Therapy in L.A.


  article of the month
November/December 2004
Written by Glenn Peters, Ph.D. and Malcolm Miller, Ph.D.
Edited by Alan Solomon, Ph.D.

To our readers,
We are altering our usual format by having Dr. Alan Solomon interview Dr. Glenn Peters and Dr. Malcolm Miller about the differences between brief and long term therapy. Although these therapists use both approaches, depending upon the needs of their clients, we felt this format would help you better understand the selective advantages of each. If you wish, you can discuss these distinctions with your current therapist, or a potential therapist, to determine which would be best suited for your needs.

1. Is the distinction between the two therapies based upon number of sessions, or the focus and philosophy of treatment?

Dr. M.: I would probably say both. Brief therapy is typically time limited; my preference is between 10-20 sessions. But this is only one part. Brief therapy has clear, focused goals, must be a collaborative process between client and therapist, and must include specific assignments for the client between sessions.

Interconnected with this, a major component of brief therapy is that change can occur from the "outside in," not just from the "inside-out." One of simplest examples of the "outside-in" involves behavioral changes which begin the process of undoing long held beliefs that one never accomplishes anything in one's life. By clients listing goals for the day, checking off what they have accomplished, moving unaccomplished items to their next day list, and keeping a log over a month of what they have done, clients realize:
a) They can learn methods to be more consistently productive.
b) The earlier messages they received that predicted failure are not life-long judgments.
c) One is not a failure if one does not accomplish something today; it can always move to tomorrow's list and be accomplished. (Just not "tomorrow, and tomorrow and tomorrow"!)
Brief therapy has become much more sophisticated than this one example of "outside-in." At the same time, with properly selected brief therapy, clients can examine and begin altering their patterns and internal messages that sabotage or minimize these accomplishments. Finally a major tenet of brief therapy is that therapy does not need to last until all goals are accomplished. Once forward momentum is solidly established, progress will continue after therapy has ended, with occasional booster sessions.

Dr. P.: Long-term therapy can go anywhere from a year or longer. Sometimes what will drive us to seek the assistance of a therapist are problems that do not get resolved in 10 to 20 sessions. Often these are problems that are more ingrained in terms of our lifestyle or character.

For example, some individuals who have suffered multiple traumas in early childhood, such as multiple forms of abuse often will need a more prolonged commitment to therapy in order to resolve these issues that continue to impact negatively on their adult lives. Another, example in regards to these long-standing problems could be manifested in our intimate relationships. Some people find that they have serious difficulties in getting close to others, and that for many years they have jumped around from one relationship to another, without developing closer or more intimate connections with another person. Furthermore, inside they may feel that they are living empty and isolated lives.

In my opinion, this kind of problem needs a longer-term focus with a longer-term commitment to the therapeutic process. These are not the only issues more amenable to long-term therapy, but they do give you a sense of the more long-standing, more established aspects of personality that often need more prolonged treatment.

2. What are the specific advantages of each form of therapy?

Dr. P.: Long-term therapy gives a person an opportunity to work out issues that are deeply rooted in their lifestyle. Some people want to gain deeper access to their emotional lives, they want to gain more insight and discover what leads them into a certain style of life that may be comfortable, but leaves them unfulfilled in regards to what they yearn for themselves. Long-term therapy gives people the time to engage in a journey of self-discovery that can lead them to develop a fuller life of more meaning and creativity.

Finally, long-term therapy gives us the time to come to grips with and relieve those areas of our life that are painful. It is very difficult for individuals to recognize and own up to their part in the difficulties in their life. For instance, individuals often will blame others for their relationship difficulties while denying or avoiding examining those painful conflicts, within themselves, that have lead to these external relationship issues. Long-term therapy allows individuals to have the time that is needed to go beyond the avoidance of examining and working through internal conflicts that if left unchecked will continue to create havoc in outer relationships.

Dr. M.: Let me try to list the advantages of short-term therapy:
a) Because brief therapy is compact and most of the therapeutic work occurs between sessions, clients are more active and responsible for the improvements that occur.
b) Because clients are more active, the focus is more on their capabilities than deficits.
c) Since it is more focused, with more specific goals, clients more clearly understand their difficulties, the reasons for their difficulties, and the changes that need to occur.
d) Because there is not the time to fully analyze all difficulties originating from childhood, brief therapy is strength based, focusing more on identifying and appreciating capabilities rather than deficits or problems. Problems are not ignored but are secondary to capabilities.
e) Related to this, at the end of therapy, clients more clearly recognize what they have achieved. This leads to a heightened sense of mastery and increase in hope--äSince Iāve seen how I can make important changes in my life in a relatively short period of time, maybe it is possible to change other areas of my life!"

3. How then does one determine whether it is best for the therapy to be long term or brief?

Dr. M.: It depends upon several factors:
a) The client's objectives for therapy
b) The length of time allotted if only managed care sessions can be used
c) The motivation of the client to actively work on assignments between sessions
d) How ingrained the difficulties are. The more their issues have extended over a number of years and are interwoven into the fabric of their personality, the less clients can achieve through brief therapy.

Dr. P.: My response is similar to Dr. Miller on this question. However, I would also like to add a comment on the larger issue concerning the current pressures on mental health services in our society. The current pressures have impact on both therapists and clients, influencing the delivery and ideal model of mental health services. Unfortunately, in this age of managed care there is a great deal of pressure to engage in short-term therapy even when an individual could gain more benefit from a more prolonged commitment to psychotherapy. The pressure in mental health services is to resolve problems quickly and to rid the person of his or her symptoms. Yet the more deeply ingrained issues, that can be manifested by severe relationship difficulties, the lack of a meaningful life, or in regards to effectively dealing with a more chronic mental health disturbance, are minimized because they donāt fit into a model of what mental health services should be. The pressure toward a short-term solution, keeps us, both mental health therapists and clients, from going further in working through these more challenging issues.

Unfortunately, even when the symptoms are resolved, more ingrained issues can become manifested at a later time, when an individual goes through a period of stress, for example. However, I do not mean to devalue the effective use of short-term therapy. In fact some recent forms of short-term therapy appear to do an admirable job in resolving some more long-standing issues. Nevertheless, the current pressures to find a quick solution have lead to the inappropriate use of many forms of short-term therapy with some individuals that are not matched for this intervention.

4. How do I determine which is best for me?

Dr. P.: It is not always so easy to determine which is the best form of therapy for you. Sometimes not until you get into therapy do you become more aware of deep-seated, long standing issues that have caused you difficulty. In my opinion, it is not unusual to enter therapy with short-term goals in mind, and then find out during a period of exploration and self-discovery that your goals change so that the therapeutic work you care to do takes a more prolonged commitment. This underscores the fact that therapy is a dynamic, interactive process of change and personality development, and the original intent for entering into therapy may very well change during the therapeutic process.

I think it is important to try and stay aware of the signs or cues that our original intentions may need to change. For instance some people find that their problems of more recent origin actually go back to problematic patterns of behavior that they have experienced throughout their lives. Yet, some people can enter psychotherapy with certain goals in mind, and then are completely satisfied when these goals are resolved through short-term therapy. I advise people to gain an awareness of their own preferences and feelings, while they enter into an honest dialogue with their therapist and to genuinely reflect on what is in their best interest. Of course even if you start in short-term therapy and leave therapy at some point, you can later decide to re-enter therapy and make a longer-term commitment.

Dr. M.: I very much agree with what Dr. Peters just stated. My answer is basically quite similar. First look at the specific reason you are considering therapy--is it related to issues that are longstanding and ingrained difficulties or of more recent origin and not a more pervasive part of your personality. Then review how you have succeeded in the past. Are you goal directed? Do small achievements give you the encouragement to make larger achievements? Do you tend to see the world and your accomplishments as the glass half full? Those seeing the glass half full would more likely benefit from brief therapy than those who see the glass as half empty. Finally discuss this with your therapist or interview some therapists and explore it with them. After you have followed these steps, you will be able to make a more informed decision. If you then begin a certain course of treatment and decide it is not working best, you can always reevaluate this with your therapist, and possibly make a change, either with the same therapist or a different one.

5. Does brief therapy only provide symptomatic relief, leaving the underlying problem intact to appear at a later time?

Dr. M.: Dr. Peters asked me to comment on this frequent critique of brief therapy by certain long term therapists. I believe when therapists make this as a blanket statement, they do not really understand modern brief therapy. They also are not aware of the excellent discussions about symptoms and symptom substitution, i.e., that another symptom will replace the first symptom, since the underlying cause was never fully treated. First a discussion of symptoms presupposes that what is observed is merely a sign of a much deeper issue. This is sometimes true, sometimes not. In the example Dr. Peters raises of the person who is living an empty and isolated life, it is clearly an indicator of a deeper issue.

There are other issues, however, where the observed or presented issues are the problem. Many people who are afraid of flying in airplanes are successfully treated in a few sessions and do not have that problem again, and no other "symptoms" appear replacing the fear of flying. Sometimes couples misinterpret each other and this results in a vicious circle of feeling misunderstood, victimized, and then retaliating. Helping these couples understand how they both have misunderstood the other, felt victimized, and reacted to something the other did not intend can often be accomplished in brief therapy. Then they can learn how to communicate more clearly and double check their understanding of what the other meant.

These couples will not necessarily re-experience further difficulties since only a "symptom" was treated. Even Sigmund Freud, the originator of psychoanalysis, which was to become long term therapy, made a very perceptive but simple analogy many years ago, "Sometimes a good 5 cent cigar, besides being a phallic symbol, can also be just be a good 5 cent cigar."

This leads to the second issue. The particular therapist's capability and the collaboration between client and therapist to assess whether the issue is amenable to brief therapy are most critical. It is not an issue of whether brief or long term is better as a general principal, but the issue is which best addresses the unique needs of the particular client. Also it depends on the skills of the therapist. Not all therapists providing brief therapy are equally proficient in this method of treatment.

Dr. Solomon is a psychotherapist in practice in Torrance. He is a member of the Independent Psychotherapy Network.

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