has always been supportive—both emotionally and financially. A new perspective is: “Sometimes, my father calls when I'm busy.” This approach essentially defused the patient's rage reaction and enabled her to move forward—extending a new way of thinking and acting. This new approach applies not only to her father but to a multiple of situations that needlessly induce rage.

It is difficult to measure results. The data out there are not comprehensive. But we can look at the work of researchers such as Martin M. Antony, Ph.D., and see that such approaches are effective.

In one study of patients with arachnophobia, Dr. Antony, director of the Anxiety Treatment and Research Centre at St. Joseph's Healthcare, Hamilton, Ont., and his colleagues evaluated 60 people who underwent 2 hours of exposure to spiders. Of these patients, 50%-63% had a panic attack when exposed to spiders before treatment; after therapy, that percentage ranged from 13% to 25% (Behav. Res. Ther. 39[10]:1137-50, 2001).

Dr. Antony also measured heart rates. During the behavioral test, those rates ranged from 88 to 92 beats per minute. After treatment, the rates ranged from 72 to 77 beats per minute.

He said other studies have shown that exposure techniques help 80%-90% of people overcome a fear of animals. In the case of patients with panic disorder and agoraphobia, with 10-15 sessions, 50% of people get over the problem completely, and others have significant improvement, Dr. Antony says. His controlled studies give clinicians greater variability for treating many disorders besides spider phobias and panic disorder.

Despite such successes, many psychiatrists seem resistant to these approaches. More and more of us are into medication management, letting other therapists do the talking. Too many professionals doing psychotherapy still use the use time-unlimited, one-dimensional approaches. But we've got to realize that we're not going to get third-party payment if we can't define what we do.

Patients do not have years to spend on theoretical psychotherapy. If psychotherapy is going to survive, it must be consistent with the economics of our times. We must change our own thinking about short-term psychotherapy. We owe it to ourselves—and to our patients.