Caring, effective, short-term psychotherapy

Understanding Short-Term Therapy

When most people think about psychotherapy, they imagine discussing their innermost feelings in a caring, supportive environment. This is reasonably accurate for some forms of therapy. It can be helpful to many people who face difficult, and confusing situations in their lives. It's just not a good way to quickly and effectively deal with a debilitating problem.

The methods used in cognitive behavioral therapy are grouped into protocols designed to treat patients with a specific diagnosis. Protocols exist for treating disorders like major depression, generalized anxiety, obsessive compulsive disorder (OCD), generalized anxiety, panic disorder, and post-traumatic stress disorder (PTSD). Each protocol tells the therapist just what to do for a typical patient on a session by session basis.

Using protocols isn't very creative, but it has advantages. Every protocol has been rigorously tested in clinical trials, just like the drug testing done for the FDA. When a patient comes in with a clear diagnosis and a typical set of problems, we can tell them how long therapy will last and what percentage of patients benefit from it. When someone comes into my office with a case of panic disorder with agoraphobia, for example, I usually know that they have a better than 75% of getting better in 20 weeks of treatment.

Of course, people are individuals. Even when they come in with the same diagnosis, patients can come in with widely varying symptoms. Their family and work situations are different. They also vary in their ability to work on problems and their preferences for how to work on them. The art of therapy, for a short-term, cognitive behavioral therapist, lies in tailoring a general purpose protocol into the treatment for a specific patient. When this is done well, treatment is even more effective than the figures given in clinical studies.

Many patients decide to go on past the point where they can function again. They want to deal with the underlying causes and all the more subtle forms of distress they may feel. I think this is a great idea. Our strategy is to first deal with the symptoms, get them back on their feet, and then work on the causes.

To work on underlying causes, I use a combination of Beck's cognitive therapy and Young's schema therapy. Both are based on a learning theory model. People are presumed to have come by their problems through exposure to difficult situations they've been exposed to, mainly in childhood. We learn from these situations, forming ideas about ourselves and others. Unfortunately, we form them with all the experience and wisdom of children, and we usually don't correct them as adults. Therapy is based on changing maladaptive core beliefs and emotional reactions.

Schema therapy is an effective way to help people change patterns of thinking, emotional reactions, and behavioral patterns that have been present throughout adult life. Obviously, it takes longer than just getting rid of major symptoms. Therapy for some people lasts as long as two years. Still, this is short-term compared to most other forms of psychotherapy.

What makes short-term therapy effective?

Over the years, I've thought a lot about the work I do: which things make a real difference, and which ones just aren't as important. I've come to believe that three factors are really significant in keeping therapy short-term and making it effective.

The active therapist's role
When I was in school, therapists in training were often told: "You never want to work harder than your patient." Over time, I've come to look at that as hogwash. As the therapist in a session, I'm paid to take responsibility for what happens. I have the skills, expertise, and the insight into what gets results. Patients need to work hard, but I have to work harder and smarter.

You may be used to the kind of therapy where the therapist mainly listens and says little. I'm not like that. My role as an active therapist is something like the role of a coach to an athlete. I actively point out where the errors are and how to correct them. This leads into the second factor.

Making every session count
My sessions start before a patient ever walks in. I start each day by reviewing notes and making plans. By the time you actually see me, I've set specific goals for the session. I also know the activities I intend to use to achieve those goals. My work continues when you've left the room. I analyze each session and make extensive notes on what we did and what needs to be done next.

Of course, this doesn't mean that my plans are rigid. Sometimes they have to be set aside while we deal with whatever has occurred in the past week. I ask my patients to come in with an agenda based on what they feel they need to get out of that session. Together we decide how to make each session important.

Homework
At the end of each therapy session, I work with my patient to come up with a homework plan. My hour with a patient has little effect unless they put new skills and insights into action.

Homework can include things like relaxation and breathing exercises, engaging in activities or situations that stretch the patient's abilities, or just practicing thinking about something in a new way. Using the sports coach analogy: I can tell you what's wrong with your golf swing and how to improve it, but you have to do the hard work of practicing.

I like to give patients three to six hours of homework a week. I also realize that most people have a hard time fitting homework into their schedules. Developing a homework plan with each patient allows us to be realistic in terms of their ability to work.

If you're in therapy to deal with a serious problem, you deserve the greatest possible bang for your buck. Doing your homework is like getting several therapy sessions each week instead of just one.

The harder a patient works, the faster they improve.