5
It should be stated at the outset that almost all psychotherapy research in the United States is based on brief therapies that last fewer than 20 sessions (Lambert, 2004). And with regard to research on the efficacy of dynamic therapies, the vast majority involve short-term (rather than long-term) approaches (Barber, Muran, McCarthy, & Keefe, 2013). Thus, when we talk about research studies on brief therapy, to a large extent we are referring to what we know about therapy in general.1
Findings from a number of studies from the 1950s to the present have repeatedly shown that the more therapy the better (Hansen, Lambert, & Forman, 2002; Knekt et al., 2008; Seligman, 1995). We offer something good, and the more of it a client receives, the better the outcome, framing what has been called the dose–effect relationship (Howard, Kopta, Krause, & Orlinsky, 1986). However, when one looks at the rate of change over time, what becomes apparent is that significant and meaningful change can occur within a relatively short period of time—that improvement curves are steeper for the first 20 sessions or so and then start to (but not quite) level out. Improvement as measured a variety of ways (e.g., self-report scales, days lost from work, observations of others) is most rapid in early sessions. Furthermore, Falkenström, Josefsson, Berggren, and Holmqvist (2016) found that the rate of change is faster for those patients attending fewer sessions.
Lambert (2013), reviewing the efficacy and effectiveness of psychotherapy, commented that a “sizable portion of patients reliably improve after 7 sessions” (p. 188) but that to meet the most rigorous success criteria, 50 sessions of treatment may be needed for some patients. He went on to say that approximately 50% of patients respond by the eighth session, whereas 75% need at least 14 sessions. Investigators (e.g., Hansen & Lambert, 2003; Howard et al., 1986; Kadera, Lambert, & Andrews, 1996), have found that 50% to 70% of clients in open-ended therapies showed clinical improvement within 20 sessions (which is within the time frame of most brief therapies). Consistent with these findings, Hansen and colleagues (2002) found that approximately 60% to 70% of clients improve within 13 sessions.2
With regard to the types of clients and problems that can be helped in a brief amount of time (according to what has been called the phase model), data indicate subjective well-being shifts first, followed by symptoms, and then characterological and interpersonal changes (Howard, Lueger, Maling, & Martinovich, 1993). Specifically, studies have found that those with acute and chronic symptoms can experience clinically meaningful change in 13 to 18 sessions, while achieving such results for those with more characterological symptoms may require as much as 30 sessions or more (e.g., Hoglend, 2003; Kopta, Howard, Lowry, & Beutler, 1994). Similarly, although clients with mild to moderate depression may be helped in less than 16 sessions, those who are severely depressed often need more (Shapiro et al., 1995).
A well-controlled study found that by the ninth session of a brief dynamic psychotherapy, clients’ sense of well-being changed most fully, followed by decreases in distress, and each of these preceded and separately predicted gains in social and interpersonal functioning (Hilsenroth et al., 2001). Abbass, Sheldon, Gyra, and Kalpin (2008) found that clients diagnosed with personality disorders markedly changed following intensive short-term dynamic psychotherapy, but it should be noted that the average length of treatment was almost 30 sessions. Messer and Kaplan (2004), reviewing the relevant literature on personality-disordered clients, concluded that improvements do occur with brief dynamic therapy, but that “moderate to longer term therapy may be needed for the more severe cases” (p. 113). Encouragingly, therapists specifically trained in brief dynamic approaches and techniques tend to be more helpful to clients (Anderson & Lambert, 1995; Hilsenroth, Defife, Blagys, & Ackerman, 2006).
Meta-analytic studies (Barber et al., 2013), which statistically combine findings from a number of studies, indicate that dynamic therapies (most of which were short term) were superior to control conditions and as effective as alternative therapies at termination and follow-up for depressive disorders, anxiety disorders, and personality disorders, and superior to control conditions. Leichsenring and colleagues (2015) that psychodynamic therapies (mainly short-term) could be considered efficacious for major depressive disorder, social anxiety disorder, borderline disorder, somatoform pain disorder and anorexia nervosa.
Additional meta-analytic studies found that brief dynamic therapy is superior to waiting list control groups and has equivalent outcomes to other psychotherapeutic treatments (e.g., cognitive-behavior therapy, solution-focused therapy) and medication and that its effects are stable (Abbass et al., 2008; DeMaat et al., 2008; Leichsenring, Rabung, & Leibing, 2004). Furthermore, combined treatment of brief dynamic therapy and medication was more effective than medication alone (Rosso, Crespi, Martini, & Maina, 2009). Using a “quality-based analysis” did not affect these results.
In a randomized trial on the effectiveness of long- and short-term psychodynamic psychotherapy, Knekt and colleagues (2008) found that the brief treatment group was able to maintain its positive gains during the 3-year follow-up. In keeping with the dose-effect model, the longer-term therapy was more effective, but it took 3 years for this difference to manifest. It is important to note, however, that 20% of the participants in the study withdrew when they learned they were being assigned to the long-term group.
Furthermore, in another study Piper, Debbane, Bienvenu, and Garant (1984) considered the cost–benefit analysis of change and concluded that brief dynamic therapy was better than longer-term treatment when one considered the monetary aspects (not to mention the savings in time and effort). Certainly there is more need for randomized controlled designs and naturalistic and process studies on brief dynamic psychotherapies, but considering the consistency of the findings, there is much to encourage the brief dynamic therapy practitioner.
Unfortunately, there has been very little work examining cultural factors and brief therapy outcome and process. Ogrodniczuk (2006) found that women benefitted more from supportive short-term dynamic approaches, whereas men benefitted more from interpretative ones. And it has been found repeatedly that most people, regardless of their cultural backgrounds, prefer briefer therapies (Sue, Zane, & Young, 1994). However, until there are research data to inform us, “mental health professionals should exercise caution in using brief models with diverse populations and should adapt them to the unique cultural and social situation of the client” (Welfel, 2004, p. 347).
Of course, practicing brief therapy is not for everyone. Intriguingly, Levenson and Davidovitz (2000) found that female therapists devoted a significantly greater percentage of their clinical time to long-term psychodynamically oriented therapies than did their male counterparts who were more likely to prefer shorter term treatments. But it is unknown how this difference might influence outcome. Heinonen, Lindfors, Laaksonen, and Knekt (2012) found that therapists who were more extroverted had better outcomes when they did shorter-term work, while more introverted therapists had better outcomes when they practiced longer term approaches.
With regard to therapeutic outcomes, Travis, Binder, Bliwise, and Horne-Moyer (2001) found that following TLDP, clients significantly shifted in their attachment styles (from insecure to secure) and increased the number of their secure attachment themes. The VA Short-Term Psychotherapy Project (the VAST Project) examined TLDP process and outcome with clients who often had psychiatric symptoms, personality disorders, and medical problems (Levenson & Bein, 1993). As part of that project, Overstreet (1993) found that approximately 60% of clients had positive interpersonal or symptomatic outcomes following TLDP (average of 14 sessions). At termination, over 70% of clients felt their problems had lessened.
A VAST Project long-term follow-up study of this population (Bein, Levenson, & Overstreet, 1994; Levenson & Bein, 1993) found that client gains from treatment were maintained and slightly bolstered. In addition, at the time of follow-up, 80% of the clients thought their therapies had helped them deal more effectively with their problems. In a naturalistic effectiveness study of 75 clients treated with TLDP, neurotic and psychosomatic clients evidenced significant improvement at termination, as well as 6-month and 12-month follow-ups (Junkert-Tress, Schnierda, Hartkamp, Schmitz, & Tress, 2001). Those diagnosed with personality disorders also improved, but to a lesser degree. Pobuda, Crothers, Goldblum, Dilley, and Koopman (2008) found that after 20 weeks of TLDP, male HIV-positive subjects’ depression, anxiety, interpersonal difficulties, and school performance were significantly and meaningfully reduced.
With regard to therapeutic process, Henry, Schacht, and Strupp (1990) found that for poor outcome cases, therapists communicated in a more hostile fashion, and the degree to which therapists used such hostile and controlling statements was related to the number of clients’ self-blaming statements. In addition, those therapists who had a more negative self-image were more likely to treat their clients in a withdrawing (i.e., disaffiliative) manner. And all of this occurred by the third session of therapy! Quintana and Meara (1990) also found that clients came to treat themselves similar to the way their therapists treated them in short-term therapy. A later investigation (Hilliard, Henry, & Strupp, 2000) further demonstrated that how clients and therapists thought about themselves (introjects) had a direct effect on the therapy process, which then affected outcome. Bedics, Henry, and Atkins (2005) found that early in treatment, therapist warmth predicted how clients treated their significant others (more affiliative and less hostile) when the relationship was rated at its best. Clearly, these process studies underscore how the interpersonal affects the intrapersonal and vice versa.
Johnson, Popp, Schacht, Mellon, and Strupp (1989), using a modification of the CMP, found that reliable relationship themes could be identified. Hartmann and Levenson’s (1995) study demonstrated that TLDP case formulation is relevant in a real clinical situation. CMP case formulations written by treating therapists (after the first one or two sessions with their clients) conveyed reliable and valid data to other clinicians. Perhaps most meaningful is their finding that better outcomes were achieved the more the therapists stayed focused on topics relevant to their clients’ CMPs.
Friedlander et al. (2016), doing multi-method analyses of the corrective experience in brief dynamic psychotherapy, analyzed line by line the six-session demonstration video I did for APA with Ann (see Chapter 4). Using a narrative-emotion process coding system (Angus, 2015), they found that Ann’s “same old story” declined as the therapy went on, and two change markers (i.e., “unexpected outcomes” and “discovery storytelling”) increased toward the end of therapy, indicating further positive shifts in Ann’s view of self and others. They also tracked how Ann and I were able to maintain a positive working alliance throughout treatment, with the strongest “safety” ratings occurring toward the end of treatment. Furthermore, the investigators looked at the type and frequency of immediacy events (i.e., metacommunication between Ann and myself) and found that there was an increasing frequency of such discussions about our relationship and the depth of those discussions as the therapy progressed.
Seven years after my brief work with Ann, I conducted an informal follow-up with her via telephone. During that conversation, Ann told me that she married her boyfriend 3 years ago. According to Ann, following our therapy, she “found her voice” and on many occasions over the years told her boyfriend how hurt she was when he ignored her or took her for granted. Over time, he changed his behavior to make her feel special to the point at which they decided to marry. This is just how one would hope a brief therapy might work. The client has new experiences of self and other in relationship during the treatment, and then is able to maintain those new behaviors after the sessions have ended, inviting a different (healthier) response from others.
Strupp and his research group undertook a direct investigation into the effects of training on therapist performance. Theirs is one of the only studies in this important area. They found that following manualized training in TLDP, therapists’ interventions became congruent with TLDP strategies (Henry, Strupp, Butler, Schacht, & Binder, 1993b) and that these changes held even with the more difficult clients (Henry, Schacht, Strupp, Butler, & Binder, 1993a). However, a later analysis suggested that many of these therapists did not reach an acceptable level of TLDP mastery (Bein et al., 2000) and that there were unintended increases in poor interpersonal processes as therapists tried to adhere to the treatment manual. Binder and Henry (2010) opined that these negative effects were due to overemphasizing the use of transference interpretations.
In a study on supervision in TLDP, Anderson, Crowley, Patterson, and Heckman (2012) found that supervisors were able to increase the therapists’ use of TLDP interventions in sessions that occurred right after supervision. Looking at a case with a poor outcome, Strupp and colleagues’ (1992) findings indicated that experienced therapists use of TLDP interventions were awkward and poorly timed; looking at a case with a successful outcome, Anderson and Strupp (2015) found that after training, therapists became more cautious, but also less spontaneous, leading them to suggest that training manuals may be useful for therapists mainly at the beginning of their training. For experienced therapists, such manuals may have a negative effect—contributing to a “cookie cutter” mentality.
Additional findings suggest that training in TLDP needs to include close, directive, and specific feedback to professionals learning the model and to focus on the therapist’s own thought processes during the training (Henry et al., 1993a). Similarly, Hilsenroth (2007) also advocates for more “focused, intensive, and task-specific instructional methods” when teaching short-term dynamic psychotherapy (p. 41).
The training approach I use (Levenson, 1995, 2003) incorporates these guidelines. In my group supervision and didactic seminar, trainees receive specific instruction in TLDP theory, case formulation, and intervention strategies, illustrated by clinical vignettes on video. They are assigned to work with one client for 20 weeks. Trainees are explicitly invited to examine their own affective, behavioral, and cognitive processes as they present and/or listen to cases in class. They write down their case formulations and goals (according to the CMP template reproduced in chapter 4) and share them with the class. Every week, they present a video segment from their most recent session and ask the class for feedback concerning a particular issue of their choosing (e.g., why a certain intervention did not seem to work, talking about their countertransferential feelings at a particular juncture, or just feeling stuck about what to say). The class and I discuss the trainee’s specific questions, while I encourage them to stay aware of the larger issues of maintaining an alliance, keeping the focus, and aligning their interventions with the goals of treatment. Thus, by the end of the 6-month, group supervision course, each trainee not only has an idea of how brief dynamic therapy works with his or her client, but also how it manifests in the very different therapist–client dyads of their classmates’ cases.
Teaching experienced (predominately long-term) therapists to do TLDP revealed that those with more hours of previous supervision were less likely “to change their accustomed style of intervention” (Henry et al., 1993a, p. 446). Regarding the training of beginning therapists, Kivlighan (1989) found that the clients of even novice TLDP therapists reported more therapeutic work and more painful feelings than those seen by control counselors, and live supervision was more likely to foster TLDP skills when compared to videotaped supervision (1991). Multon, Kivlighan, and Gold (1996) demonstrated that prepracticum counselor trainees were able to increase their adherence to TLDP strategies with training; furthermore, a related study (Kivlighan & Schuetz, 1998) found that the more trainees focused on learning as an end in itself, the better they did. In another training study, Levenson and Bolter (1988) found that trainees’ values and attitudes toward brief therapy became more positive after a 6-month seminar and group supervision in TLDP. Other research has supported these findings with professionals attending brief therapy workshops (Neff, Lambert, Lunnen, Budman, & Levenson, 1996).
Phillips (2009) studied how trainee-therapists dealt with alliance ruptures in 42 TLDP training sessions. Findings indicated that these trainees did not often use here-and-now interpersonal interventions to repair ruptures. Phillips concluded that more training is necessary to help beginning therapists process their countertransferential reactions to clients in a non-blaming and empathic manner. She made seven suggestions for TLDP therapists in this regard:
1. Focus on more here-and-now enactments;
2. help clients identify and express their relational needs;
3. deepen the emotional response of clients to increase their awareness;
4. recognize and attend to subtle rupture markers in sessions;
5. when there are reenactments, take ownership of one’s own contributions to any negative therapeutic process;
6. share countertransferential feelings in the session in nonjudgmental and warm ways; and
7. when such sharing does not occur, learn what keeps you from doing so.
Austin (2011) studied self-involving disclosures (a type of metacommunication) in 66 audiotaped TLDP sessions. Using a task-analytic paradigm, she found that it was best for the therapist-trainees to wait for clients to reenact their CMPs with them in the sessions before making such disclosures. Similar to the suggestion of Phillips, Austin also found that using a supportive, encouraging tone within the context of a positive alliance was critical.
In a naturalistic study by Fauth, Smith, and Mathisen (2005), doctoral trainees participated in a 20-week training in TLDP. Findings indicate that while trainees’ effectiveness peaked in the training phase, it deteriorated posttraining. Based on feedback from the trainees, the investigators concluded that they had failed to take into account the lack of support in the organizational/treatment culture where the students’ individual supervisors were not TLDP proponents. In a more recent article on “big ideas” for psychotherapy training, Fauth, Gates, Vinca, Boles, and Hayes (2007) made the excellent point that for training to have lasting effects, it “needs to be aligned with and embedded within the organizational/treatment culture” (p. 387). In my experience with psychodynamically oriented training programs, this often means dealing with supervisors’ skeptical attitudes, values, and assumptions about briefer modes of intervention.
In one of the few follow-up studies dealing with the long-term effects of training, LaRue-Yalom and Levenson (2001) questioned 90 professionals who previously (on average, 9 years ago) learned TLDP during their 6-month outpatient rotation at a large medical center. Results indicate that these professionals still used TLDP almost a decade later and reported that they called upon aspects of their TLDP training in their daily work. Of particular interest is the finding that many respondents said they had integrated TLDP formulation and intervention strategies into their longer term work as well.
As previously mentioned, some problems do not lend themselves to a brief dynamic intervention—for example, severe characterological issues and severe depression. Also, some practitioners are not well suited to the interactive, directive, and self-disclosing strategies of brief dynamic psychotherapy. The “very intense and deep work of brief therapy is very demanding for the therapist” (Rawson, 2005, p. 159). In addition, the therapeutic perspectives necessary for the best practice of short-term dynamic approaches (outlined in Chapter 1) may be too much of a leap for those therapists who hold different attitudes, such as the belief that change can only come through a lengthy process of working through (Bolter et al., 1990). Without appropriate training and attention to these “resistances,” we have found that asking such therapists to practice brief interventions will likely put them in situations of high ambivalence and inauthenticity (Levenson & Davidovitz, 2000).
The brief therapist has to have a high tolerance for ambiguity and deferment of gratification (perhaps indefinitely). For the therapist who has to bask in the success of his or her clients, the practice of short-term therapy should be avoided. So often by the time therapy ends, the journey for the client has just begun. There are often not the dramatic changes for self-congratulatory feelings or effusive appreciation from clients. Finally, brief therapists need to be able to say “hello” and say “goodbye” frequently. This can be wearing emotionally, and one needs to have good self-care skills and support.
Having said all of this, doing brief therapy is extremely rewarding. The work combines an optimistic, pragmatic, results-oriented attitude with the experience of deep emotional connection. Seeing positive shifts in the sessions and hearing about changes clients have made years later are profoundly satisfying. On a personal level, in the 40 years I have been conducting brief therapy, I have been phenomenally enriched, changed, and moved in countless small and dramatic ways by the power of being let into someone’s life, albeit for a short stay.
In the next chapter I discuss some of the ways brief dynamic therapy may change in the future, with my suggestions for developments in the field.
1It is certainly beyond the scope of this chapter to review the vast empirical literature on brief dynamic therapy. The reader is referred to overviews by Fonagy, Roth, and Higgitt (2005); Gibbons, Crits-Christoph, and Hearon, 2008; and Lambert (2004).
2As previously pointed out in Chapter 1, brief dynamic therapy is not ultra-brief therapy. Research on clients receiving psychological treatment via managed health care organizations where the number of sessions is five or less indicates that fewer than 25% have meaningful improvement (Hansen, Lambert, & Forman, 2002). “These values are far below the number of sessions assumed necessary in clinical trials to produce improvement, let alone recovery” (p. 338). However, Sanderson (2002) observed that perhaps the outcomes were poor in these very brief treatments because the treatments themselves were ineffective. Barkham, Shapiro, Hardy, and Rees (1999) at the Sheffield/Leeds psychotherapy of depression research group found that a substantial proportion of clients with mild depression were helped in three sessions. Clearly, future work on the effectiveness of these ultra-brief therapies is warranted, although at present their effectiveness remains to be demonstrated.