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Treatments & Interventions

by Simon H Budman and Alan S Gurman
Guilford Press, 1988
Review by Roy Sugarman, Ph.D. on Sep 9th 2004

Theory and Practice of Brief Therapy

To suggest that this book might have had problems in selling since 1988 when it was published, is probably reasonable, given a brief look at the chapter titles.  They are:

Ch 1: The practice of brief therapy

Ch 2: Initiating brief therapy

Ch 3 Common foci in brief therapy and some basic assumptions

Ch 4: Losses

Ch 5: Developmental Dysynchrony (your spell check will find this one)

Ch 6: Marital and Family Conflicts: early treatment issues and assessment

Ch 7: The brief therapy of marital and family conflicts

Ch 8: Symptomatic presentations: the uses of clinical hypnosis

Ch 9: Treating personality disorders

Ch 10: Time limited group therapy

Ch 11; Time and termination

Ch 12: A case transcript

None of this is likely to get a potential buyer to pay out the $27 at Amazon might want more than this grouping of chapters to entice them.  Freud after all did his initial therapies over very short spaces in time, Sandor Ferenczi took him six weeks, but others, towards the end of his life, took longer (page 1).  It all depends on the goals of therapy.

Today we would easily accept periods of 8-12 sessions, goal directed and client focused, with the therapist dictating approaches from a manual, and with the evidence base suggesting that all can be dealt with, therapeutic goal by therapeutic goal, in a handful of weeks or months.  Most of the lay public would see a long series of meetings over months and years as probable, but most professionals today would see Motivational Interviewing, done with in a matter of hours, as more feasible, affordable and effective.

Brief interventions are now acceptable for even such albatrosses as alcohol addiction with family and other therapies increasing used and brief. Gurman quotes his studies as showing that less than 20 sessions was accompanying effective outcomes, by default, not by design.

Length, after WWII was increasing not seen as 'strength', or in our terms, necessarily indicative of the 'depth' of therapy, as many had found themselves intervening briefly in wartime for battle fatigue and stress.  By design, such as those from Butcher and Koss (names seen in the MMPI-2), showed no differences in the measures of effectiveness used between time limited and time unlimited therapies.  The difference is asserted by the authors here to be in the planned, focused use of time in psychotherapy.  The goals are different, and they contrast the long-term desire to change basic behavior to the short-term pragmatic, parsimonious intervention that will do the trick. Here, psychological change is seen as inevitable, strengths and resources are emphasized, accepts the ripple effect of perturbation, with change antedating the interventions into the future, and values the world experience over the therapeutic.  So the therapist values the least costly, the least radical intervention, a prompting to change rather than an endless journey with the therapist.  Cure is thus inconceivable as we are at core designed to experience anxiety and fear as protective mechanisms.  Humans are seen as never static, and always in flux. Orientation is thus to health and wellness, not illness and cure.  It is clear that 16 years later we are still struggling with these models, and consumers (or rather 'users') of our services, are less than happy with our viewpoints on who is what and why and what helps and how.

Further exposure to therapy in the media and elsewhere has also come a long way, and hence preconceptions and suppositions around what we do as professionals are also likely to play their part in the interface.  This interface is then negotiated with by the provision of homework tasks for the real world outside therapy, involvement of others in the therapy, use of groups or resources outside of therapy, inextricable links between evaluation and treatment, greater flexibility of interventions and time, as well as planned follow up of outcomes.  All of this revolves around the idea of an interpersonal-developmental-existential (IDE) domain as focus, and many of the names I studied to get my degree are mentioned here, Watzlawick, Fisch, Segal, Steve De Shazer, Yalom, McGoldrick, Carol Gilligan, Milton Erickson, Jay Haley, Prochaska and DiClemente, all targeting the IDE developmental line.  In essence, this is again a forerunner of the biopsychosocial approach, Why this client?…..Why these symptoms?…..Why now?  In this way, therapists exploring the IDE continuum of developmental lifespan issues are concerned with the context of losses, developmental dysynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders.  People therefore seek therapy at a time when there is a particular conjunction of IDE events or issues. The IDE approach thus allows for focus and clarification, as the symptomatic presentation may obscure the issues underlying the presentation.

I use my own example here: A couple approach for marital therapy, and argue endlessly in the first session.  I prescribe to them that they should go to the newsagent and buy the cheapest book on sale irrespective of what the title or content is.  They are to take the book home, and then flip a coin.  The winner gets to sit in the bath with the loser that night, reading aloud the first two pages of the book, ripping it out, and then dictating to the other, the deep hidden message this has for their relationship.  They then carry the pages around with them for the rest of the week and when they think of the other person, they can then ponder on what transpired around the pages now in their possession, and reflect on the hidden message.

After buying Henry the Hippo, my couple return a week later.  They have discovered that any issue between them follows a prescribed path: she attacks him on one level, he replies on another, and different level of abstraction and vice versa, hence they are never able to resolve any issues.  They each have resolved to stay with the level of attack from the other, and they find they resolved all arguments without me.  Therapy terminated.  Henry the Hippo of course forced them into a neutral argument devoid of their normal context, and the IDE issues came together in a neutral debate, allowing them some vision or meta-perspective on losses, developmental dysynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders

In chapter three, the five frequent or common foci mentioned above (losses, developmental dysynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders) are discussed in more detail.  Particular note is made here of the complications of substance abuse, which will then take precedence over all the other treatment foci.  The decision tree thus runs Why now: is this visit related to any of the following, loss, DD or IP? If not, then symptoms are focused on, and if not successful, one moves on to character, again with the caveat that substance abuse must be addressed before or currently with any of the above.

In these contexts, basic assumptions are clearly evident.  The authors assume the patient has been subjected to faulty learning at some point early on in life, and in a systemic way, the patient and his or her environment are in constant interaction with the context and environment of the problem formulation, and this interaction is reciprocal.  This environmental interaction can be buffering or perhaps exacerbate the problem, and although personality, character, social supports etc. play an important part in contributing to an individual's life pattern, chance factors and encounters are also seen as contributory in shaping the life course as opposed to the things psychologists usually regard as deterministically active, such as the self, or object relations with significant others only, with reference to Bandura and others.

The next chapter, on Losses, calls on attachment theory (see the review of Treating Attachment Disorders in Metapsychology August 2004) in order to illustrate both interpersonal and existential losses.  There is a closer look here at brief therapy approaches to I-P and existential loss, with the overall goal to transform the patient from victim to survivor.  Special attention is giving to regrieving, using photos, films, diaries and tapes, as the strategic therapists or brief directive therapists would do, finally drawing on Kushner's 1981 work, when bad things happen to those of us considered unworthy of such suffering (see page 95-96) avoiding the hostile or the rescue the victim response.

Chapter five concentrates on developmental dysynchrony, a feeling of being "off-time" with a sense of "dis-ease".  This would include leaving home therapies, not having found a partner in the expected age zone, aging without having had kids, losing a partner to death early on, aging with a feeling of lack of closure on career or marriage, or finding oneself aging whilst children still are dependant.  Again, the brief therapy is described.  Typical skills involve complex reframes and advanced accurate empathy being used to define and specify the 'dd' here, with some focus on the narrative.  A combination approach, a) to achieve goals or b) to adjust to limitations is also described.  The chapter is helpful in that it tries to protect therapists from fundamental attribution errors, and steer us towards seeing the problem as developmental.

Chapters 6 and 7 are more extensive, as the idea of therapeutic neutrality and the formation of coalitions is vital to the treatment of family and marital issues, and Ch 7 is devoted to the brief therapy of marital and family conflict, and the concept of reframing the therapeutic 'crisis' in change. Stage theory, in other words managing divorce in stages, is part of this pursuit. 

Chapter 8 discusses hypnosis in the context of symptomatic presentations and conducts a nice historical look at hypnosis and the state/trait dilemma with its strategic components.  Smoking, obesity, anxiety, and pain, all receive special attention.

Chapter 9 deals with personality disorders, and again the design is developmental rather than attributional, designed to help the patient experience and realize patterns of interaction, conceive of the possibility of other modes of interaction, and enable the testing of these.  Corrective emotional experience (somewhat akin to Linehan's 'wise mind') and the intervention sequence are the focus here, with disconfirmation of the expected response from the therapist.  The focus narrows somewhat mid chapter to specify specific approaches to specific clusters of disorder, and refers to interminable brief therapy as a concept.

Chapter 10 shifts to time limited groups, as opposed to individuals, around core competencies such as establishing and maintaining a focus in the group, preparing and screening for the group, maintaining group cohesion, and dealing with the existential and time factors that create problems in the group setting. Several tables with examples of disruptive behaviors are useful here.

An issue of time and termination take up chapter 11, and 12 is an extended case study.

Anyone who was trained in the mid to late 80's will recognize many of the words, phrases, and authors referred to in this book, reminiscent of the era.  Psychodynamic theories were being challenged, pathology was moving out of the intra-psyche and into general systems theory applications and the neo-biological determinism of the partly open, partly closed biological systems of Maturana and Varella. Margaret Mead and Gregory Bateson were divorced, Bateson's daughter struggling on, and the Milan School was breaking up or using psychotropic medication.

This book has dated well however.  The mix of pragmatics and aesthetics that warmed Paul Dell's heart, the provision of an alternate epistemology and ontology, the advent of heuristically useful devices, all impacted on freeing the client and their family from blame, and allowed the interaction to become systemic rather than linear, all live on and return to many of the modern books I have recently reviewed.  Mainstream psychiatry is moving to a biopsychosocial model, neuropsychiatry has an evolving ecosystemic view of the chemistry of the brain as an emerging neuro-epistemology, and one is falling through the roof of a second order neuro-epistemology to land in a changing and complex ontology, to paraphrase Dell.

So this 1988 work still allows us a pragmatic view, a method of delivering brief, and certainly directive therapies in many settings, and Milton Erickson's tomato plant-style of delivering metaphor is still valuable in maintaining the therapist's freedom.

The book could do with an update and a new foreword, and some bits are looking cranky, but not nearly as much as the Haley-Watzlawick-Milan school texts do, and I enjoyed the refresher course in this style of doing the work of psychotherapy.  It's worth the $27, and there are cheaper, second hand versions in both hard and soft cover available too.

 

© 2004 Roy Sugarman

 

Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.