Salyer, K., 2002. Time Limited Therapy: A Necessary Evil in the Managed Care Era?. Reformulation, Autumn, pp.9-11.
Kathleen Salyer PhD
HMO is an abbreviation for "Health Maintenance Organization" which, in brief, stands for the system of health care most widely available here in the US. It is operated by Big Business with its primary objective being to bring in mega bucks. It does so by restricting the services provided to its members and by finding as many ways as possible to avoid paying providers for services rendered that were previously authorized by HMO representatives.
This includes using stall tactics when it comes to paying providers, requiring huge amounts of paperwork from network providers and then requiring providers to fill out three to five pages of clinical busywork for every three to five sessions. Claims must also be returned within short time periods. Needless to say provides are overworked, patients often don't get services they need and HMO's are quite unpopular here ... except with the HMO executives and their lawyers (all of whom make the mega dollars) and the politicians whose pockets are lined with money by the HMO's!
Unfortunately, because of this many mental health professionals associate short-term therapy and time-limited therapy with HMO's because they limit the number of sessions patients can see their therapists. Hence my article is a revisiting of this negative perception of short-term/time-limited therapy.
In this age of managed care, time-limited therapy has become associated by some with greedy business practices, to be resorted to out of necessity when needing to comply with profit driven HMO's, rather than having merit in its own right. Yet time-limited therapy (i.e. therapy with a pre-established time frame) has been around long before managed care came on the scene. It may come as a surprise to some that the roots of brief therapies are firmly planted in the early years of the psychoanalytic movement. Sigmund Freud conducted brief therapies ranging anywhere from 1 session to 6 months in duration. In fact, he expressed dismay at the extended time treatment began to take following the introduction of free association into psychoanalytic treatment.
Noteworthy, two of Freud's short-term cases were of famous musical conductors; Gustav Mahler, who was treated for impotence during a four hour walk down city streets (and long before confidentiality became an appropriate concern!), and Bruno Walter, who reported having had a successful treatment for inability to compose music, in 6 sessions, while walking in the Alps. Perhaps we could get managed care to authorize this form of therapy?
Others who experimented with short-term therapies include Sandor Ferenczi and Otto Rank. With the introduction of free association the psychoanalytic community gradually began to extend treatment longer and longer. Short-term therapies began to die out but were briefly revived by Franz Alexander, one of the pioneers of Short-Term Dynamic Psychotherapy. In the late 1940's at the Chicago Institute of Psychoanalysis he began talking about the baffling discrepancy between the length of psychoanalytic treatment and therapeutic success. Not surprisingly, his colleagues were not impressed by his views.
Time-Limited vs Time-Unlimited - Which Is Better?
In some circles, time-unlimited or long-term therapy is seen as the treatment of choice. However, this is not necessarily the case. Outcome research on this topic is at best equivocal. Several well-planned literature reviews found "little empirical evidence of difference in overall effectiveness" between time-unlimited and time-limited therapy. Research done by Smith and colleagues (1980) led them to conclude, among other things, that the most significant gains in treatment occur during the first six to eight sessions.
Empirical data brings a new slant to the issue by showing what is actually taking place in therapy settings. One study found that the median length of treatment in all settings is between 6 and 10 sessions! Earlier studies done before 'managed care' came on the scene report similar trends. Gunderson et al (1989) indicated that between one fourth and two thirds of borderlines dropped out of treatment within six months. Somewhat similar findings were reported in a 1983 article by Stern, although he did not limit his focus to borderlines. He found that between 75% and 90% of all patients terminate before the 25th session. He concluded that, "A tremendous proportion of the psychotherapy conducted in the U.S. is what can be called 'naturally occurring brief therapy'." However, he noted that therapists often had not expected therapy would end so soon.
I think this later point is an important observation for several reasons. First, many therapists are not used to thinking in terms of short-term work. It is easy to want to believe that one is needed by the patient until they arrive at that blissful state of nirvana, wherever that might be; however, in our line of work this may reflect more on the needs of the 'therapist mother' in us than on the needs of the patient. In fact, the high frequency of early attrition from therapy may reflect that most patients want shorter-termed therapies that help them get headed in the right direction and sooner rather than later.
A second reason why the high incidence of early unplanned termination calls for thoughtful reflection is that many patients don't include the therapist in this decision-making process. Consequently, a number of important underlying issues and conflicts may go unaddressed. Patients who leave therapy in this manner may be so relieved over what they have thus far accomplished that they are unaware that they are ill-equipped to deal with issues that may resurface in their life; for example, internalized guilt and/or shame, unrecognized and intolerable anger, self-defeating behaviors. Having not recognized these issues the patient may face major disruptions in their life that might otherwise have been averted.
Benefits of Setting Goals and Time Limits Up Front
Identifying issues and conflicts, setting goals and establishing a time limit, all with the patient's participation, and doing so early on in the treatment process, can increase the likelihood that patients will remain for the duration of therapy. It also helps maintain the focus and momentum of therapy and averts the vagueness and lack of direction with which therapy is sometimes conducted.
Over lunch one day, Morris Parloff, former Chief, Psychosocial Treatments Research Branch at NIMH, highlighted some of the perplexities associated with time-limited therapy, as it is sometimes conducted. He began by likening it to hiring an architect to build a house and in the process inquiring as to how long the project will take. The architect responds "Well, that all depends. There are many things we will need to consider before I can answer that question". You then ask "Will there be windows? I like to look out windows" and the architect replies "We'll have to determine that as we go along". With greater urgency you then inquire "Well, how about the roof? This is a very important part of the house I had in mind" and the answer is "Yes, I agree that's important but we'll need time to see if there are enough materials for that". Although scenarios don't always produce perfect analogies, this little vignette highlights the value of clearly defining issues and conflicts and of identifying goals to enhance motivation and shorten the time needed to complete therapy.
Duration of Therapy and Time Limits
Reluctance to use time-limited therapy may be linked with realistic concerns that short-term therapy will drastically decrease ones caseload. Although altruistic goals of helping others are an important part of our work, it is also our form of earning a livelihood. This concern cannot be overlooked for long without creating countertransference issues. Thus, I found it encouraging that the literature suggests that patients tend to stay in time-limited therapy longer than when therapy has no time limits! This is also consistent with my clinical experience.
In the light of these findings, it would seem appropriate to endeavor to help patients address their problems without taking up a major portion of their life (this would seem even more so with children) and draining them or their parents of their financial resources in the process. In fact, one could argue that it is our ethical obligation to do so. Along this line, Freud is quoted as saying "treatments often reach a point where the patient's will to be cured is outweighed by his wish to be treated". He stressed the importance of keeping it always before the patient that therapy should be completed as soon as possible.
The literature on short-term therapy presents an interesting array of time-limited therapy models. However, the intention of this discussion is not to enumerate on these models but rather to focus on the benefits of time-limited therapy, irrespective of ones theoretical perspective. An additional purpose is to outline several strategies that have been effectively used when introducing this approach to patients.
Introducing Time Limits to Patients
The notion of a time limit can be introduced to the patient by indicating that somewhere between session 8 and 10, "when both of us know a bit more about each other, we can review what we have accomplished and determine what's left to be done". One can then add "and at that time we can decide how many more sessions to plan on". It has been my experience that patients express relief that I am not expecting therapy to go on forever. With neurotics and 'normals'*, 16 or fewer sessions may be sufficient. Setting the review at around the 8th to 10th session gives the clinician the opportunity to assess clinical and financial concerns and gives the patient the opportunity to evaluate what they have accomplished and what they have left to do. It also helps prevent the tendency of some patients to leave therapy prematurely because they don't realize that more work is left to be done.
The Termination Process
Due to the brevity of time-limited therapy, termination does not require as lengthy a period of preparation as is typically a part of long term therapy and it is not expected to generate the intensity of feelings that are likely to arise in time-unlimited therapy. However, that does not mean that issues around termination are not present. The matter has been on the table throughout therapy and needs to be addressed whenever the patient brings it up. Many dynamic time-limited models view termination as a process or stage of therapy that should become an active part of the dialogue at least three sessions before the last appointment.
Endings are a part of life for all of us. The therapist may want to carefully think through countertransference issues that could influence their personal desire to delay or hasten the "saying goodbye" process. Acknowledging the complexity of feelings this process generates in the patient, the longing to remain and the desire for independence, attempts at avoidance or denial, feelings of anger, etc., all need to be watched for, listened to, working through and honored, not just as they pertain to the therapy dyad but to the many endings the patient has experienced and will continue to face.
Follow Up Sessions
Following termination follow-up sessions at less frequent intervals (graduating from every other week to monthly for several months) can be offered if warranted and allows the patient time to try out their newly acquired learning while keeping a foot in the door. This also gives the therapist opportunity to evaluate whether the patient is maintaining their gains and following through on goals they agreed to pursue on their own. During this time, if the patient appears to need further therapy the initial plan can be revised and the patient returned to weekly sessions; however, this option is not discussed with the patient prior to this time and, historically, has rarely been found necessary. Another option is that patients may be referred to a therapy group in the event their current issues might better be served through this modality.
*Research on several short-term therapy approaches for treating borderlines, Cognitive Analytic Therapy and a psychodynamic short term therapy model, have reported promising results but will not be included in this discussion due to space limitations.
The material for this paper was drawn from "Models of Brief Psychodynamic Therapy. A Comparative Approach" by Stanley B. Messer & C.Seth Warren, Guilford Press, New York,1995 and "Cognitive Analytic Therapy and Borderline Personality Disorder. The Model and the Method" by Anthony Ryle, John Wiley, New York, 1997.
This article appeared in the Newsletter of the Northern Virginia Society of Clinical Psychologists, Spring, 2001, and was reprinted in the Psychogram, Summer, 2001, Newsletter of the Virginia Academy of Clinical Psychologists.
Kathleen Salyer PhD
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