Brief Psychotherapies Research Paper

Patients typically have opted for, or been offered, brief therapy but without the planfulness and focus of current models. Based on data from a large variety of settings where time-unlimited as well as time-limited therapy are practiced, Phillips (1985) concluded that the modal number of therapy sessions is one, the median, three to five, and the mean, five to eight. More recently, the National Medical Expenditures Survey sampled 1,000 individuals about their use of psychotherapy (Olfson & Pincus, 1994). Thirty-four percent had 1–2 visits; 37% had 3–10; 13% had 11–20; and only 16% had over 20 visits. Stated differently, about 90% had fewer than 25 sessions, the usual cut-off point for labeling a therapy as brief. What distinguishes the current scene in terms of usage of brief therapy is that it is now more likely to be structured and planned. Factors such as formulating and working within a therapeutic focus, setting goals, having a known time limit, and increased therapist activity all have the potential to bring about change in a timely way. Before examining how the different brief therapies achieve that aim, we will present some of the main findings of research on the outcome of brief therapy.

Empirical Studies of Brief Therapy

These studies include dose-effect relationships, a consumer survey, and meta-analyses comparing the relative value of different therapies. Process and outcome studies of each form of brief therapy can be found in the following sections.

Dose-Effect Analysis

Howard, Kopta, Krause, and Orlinsky (1986) studied the relationship between dose (number of sessions) of therapy (largely open-ended) and the percentage of patients improved. They found that by 13 sessions 55–60% of patients had improved, as was true for 75% by 26 sessions. Figures differed according to diagnostic group, with borderline patients making gains more slowly. Their review of the literature yielded an even lower estimate of eight sessions for 50% improvement, but the same figure of 26 sessions for 75% improvement. Except for the 8-session finding, subsequent studies have tended to support these figures. For example, Kadera, Lambert, and Andrews (1996), employing the more stringent criterion of clinically significant change, found that 50% of patients had improved by 16 sessions, and 75% by 25 sessions. Similar to Howard et al.’s findings, Anderson and Lambert (2001) reported that 13 sessions were necessary before 50% of outpatients attained clinically significant change. Again, 25 sessions were required for 75% of patients to show such improvement.

In sum, it probably takes between 8 and 16 sessions for 50% of patients to improve and about 25 sessions for 75% of patients to show significant gains. It should be noted that change in these studies usually refers to symptom improvement or to feeling and functioning better, but does not include other kinds of outcomes measures valued in particular by experiential and psychodynamic therapists (e.g., Messer, 2001a).

Survey of Consumer Satisfaction

An examination in a Consumer Reports survey of clientreported outcomes shows that the degree of felt improvement and satisfaction rises rapidly until 3–6 months of therapy have been experienced (Seligman, 1995). It then increases rather slowly until 2 years or more have passed, at which point it takes a further jump. The 3–6 month period would cover 12–25 sessions—the same as the figures for 50% to 75% improvement according to most of the dose-effect studies. It seems to be the case that a considerable amount of symptomatic and global change takes place within 12–25 sessions, with further improvement occurring slowly with more sessions.

Meta-Analysis

In the meta-analysis carried out by Wampold et al. (1997), bona fide treatments—the great majority of them shortterm—were compared. By bona fide the authors meant therapies that were delivered by trained therapists, about which there existed professional books or manuals, and that were tailored to the individual patient. They found that the therapies were not differentially effective. In general, this conclusion has been supported in meta-analyses but not necessarily in individual studies or meta-analyses employing specific diagnostic conditions (e.g., Dobson, 1989).

There seems to be a consensus that brief therapy is probably unsuitable for patients with more severe disturbances, including some of the personality disorders. In particular, borderline and avoidant personality disorders need more sessions to improve than the usual limits (25 sessions) of brief therapy (e. g., Barber, Morse, Krakauer, Chittams, & CritsChristoph, 1997). On the other hand, obsessive-compulsive personality disorder (Barber et al.), and an undifferentiated group of the milder personality disorders, known as Cluster C (Winston et al., 1994), have been found to be responsive to brief-therapy approaches.

Six Forms of Brief Therapy

This research paper describes six brief therapies, each stemming from a different theoretical tradition. Even if clinicians incorporate or assimilate techniques or perspectives from other models (Jensen, Bergin, & Greaves, 1990; Messer, 2001b), they continue to ground their therapeutic work in a particular theory. The six theories presented here include some of the most widely employed in the field of psychotherapy: psychodynamic, behavioral, couples and family systems, experiential, strategic, and integrative. All have well-worked-out brief forms of their traditional therapeutic outlooks, or are largely synonymous with brief therapy (e.g., strategic and family therapy).

In the case of three of these therapies—behavioral, systems, and strategic—the very way in which they were developed and are practiced predisposes them to be short term. That is, insofar as any therapy is symptom oriented or problem focused, it is more likely to be brief. On the other hand, therapies that developed as open-ended ventures, often emphasizing personality issues over symptoms per se, have made accommodations to a short-term format. These include the psychodynamic, experiential, and some varieties of integrative therapy.

The outline for the six sections typically included the following topics: (a) a brief historical introduction, (b) selection criteria, including diagnoses or problems treated, (c) techniques of the therapy, (d) the theory of change, (e) research supporting the approach, and (f) future directions. We start with the oldest of the therapeutic traditions—psychoanalytically based therapy.

Brief Psychodynamic Therapy

Introduction

Brief psychodynamic therapy (BPT) applies the principles of psychoanalytic theory and therapy to the treatment of selected disorders within a time frame of roughly 10 to 25 sessions. A time limit is usually determined at the outset of therapy, and sets in motion psychological expectancies regarding when change is likely to occur. In this way, BPT takes advantage of Parkinson’s law that completion of a task is a function of the time allotted to it. BPT employs major concepts of psychoanalytic theory to understand clients, including the enduring importance and impact of psychosexual, psychosocial, and object relational stages of development; the existence of unconscious cognitive, emotional, and motivational processes; and the reenactment in the client’s relationship to the therapist of emotion-laden issues from the past.

Principal techniques include reflection, clarification, interpretation, and in some models, confrontation of maladaptive interpersonal patterns, impulses, conflicts, and defenses along the axes of the triangle of insight. The latter refers to the threefold interpersonal context of (a) important current people in the client’s life; (b) the transference, or perceived relationship to the therapist; and (c) childhood relationships, typically with parents and siblings. Links are made connecting various combinations of such past, present, and transferential relationships. In addition to its aim of enhancing insight, the therapy provides a corrective emotional experience in which old and current traumas, shameful secrets, and other warded-off feelings and memories are brought to light in the benign presence of the therapist. In the broadest sense it is the therapist’s creation of a caring, empathically attuned relationship that allows therapy to bring about insight, healing, and growth in a suitably selected client.

BPTtypically involves more active dialogue and challenge than long-term psychoanalytic therapy. There is an early formulation of a therapeutic focus that is expressed in psychodynamic terms such as core intrapsychic conflicts, maladaptive interpersonal patterns, or chronically endured psychic pain. Special attention is given to feelings that arise around termination, such as sadness, guilt, anxiety, and anger. Goals are set that are potentially achievable and might include conflict resolution, a changed interpersonal pattern, greater access to feelings, and more freedom of choice, as well as symptom remission. For a historical overview of the roots of BPT, see Borden (1999) and Messer and Warren (1995).

Selection Criteria

In general, brief dynamic therapists rule out those patients whose severity of disturbance precludes their ability to engage in an insight-oriented therapy, or who need more time to work through their problems. Although it is difficult to generalize because the different models set narrower or wider criteria, the following sections describe the general indicators in favor of and against recommending BPT.

Diagnostic Contraindications

These include serious suicide attempts or potential; current alcohol or other drug addiction; major depression; poor impulse control; incapacitating, chronic obsessional or phobic symptoms; some psychosomatic conditions, such as ulcerative colitis; and poor reality testing. With reference to the Diagnostic and Statistical Manual of Mental Disorders (DSM), this would encompass major depressive disorder, schizophrenia, sociopathy, paranoia, and substance abuse, as well as the more severe personality disorders such as the borderline and narcissistic. Although the latter two syndromes can be treated with BPT, they require modifications in focus, technique, and goals that have been discussed at length elsewhere along with the treatment of other difficult patients (Messer & Warren, 1995). Examples of what such patients may require are a more adaptive, here-and-now focus; auxiliary modalities such as group therapy or family sessions; medication; and a more flexible approach to termination, such as the gradual tapering off of therapy.

Diagnostic Indications

In terms of DSM, these include the adjustment disorders; the milder personality disorders such as avoidant, dependent, and obsessive-compulsive; and the less severe anxiety and depressive disorders.

Psychotherapy Process Indications

Many of the diagnostic criteria stated previously are descriptive or static, based largely on the patient’s history garnered from the initial interviews. Some BPT therapists such as Malan, Davanloo, and Sifneos (Davanloo, 1980), however, also stress a patient’s response to the active, frequently confrontational techniques of their approach. Davanloo in particular refers to the importance of making trial interpretations in the initial interviews and noting whether the patient responds with deepened involvement versus some form of decompensation. If the latter occurred, he would consider the patient unsuitable for his form of brief therapy.

Interpersonal or Motivational Indications

In a group of brief dynamic therapies referred to as relational, the criteria are expressed in interpersonal terms that are also best assessed from within the therapeutic situation. For example, Strupp and Binder (1984, pp. 57–58) list the characteristics they associate with a successful brief treatment as follows: The patient is sufficiently uncomfortable with his or her feelings or behavior to seek help via psychotherapy; has basic trust in the possibility of relief from distress through the therapist-patient relationship; is willing to consider conflicts in interpersonal terms and to examine feelings; can relate to others as separate individuals; allows his or her relationship predispositions to be played out in the therapy relationship and collaboratively examined; and is motivated, as determined by the extent of the previously listed characteristics.

For research findings on selection criteria for BPT, see Messer (2001c).

Techniques of Therapy

All approaches to BPT rely on a number of common technical characteristics, including (a) an individualized central clinical focus, (b) a time limit, (c) a relative emphasis on the termination stage of treatment, (d) active techniques to accomplish therapeutic goals within the time limits, and (e) goals.

Use of a Central Focus

This involves the formulation of a central clinical theme developed in the early sessions that serves to organize clinical observations and to guide therapist interventions. The central focus is a statement of the therapist’s understanding of the patient’s presenting problems as an expression of an underlying dynamic central issue or conflict. Such formulation seeks to incorporate as much of the current situation and relevant history as possible. This central focus may be verbalized directly to the patient as a form of a working contract or used to engage the patient in the therapy process. When this goes well one would expect the patient to feel understood and to become more motivated for further therapeutic exploration.

Although all forms of psychodynamic treatment rely on clinical formulations, in short-term therapy the central focus tends to be more circumscribed in scope, limiting the therapeuticinquirysothatclinicalgoalsmaybeachievedwithinthe time frame. In addition, the focus is generated more rapidly at the outset of treatment and is used more actively in brief therapy than in open-ended treatment.

Use of a Time Limit

All brief psychodynamic treatments operate within implicit or explicit time limits. One brief therapist, James Mann (1973, 1991), makes the time limit a central theoretical and clinical construct, organizing his approach to brief therapy around the effects on the clinical process of a fixed number of sessions. He advocates the use of a 12-session time limit with a clear termination date that the therapist sets by the first or second session. Mann relies on the universality and poignancy of the experience of loss and on its impact at termination to make the time limit a central technical feature of his brief treatment. The patient’s ambivalent responses to the issues of loss and separation are utilized therapeutically throughout the treatment, but especially at termination.

In models of BPT in which time limits are not made explicit, it is still utilized by the therapist to organize therapeutic activities and aims. In all psychodynamic approaches to brief treatment the time limit is understood to accelerate the process of psychotherapy by increasing the sense of urgency and immediacy and the emotional presence of the patient. Undoubtedly, the time limit influences the therapist as much as it does the patient, increasing, for example, therapist activity.

Role of Termination

Termination is considered to be the phase of treatment in which the clinical gains of therapy thus far can be consolidated, and in which the issues of loss, separation, and individuation can be addressed directly within the here-and-now context of the ending of treatment. It is given a heightened importance in brief psychotherapy. Since the time limit is present from the beginning, the process of termination is activated at the start of the treatment. Resistances to termination can appear early in brief therapy, and are addressed throughout treatment. The brevity of treatment means that the pain of separating cannot be postponed to an indistinct and distant time and place, as is true of long-term therapy.

Active Inquiry

The notion of active technique (Ferenczi, 1920/1950) can be contrasted to the traditionally lesser role of therapist activity in long-term psychoanalytic therapy. It refers to any of a variety of techniques aimed at accelerating the therapeutic process to make it possible to accomplish goals of psychodynamic importance in the more limited time frame of brief therapy. These have typically involved the use of time limits as already mentioned, direct suggestions (Ferenczi), the active confrontation and interpretation of defenses and resistances (Davanloo, 1980; Sifneos, 1972), and early and active interpretation of transference (Davanloo; Malan, 1976).

The use of confrontation and active interpretation of resistances and defenses is especially characteristic of the approaches of Malan, Davanloo, and Sifneos, and is intended to accelerate the emergence of unconscious conflicts, permitting their more rapid resolution. Advocates of such techniques tend to point out relentlessly to the patient where he or she is avoiding feelings, leaving out significant information, or being vague. Defenses may be interpreted in rapid-fire succession, with the therapist in persistent pursuit of the patient’s authentic emotional experience. Such persistence is justified on the basis of the unconscious relief patients are said to feel when forced to recognize emotional truths—often unacceptable sexual or aggressive feelings—they have avoided and defended against. Breakthroughs are followed by the emergence of significant new clinical material, and the cycle of resistance, interpretation, and breakthrough is continuously repeated.

Other brief psychodynamic therapists in the more relational tradition (e.g., Book, 1998; Levenson, 1995; Luborsky, 1984) are less inclined to use confrontational techniques, but instead follow more in the tradition of conducting a detailed inquiry. This form of activity refers to a persistent curiosity on the part of the therapist that takes the form of ongoing clarification, questioning, seeking after more detail, and pointing out gaps or inconsistencies in the patient’s narrative.These brief therapists also actively use their awareness of developing and ongoing interpersonal patterns in the patient-therapist relationship, and come to focus on these as a major source of clinical information. Such interpersonal transactions are thought to be indicative of enduring relationship patterns, and their active identification and clarification forms the basis of more relationally oriented brief-therapy technique.

The following clinical vignette illustrates the here-andnow focus on patient-therapist transactions. The therapist uses his own experience in the context of active transference interpretation linking past relationship patterns to the current therapeutic relationship.

T: Each time I notice and comment that you are looking attractive or that you’re doing well in your work you get tearful and cry.

P: (crying) I feel I am not attractive. I feel I will be rejected. Father could never stand it. I won a ribbon in a race and he only could say the competition was not too great. Dad did the same restricting with Mother. She even had to limit her vocabulary for him.

T: I see, so you feel you have some well established old reasons for feeling that way with me. (Luborsky, 1984, p. 96)

Goal Setting

Goal setting is linked to the use of a central focus, as well as to the time limit and the centrality of termination. It reflects the therapist’s acceptance of limitations on what can be accomplished, and embodies an individualized approach to the aims of psychotherapy. It also requires assessing therapy outcome in an individualized and dynamically informed fashion. Although not necessarily a formal feature of all brief dynamic psychotherapies, the use of goal setting is at least implied. On the one hand, the concept reflects the greater degree of problem solving and symptom focus that is characteristic of time-limited treatments. On the other, it also includes psychoanalytically informed ideas about emotional health such as insight into personal conflicts, emotional maturity, and capacity for intimacy in relationships, as well as a lessening of anxiety and depression. Such goals are set with an individual patient in mind and directed at those problems that are of immediate concern.

Theory of Change

For the more traditional models of BPT, it is patients’ deep and emotionally meaningful realization of the impact of intrapsychic conflict on their lives that enables them to be freed from the emotional traps and pitfalls that have stymied them. In particular, these conflicts are interpreted in the context of the relationship with the therapist, which is understood in the light of the psychoanalytic concept of transference. Freud used this term originally to describe the repetition in the psychoanalytic situation of a relationship with a developmentally early, significant other, usually but not always a parent. The repetition for Freud represented the activation of early infantile sexual and aggressive impulses that had been frustrated. As the therapist articulates patterns in the current patient-therapist dyad, important clues are identified as to the patient’s central emotional conflicts. When these come to light, they can be interpreted by the therapist and taken in by the patient, enabling significant modifications in the relationships among wishes, defenses, and anxieties, and thus in the symptoms that arise from them. There is very good evidence that outcome in BPT is related to the therapist’s application of psychodynamic technique (Crits-Christoph & Connolly, 1999; Messer, 2001d).

From the viewpoint of relational theory, conflict is seen as arising in interpersonal relationships as the result of conflicting wishes in relation to others. Conflict need not be related to infantile sexual or aggressive drives as posited by Freud, but can instead include a wide range of affects, wishes, intentions, and subjectively experienced needs in relation to others (Sandler & Sandler, 1978). In addition, there tends to be more emphasis on the current maintaining factors in psychopathological transactions, with systemic notions such as cyclical and self-perpetuating dynamics, as opposed to strict causal linkages to the past (e.g., Wachtel, 1997). In this sense, psychopathology is understood to be a dynamic, self-fulfilling process in which feared and anticipated relational events tend to be enacted by individuals in their interactions with others, who will then tend to respond in complementary ways. The mechanism of change is not insight alone, but a corrective experience that takes place for the patient in the presence of a therapist who does not respond in the usual way to the patient’s interpersonal expectations. This may be why measures of the therapeutic alliance between patient and therapist turn out to be such good predictors of therapy outcome (e.g., Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Martin, Garske, & Davis, 2000).

Supporting Research

Brief psychodynamic therapy has been compared to wait-list controls and to alternative therapies; it has been studied via meta-analysis, which accumulates results from individual studies; it has been compared to long-term therapy; and it has been explored via dose-effect relationships in which number of therapy sessions is charted against the percentage of patients improved (Messer, 2001c; Messer & Warren, 1995).

As an example of a study comparing BPT to an alternative therapy, Piper, Joyce, McCallum, and Azim (1998) compared BPT to brief supportive therapy for patients with mixtures of depression, anxiety, low self-esteem, and interpersonal conflict. Both treatment groups showed significant improvement according to statistical and clinical criteria, but did not differ from each other. This finding, showing equivalence of different kinds of brief therapy, is typical when brief therapies (or longer ones) are compared via meta-analysis as well. For example, in their meta-analyses, both Crits-Christoph (1992) and Anderson and Lambert (1995) found, on average, no difference between BPT and other treatments across many studies. Both, however, found BPT to be superior to wait-list controls, which speaks to the benefits of brief dynamic therapy.

Piper, Debanne, Bienvenu, and Garant (1984) directly compared brief to longer term psychoanalytic therapy for patients suffering anxiety, depression, and mild to moderate characterological problems. BPT (about 22 sessions) was found to be as effective as and more cost-efficient than longterm therapy (about 76 sessions), and the findings held true at 6-month follow-up. To summarize, brief psychodynamic therapy is helpful to a substantial proportion of patients and its effects seem to continue beyond the termination of therapy.

Future Directions

One of the prominent current trends is the application of BPT to the personality disorders where some degree of character change is called for. This means improvement not only in symptoms or target complaints but also in chronic maladaptive patterns or personality traits. Working with this population frequently brings another current trend to the fore, namely, the integration of techniques from outside the usual domain of psychodynamic therapy. For example, McCullough Vaillant (1997), in her book Changing Character, focuses on the elicitation of affect and the use of cognition to guide affect into more adaptive channels. The defenses are confronted, but in an empathic or supportive manner. She incorporates active interventions such as systematic desensitization (behavioral), dispute of logic (cognitive), guided imagery (experiential), or linking feelings to bodily experience (Gestalt; McCullough & Andrews, 2001). Similarly, Magnavita (1997),in his psychodynamically based volume on BPT entitled Restructuring Personality Disorders, describes anxiety-dampening techniques of a cognitive or behavioral origin. These might include teaching problem-solving skills, desensitizing patients through imagery work, or teaching more adaptive methods of dealing with defenses. Given the variable results of BPT with at least some personality disorders, the themes of integration, pragmatism, and flexibility are a welcome trend.

Other special populations to which BPT is being applied are children, adolescents, and the elderly (Messer & Warren, 1995, 2001). This brings in a developmental life-span approach to brief therapy, in which normative transitions, life stages, and developmental challenges are the focus of treatment. Within a developmental perspective, the patient’s problem is defined in terms of an adaptive failure in light of situational factors and emotional crises. The goal of such an approach is to enable the patient to attain new and stable adaptive structures with a greater capacity to manage life stresses. There is less emphasis on conflict or personality structures and more on the interaction of patient and external events (Borden, 1999; Budman & Gurman, 1988; Warren & Messer, 1999). For example, the time-limited treatment setting recapitulates the central dilemmas of old age, namely, mortality and loss. This may permit a reworking of older patients’life stories to enable them to mourn, to accept what was, and to embrace their existence in a fresh way (Messer &Warren, 2001).

Cognitive Behavior Therapy

Cognitive behavior therapy (CBT) has been traditionally utilized as a short-term treatment for a wide range of emotional disorders and problems. Although CBT was not intentionally derived as a brief treatment, the nature of CBT lends itself to being relatively brief in comparison to more traditional psychotherapeutic modalities (cf. McGinn & Sanderson, 2001). Generally speaking, CBT maximizes its efficiency by utilizing manual-based empirically supported treatment strategies and defines specific, measurable, and achievable target goals. A focused assessment process and a relatively structured session format facilitate the implementation of treatment strategies and allow the therapist to make efficient use of session time. Once treatment is implemented, a periodic review of progress using objective criteria enables the therapist and client to make informed decisions about the direction of treatment. CBT utilizes strategies to enhance generalization and prevent relapse and empowers patients by providing them with skills they can use outside therapy sessions. Finally, the therapist’s active, directive stance plays a critical role in making CBT time-efficient.

Introduction

Behavior therapy, a term coined by Lazarus (1958), arose and gained prominence in the 1950s as an alternative to psychodynamic psychotherapy. In contrast to the practice of psychodynamic therapy, which relied on clinical judgment based on theory and experience, behavior therapy endeavored to apply principles of learning established in the laboratory toward the understanding and remediation of psychopathological behavior. The roots of behavior therapy may be traced as far back as the beginning of the twentieth century. Ivan Pavlov’s seminal work on classical conditioning conducted in Russia (1927) may be credited with having the most influence on behavior therapy as we understand it today. Learning theory also played a significant role in the evolution of behavior therapy. Behavior modification, a term often used interchangeably with behavior therapy, has developed from the work of B. F. Skinner (1953), emphasizing operant or instrumental conditioning.

The cognitive influence on CBT was stimulated in the 1950s by the work of Aaron T. Beck, whose general theory of emotional disorders posited that emotions are mediated by ongoing cognitive appraisals and that biases in information processing are central to understanding psychopathology. Cognitive therapy developed as a movement away from both the theoretical outlook and practical limitations of psychoanalysis and the restrictive nature of behaviorism (Dobson, 1988). In contrast to both the psychoanalytic model, which assumes that individuals are motivated by unconscious motives and impulses, and to the behavioral tradition, which assumes that individuals are controlled by external contingencies, Beck proposed that dysfunctional thoughts, which could readily be brought into conscious awareness, are responsible for emotional dysfunction.

Although a few cognitive and behavior therapists still conduct pure versions of these approaches, during the last quarter of the twentieth century, cognitive and behavioral traditions have been increasingly integrated in their treatment of emotional disorders. This marriage between cognitive and behavioral approaches has largely occurred due to their common emphasis on targeting symptoms and problems, and on their use of the experimental method to understand, remediate, and assess changes in psychopathology. Over the years, a variety of cognitive behavioral therapies have evolved and demonstrated efficacy in remediating a wide range of psychological problems.

Selection Criteria

Cognitive behavioral therapies have been utilized and shown to be effective for a wide range of psychological problems experienced by children and adults (see the Brief Overview of Research Supporting the Efficacy of CBT later in this research paper). These include almost all of the DSM Axis I disorders (e.g., major depression, substance abuse, bulimia, enuresis, hypochondriasis) as well as a variety of other problems (e.g., headaches, stress, suicidal behavior, interpersonal communication, coping with chronic illness, procrastination). Essentially, CBT offers a range of strategies that can be tailored to address a number of psychological problems and disorders that individuals may experience.

However, the bulk of controlled evidence suggests that while brief CBT is effective in treating DSM Axis I disorders (cf. Nathan & Gorman, 1997), it may not be as effective in treating Axis II personality disorders. For example, although CBT appears to be an effective treatment for borderline personality disorder, the typical treatment is quite intensive (not limited to one session per week) and occurs over several years (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Although treatment outcome data for other personality disorders are not available, innovative clinicians adapting CBT for these disorders suggest that the treatment is not brief (e.g., Young, 1999).

For the most part, the focus of treatment in CBT is the remediation or amelioration of symptoms (e.g., depression, panic attacks, negative self-image) or problems (e.g., social disconnection, lack of assertiveness, relationship distress), and on helping clients attain better functioning and quality of life. Treatment typically includes the use of strategies that focus on reducing symptoms directly (e.g., cognitive restructuring of depressive cognitions, exposure therapy for phobias) and strategies aimed at building skills (e.g., relaxation training, assertiveness training, problem solving) to increase the patient’s ability to cope with situations that are problematic for the patient and that lead to negative emotional reactions. Specific and measurable outcomes are defined at the outset of treatment and success is defined by meeting these goals (e.g., reducing panic attacks to one per month, reducing the severity of depression to a score of 10 or below on the Beck Depression Inventory, etc.).

Once the stated goals are met, CBT aims to builds skills to maintain gains and prevent relapse and develops strategies that allow patients to alleviate symptoms or problems if they recur. The therapist and patient collaborate to decide on the intervention goals in CBT (i.e., which symptoms or problems will be targeted and which intervention techniques will be used). They also decide on what degree of improvement will be judged reasonable and what yardsticks they will use to decide whether set goals have been reached (e.g., an inventory, a behavioral measure such as no phobic avoidance of elevators). Reaching a consensus at this stage ensures that patient and therapist have similar expectations about how treatment will progress and when it will be terminated.

For the most part, treatment emphasis is on the present and future rather than on early childhood or historical antecedents (e.g., the parent-child relationship). The focus of treatment is to increase the patient’s ability to function effectively within his or her current environment and on improving the client’s sense of hope about the future. CBT theory posits that, ultimately, developing adaptive cognitions and behaviors will result in the modification of maladaptive core beliefs and schemas. To accomplish this, sessions focus on building the patient’s available resources and developing new skills rather than solely providing insight into the patient’s personality in an effort to transform it.

As outlined previously, the therapeutic relationship in CBT is quite different from the ones used in more traditional forms of therapy. The therapist and patient form a collaborative team and together identify maladaptive thoughts and behaviors and develop strategies to remediate them (Beck, 1995; Beck, Rush, Shaw, & Emery, 1979). Thus, the therapist is more active and directive in CBT than in BPT. Although the relationship between the patient and therapist is seen as playing an important role in CBT and a good therapeutic relationship is associated with better outcomes (e.g., Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996), it is not considered the primary vehicle of change. Instead, the specific cognitive and behavioral strategies employed within the treatment are believed to be responsible for change.

Techniques of Therapy

CBT involves the application of specific, empirically supported strategies focused on maladaptive thinking (e.g., Beck et al., 1979) and behavior (e.g., Lewinsohn, Munoz, Youngren, & Zeiss, 1986). The techniques used for brief CBT are the same as those employed for more extensive therapy. Typically, treatment is directed at the following three domains that are present in most emotional disorders: cognition, behavior, and physiology. In the cognitive domain, patients learn to apply cognitive restructuring techniques so that negatively biased thoughts underlying negative emotional states can be modified to become more logical and adaptive, thereby leading to a less negative emotional response. Within the behavioral domain, techniques such as exposure to the feared stimulus, response prevention (e.g., stopping a maladaptive response that ultimately reinforces the problem, as when escaping from a feared stimulus), activity scheduling to increase reinforcement, skills training to remediate interpersonal deficits, contingency procedures (e.g., making reinforcement or punishment contingent on a particular response to increase or decrease its frequency), and problem solving are used to remediate behavioral deficits that contribute to and maintain negative emotional states (e.g., avoidance, escape, social withdrawal, loss of social reinforcement). Finally, within the physiological domain, patients experiencing negative affective states are taught to use imagery, meditation, and relaxation procedures to calm their bodies. It is important to note that the three domains are believed to influence each other in a reciprocal fashion. Hence, although interventions are directed at the individual domains, therapeutic effects are expected to occur in all three.

CBT attempts to empower patients and thus there is an emphasis on providing them with skills to offset their negative emotional states and dysfunctional behavior. The use of treatment strategies is not limited to the therapy session. A primary and perhaps unique goal of CBT is to facilitate the use of treatment techniques outside therapy sessions. Patients are strongly encouraged to implement specific strategies to deal with the problems experienced in their natural environments (e.g., cognitive restructuring is used to offset negative thought patterns elicited by an interpersonal conflict and thus to avoid the consequent depressive affect; breathing exercises are used at the first sign of anxiety to circumvent hyperventilation that may occur during a panic attack; exposure therapy is used when someone encounters a phobic situation).

Although the specific details of treatment vary from disorder to disorder, in general each of these strategies is used to address the specific cognitive, behavioral, and emotional psychopathology for the respective disorder or problem (cf. Persons, 1989). Depending upon the presenting problem, some of these strategies may be more appropriate than others. Based on a case conceptualization and formulation of the nature of the problem, the clinician selects relevant strategies to address the patient’s symptoms and problems. For example, the therapist may develop a case conceptualization that describes dysfunctional schemas (I’m undesirable), assumptions (If people get to know me they won’t like me), automatic thoughts (She would not go out with me if I asked her), emotions (anxiety, depression), and maladaptive behaviors (social avoidance, not revealing information about oneself in social situations). The therapist then carries out interventions such as cognitive restructuring to produce changes in these areas, and thereby in the dysfunctional emotional states. (For a full description of CBT treatment strategies as applied to a wide variety of disorders, see Clark & Fairburn, 1997).

Theory of Change

As mentioned previously, CBT utilizes strategies to change cognitions (e.g., to reduce harsh self-criticism that may lead to depression, and catastrophizing about events that may lead to anxiety) and behaviors (e.g., to decrease phobic avoidance; to increase assertiveness) related to the patient’s psychopathology. Although cognitive and behavioral methods are aimed at different psychopathological processes, in fact, they have an overlapping effect (i.e., cognitive methods may produce a change in behavior, and behavioral methods may produce a change in cognition). For ease of discussion, the theory of change will be presented separately for cognitive and behavioral methods.

Cognitive Model

Central to the cognitive model of emotional disorders (Beck, Emery, & Greenberg, 1985; Beck et al., 1979) is the notion that the thinking of emotionally disturbed individuals is characterized by faulty information-processing styles. In this model, affect and behavior are seen as being mediated by cognition. Thus, the focus is on understanding how patients interpret events in their lives. If maladaptive thoughts and images can be changed then the accompanying negative emotional states and behaviors will change as well. If the patient feels angry, then cognitions associated with threat should be identified and changed; if a patient feels anxious, then cognitions associated with danger should be modified; and so on. When these faulty appraisals are replaced with more adaptive perceptions, the negative emotional states decline without requiring the use of pathological coping methods such as avoidance, escape, distraction, and the like.

Behavioral Model

Learning theory (e.g., Lewinsohn et al., 1986) posits that negative emotional states frequently are a result of changes in reinforcement from environmental interactions. For example, in depression there is a loss of positive outcomes (e.g., the loss of a relationship decreases satisfying interpersonal situations) and an increase in negative outcomes (e.g., being criticized by one’s spouse). Changes in reinforcement may be a result of the unavailability of previous sources of positive outcomes (e.g., a relationship has ended, one retires from work) or the lack of skills to achieve positive outcomes (e.g., a lack of assertiveness results in continuous negative events at work, where the person is continually taken advantage of; a lack of social skills leads one to be alone frequently; one sets such high standards for performance at work that they are never met, leading to continuous dissatisfaction).

According to learning theory, the mechanism of action of cognitive behavioral treatment is a change in reinforcement, which is a result of instituting new sources of reinforcement (e.g., having an individual find a new relationship) or providing skills to allow patients to be more effective, thereby accessing positive reinforcement and feelings of mastery. At times, especially with anxiety disorders, directly altering the conditioning process is necessary. Patients suffering from anxiety typically engage in avoidance behavior of a feared stimulus. When the individual continues to avoid a phobic stimulus, this avoidance will lead to a decrease in anxiety and thereby negatively reinforce (strengthen) the avoidance behavior. In such cases, systematic exposure to feared situations is necessary to break the connection between avoidance and reduced anxiety (i.e., in exposure therapy, the anxiety is elicited but the avoidance behavior is blocked, leading to a disassociation between the two). Theories of the process of anxiety reduction from exposure emphasize both the cognitive aspects (e.g., one develops thoughts that the stimulus is no longer dangerous, and as a result, does not experience anxiety when confronted by the stimulus) and behavioral aspects (anxiety is a conditioned response that is reinforced by avoidance or escape; once the avoidanceescape is discontinued, the stimulus loses its ability to provoke anxiety).

Supporting Research

Although space does not permit a thorough review of the research literature supporting the efficacy of CBT, one can say that short-term (12–15 sessions) cognitive behavioral treatment results in substantial improvement for patients with a wide range of disorders (Clark & Fairburn, 1997; Hollon & Beck, 1994; Nathan & Gorman, 1997). Perhaps the strongest support for the efficacy of CBT comes from the American Psychological Association Division of Clinical Psychology’s Task Force on Psychological Interventions, a group whose mission has been to develop criteria to judge empirically supported psychological interventions (Chambless et al., 1998). The criteria are quite rigorous, requiring the inclusion of a comparison group such as an alternative treatment or placebo group. Cognitive behavioral treatments represent approximately 90% of empirically supported treatments identified by the task force.

Based upon the latest report, cognitive behavioral treatments have demonstrated efficacy in the treatment of panic disorder with and without agoraphobia, obsessive-compulsive disorder, social phobia, posttraumatic stress disorder, generalized anxiety disorder, specific phobia, stress and coping, depression, chronic headaches, bulimia, chronic pain, smoking cessation, enuresis, parent training for children with oppositional behavior, and marital discord. Cognitive behavior therapies have also demonstrated substantial efficacy in the treatment of substance abuse and dependence, obesity, binge eating, irritable bowel syndrome, encopresis, childhood anxiety, female hypoactive sexual desire, sex offenders, borderline personality disorder, family intervention and social adjustment in schizophrenia, and habit reversal and control. Typically, these treatments were implemented in protocols that were no longer than 15 sessions.

It is important to note that most of the efficacy studies used to determine empirically supported treatments examine outcome only at the end of treatment; thus whether these treatments have sustained effects is unclear. However, that being said, data that do exist on this topic (most extensively for treatment of depression and panic disorder) suggest that CBThas a lasting effect beyond the treatment period, and that it outperforms medication over the long run (cf. Sanderson & McGinn, 2000, on depression; Clark, 1999, on panic disorder).

Future Directions

Although the scope and efficacy of brief CBT are impressive, much work remains to be done. In particular, future efforts of CBT clinical researchers must demonstrate the effectiveness of treatment outside research centers as well as turn more attention toward disorders overlooked by CBT (e.g., personality disorders).

Critics have pointed out that although brief CBT has been demonstrated to be an effective treatment in clinical research settings, few data are available on the effectiveness of CBT whendeliveredinsettingstoadiversegroupofpatientsoutside the research clinic. Clearly, the demonstration of treatment efficacy in controlled research environments is only the first step in treatment research. Once a positive therapeutic effect has been demonstrated under such conditions, generalizability becomes of paramount importance. This problem is not unique to CBT, but applies to other empirically supported treatments, such as pharmacological approaches, and is clearly an important area in need of further investigation. While caution may be warranted until data are generated, it is reassuring to note that data are beginning to appear that support the effectiveness of brief evidence-based treatments outside controlled research environments (e.g., Sanderson, Raue, & Wetzler, 1999; Wade, Treat, & Stuart, 1998; Wilson, 1998). In addition, a recent meta-analysis of psychotherapy studies found that the effect sizes of psychotherapy in clinically representative settings is only 10% lower than those obtained in clinical research settings (Shadish, Navarro, Crits-Cristoph, & Jorm, 1997). Thus, preliminary data are suggesting that in fact, the efficacy of CBT generalize beyond clinical research centers, even when administered during a brief course of treatment.

A second future direction of CBT is to focus on disorders that, to date, have been largely overlooked by CBT—most notably personality disorders. Critics of CBT have noted that the scope of CBT may be limited to straightforward Axis I disorders, such as anxiety and depressive disorders, for which specific symptoms are clearly the target of treatment. Patients experiencing personality disorders do not always have clear symptom patterns and may not fit into the standardized treatment protocols frequently utilized in CBT. In addition, patients with long-standing characterological problems may not be responsive to brief treatment. Fortunately, work has begun in this area and clinical theorists and researchers are beginning to turn their attention to the treatment of personality disorders (e.g., Linehan, 1993; Young, 1999). While preliminary data are promising (e.g., Linehan et al., 1991), it remains to be seen whether CBT is an effective treatment for personality disorders, especially in its traditional brief format.

Brief Familyand Couple Therapy

Introduction

Although the temporal standard for the length of a great many of the individual therapies historically has been quite long term, this has never been the case for family and couple therapy (Gurman, 2001). Family therapy emerged during midcentury as a challenge to dominant psychoanalytic ideas of the times, and most influential models of family therapy have strongly emphasized clinical efficiency, parsimony, and problem-centeredness, although family therapists rarely explicitly set time limits for treatment. Likewise, contemporary marital therapy methods, almost irrespective of their theoretical orientations, overwhelmingly tend to be short term (Gurman & Fraenkel, 2002). Indeed, there has never been an enduring, influential method of long-term marital or family therapy that has served as a standard for the ideal practice of systems-oriented treatment. Overall, then, Gurman (2001) has argued that the notion of brief family and couple therapy is largely redundant.

This is not to say that brief therapy and family and couple therapy are the same. They differ in terms of their dominant views of what maintains problems and what needs to be done to resolve them. Almost all influential theories of family and couple therapy tend to be brief by prevailing standards because they emphasize the central factors, discussed shortly, that characterize the conduct of all brief therapies. Unlike most discussions of family therapy, the present one will identify the conceptual commonalities between most family and couple therapy and most brief individual therapy (cf. Donovan, 1999).

All of the controlled trials of the research that has been conducted on family and couple therapy (Pinsof & Wynne, 1995) have studied treatments that were time limited for research design purposes, so that the family and couple therapy research literature, in effect, is a literature of brief therapies. At the same time, all of these approaches and all of the family and couple therapy methods (Chambless et al., 1998) that have been empirically validated to date are decidedly brief even when practiced outside the research context. The irony in all this is that most family and couple therapy has been brief by default rather than by design. There is very clear evidence (Gurman, 2001) that most family and couple therapies inevitably tap into the major factors that tend to keep any treatment brief, although they do not necessarily do so for that explicit purpose.

Selection Criteria

Although some family and couple interventions have been designed specifically for the treatment of patients with Axis I psychiatric disorders, such as schizophrenia and bipolar disorders, in general, family and couple therapists are not very interested in psychiatric diagnosis. Likewise, most family and couple therapists do not conduct broad-scaleassessmentsatthe outset of treatment, or do extensive history taking. Still, an active psychosis, a current episode of alcohol or other substance abuse, violence, and some personality disorders may preclude family and couple therapy.

At the same time, existing research (Lebow & Gurman, 1995) makes it clear that family and couple therapy,aloneorin combination with other interventions, is indicated and is most likely the treatment of choice for the following common clinical problems: marital conflict and dissatisfaction, parent-child conflict, childhood conduct disorders, depression accompanying marital discord (especially in women), agoraphobia (especially in women), alcoholism (especially in men), adolescent drug abuse, and juvenile delinquency.

In terms of patient selection, what is generally more important than standard psychiatric diagnosis in the eyes of family and couple therapists is the problem-maintaining role of people involved in the lives of index (or so-called identified) patients. Family and couple therapists are primarily concerned with behavior that is functionally relevant to the symptoms or problems brought to their attention. That is, their primary assessment concern is to identify how problem behavior is currently reinforced. People who may be selected to be part of ongoing family therapy are those who appear to have leverage in everyday life to effect change for a given family or couple. Thus, it is not necessarily family members alone who comprise the treatment group in family therapy. Although others (e.g., treating physicians and school personnel) certainly may be appropriately included in treatment, most family and couple therapy occurs with members of the same household and extended family.

Techniques of Therapy

With well over two dozen influential methods of family and couple therapy in existence (Gurman & Jacobson, 2002; Gurman & Kniskern, 1991; Nichols & Schwartz, 1998), the variety of frequently used therapeutic techniques available is enormous. Moreover, as family and couple therapy becomes more integrative (Gurman & Fraenkel, 2002; Gurman & Jacobson), techniques are commonly borrowed from alternative treatment approaches, sometimes systematically, sometimes not.

Although some family (and especially couple) therapies emphasize the development of insight, the majority of systems-oriented treatment methods emphasize behavior change, even those that are not rooted in behavior therapy per se. In-session techniques that are action focused may include, for example, a marital therapist’s interdiction of a couple’s persistent fighting and an urging of the couple to see aspects of one another’s behavior that are (defensively) blocked from conscious awareness.Astructural family therapist may challenge the overwhelmed parents of an acting-out child to find some new, more effective, and unified strategy to assert their executive power with the child in the session. Alternatively, a family and couple therapist may try to elicit previously unexpressed feelings among family members, not for cathartic reasons, but to change the way in which they communicate with one another.

Moreover, many family and couple therapists see real value in the use of out-of-session change-inducing experiences. The types of planned homework used in family and couple therapy vary considerably. Some, such as those used typically by behavior therapists and structural therapists, focus on very specific directives for behavior change, the results of which are explicitly followed up at subsequent sessions. Other family and couple therapists, such as those with psychodynamic or humanistic orientations, might be more inclined merely to suggest that their patients reflect on certain issues outside the sessions.

Family and couple therapists also commonly emphasize the use of techniques that are intended to change meaning and attribution in the present and in reference to the present (where the consequences of the past are to be found), although the techniques are not usually those rooted in cognitive therapy strategies per se. Such cognitively oriented techniques can take on many forms. For example, a therapist might attempt to externalize the behavior of a particular family member by examining how that person learned this typical behavior as a means of self-protection in the family of origin. This perspective would tend to lessen other family members’ tendencies to see the undesired behavior as motivated by malevolence or a lack of caring. Alternatively, the therapist might attempt to shift the meaning attributed to a particular behavior pattern by positively reframing the behavior as having unacknowledged benefits for the family as a whole, and so forth. Interest among therapists in patients’ internal experience, central to the work of more psychoanalytic practitioners in family therapy’s early days, has been renewed in the last several years as family and marital therapy have become more integrated into the psychotherapy mainstream.

There are certain rather predictable attitudes of most family and couple therapists (cf. Budman & Gurman, 1988; Gurman, 2001) that enhance the likelihood that treatment will be relatively short term. Most family and couple therapists seek to define treatment goals relationally, as well as individually; to emphasize a developmental perspective on the family as well as on individual family members; to emphasize the strengths of family subsystems, as well as those of individuals; and to view the family or couple as the most powerful natural healing environment for change.Aconstellation of sociocultural factors involving race, ethnicity, and social class constitute significant elements in these natural healing environments, and family and couple therapists regularly consider such factors in planning and carrying our their work (e.g., Falicov, 1983; McGoldrick, Pearce, & Giordano, 1982).

In addition, most family and couple therapists seek relatively rapid change, value intermittent intervention, and prefer parsimonious interventions that may resolve presenting problems. These dominant values of most family and couple therapists, in combination with patient expectations that usually favor relatively briefer treatment experiences, may help to foster a collaborative set toward treatment. Such atemporal alliance, that is, a shared set of expectations about treatment length, may serve as an antidote to the affective intensity that occurs in most family and couple therapy, thereby facilitating the development of a relatively collaborative working relationship (Gurman, 2001).

Establishing a Therapeutic Focus

Beyond these influential patient and therapist expectations, perhaps the most important factor in the conduct of brief marital and family therapy is the way in which most systemsoriented therapists highlight the nature of what is to be focused on in therapy sessions. In general, family and couple therapists focus on the relational patterns that center on the presenting problem or symptom; at the same time, they typically show relatively little interest in a family’s or couple’s general relationship style or patterns.As has often been said, “The system is its own best explanation.” That is, no explanations of a system’s ways of operating are needed beyond a careful observation of its dominant recurrent patterns.The best explanation of a particular family system, of course, necessarily includes a sensitive assessment of the role of sociocultural factors such as race, ethnicity, social class, religious affiliation, and sexual orientation. Note that in an eclectic or integrative style of family and couple therapy, which is probably the most common theoretical orientation among family therapists, problemmaintaining patterns need not be limited to observable behavior, but may include functionally relevant private experience as well (i.e., thoughts and feelings that precede or follow problematic interactions).

The Meaning and Use of Time

In addition to the kinds of techniques used by family and couple therapists, and the ways in which they establish and maintain a treatment focus, there are certain recurring patterns of how systems-oriented therapists tend to view time in psychotherapy, and how they tend to use time. For example, in establishing a therapeutic focus and treatment goals family therapists emphasize the question, “Why now?”This question goes to the heart of the developmental or life-cycle view of problems that most family therapists adopt. That is, difficulties are almost always assessed in the context of the family’s evolving life-transitions, both as a unit and as an interconnected collection of individuals. Moreover, recognizing that most families and couples do not expect protracted treatments, most family therapists attempt to initiate changes in families’ functionally relevant transactional patterns quite early in treatment, often even as early as the first session.

Time is also used very flexibly by most family and couple therapists. The length of sessions is not the standard 50-min hour, and can change over time. In addition, family therapists often vary the interval between sessions to allow families and couples time to experiment with new interactional possibilities; to accommodate the family’s sense of moving too fast therapeutically; or alternatively, to increase the pressure toward change. Indeed, an important aspect of the therapeutic focus in much family and couple therapy involves the many ways in which time is both respected and manipulated in order to achieve positive outcomes.

Theory of Change

In addition to present-oriented techniques, and an emphasis on family behavior patterns centered on a problem or focus, the orientation of family and couple therapy toward the patient-therapist relationship has an enormous bearing on its brevity. In fact, the nature of this relationship captures the essence of the major mechanism of change in systemsoriented treatments. In contrast to psychoanalytic therapy, in which the transference relationship is often seen as the primary source of change, in family and couple therapy it is rather muted. Also in contrast to psychoanalytic therapy, the transferences and affective responses between and among family members are usually considered far more intense. The corrective emotional experience in systems-oriented therapy is seen as occurring within the family as patient, much more so than between therapist and patient.

Supporting Research and Future Directions

Several types of family and marital therapy have been shown by empirical research to yield positive outcomes, with effect sizes comparable to those of individual psychotherapies (Gurman & Fraenkel, 2002; Lebow & Gurman, 1995). While such therapies are routinely given predetermined time limits in controlled clinical studies, these artificially applied limits closely approximate the usual duration of most family and couple therapy (Gurman, 2001). Thus, the most important questions calling for further empirical study in family therapy in general (e.g., Pinsof & Wynne, 1995) substantially overlap the domain of brief family therapy. Certainly, among the most important directions for research in the study of therapeutic brevity is greater specification of the functional components of patients’and therapists’temporal expectations of therapy. It is when significant discrepancies between such expectations arise that the possibility of a strong early therapy alliance may be weakened or even precluded. Further study of the mechanisms of change in family therapy, and of how the formation of a patient-therapist temporal alliance (Gurman) may activate basic change mechanisms, is clearly called for.

Brief Experiential Therapy

Introduction

Three distinct therapeutic traditions—client-centered, Gestalt, and existential—led to the development of brief experiential therapy (BET). Appearing in the 1950s, they were referred to as the humanistic therapies or the so-called third force in psychology, alongside psychoanalysis and behaviorism. In Rogers’s (1951) client-centered therapy, the therapeutic relationship was considered the primary vehicle of change insofar as the warmth, unconditional positive regard, and genuineness of the therapist (or parent) were considered the soil needed for the client (or child) to develop into a fully functioning person. In contrast to behavioral or psychoanalytic therapy, therapists are not seen as actively bringing about change through behavioral techniques or deep interpretations, respectively, but by giving clients their undivided attention and the psychological space in which to grow. Clients are viewed as the experts on their own experience. Rogers was prescient insofar as the therapeutic alliance, an important feature of the quality of the relationship between client and therapist, has been consistently found to be a good predictor of therapy outcome (Martin et al., 2000).

In Gestalt therapy, as in the client-centered model, it is the client who is viewed as discovering that which leads to change, but the role of the therapist is more active (Perls, Hefferline, & Goodman, 1951). To help clients resolve conflicts, the Gestalt therapist encourages expression of emotions and helps clients articulate what they are experiencing (Greenberg & Rice, 1997). They may use techniques such as the empty chair, in which clients are prompted to express their feelings aloud to a significant, albeit absent, party. It is not the therapist’s interpretations that are said to bring about change, but the clients’ enhanced awareness, especially of their own feelings.

In existential therapy (May, Angel, & Ellenberger, 1958) the concept of personal responsibility is paramount. Existential therapists strive to develop a climate of safety and security for clients before confronting them with their roles in, and responsibility for, creating their own life situations (Watson, Greenberg, & Lietaer, 1998). They attempt to direct clients’ attention to fundamental and inescapable features of human existence such as loneliness, death, and existential anxiety. The last three are said to block a person’s capacity for making authentic choices. Clients are helped to come to terms with these givens through the active support and even, at times, advice of the therapist.

Process-experiential therapy, whether in its brief or openended version, is an integration of client-centered, Gestalt, and existential therapies (especially the first two), with the addition of emotion theory, attachment theory, and constructivist, postmodern theories of knowledge and the self (Elliott, 2001). An authentic, I-Thou relationship between client and therapist is seen as central (Elliott & Greenberg, 1995). Processexperiential therapy focuses on the client’s present experience and attention to bodily feelings. In addition, the person is regarded as being future oriented and goal directed rather than influenced primarily by the past, as claimed by psychoanalysis. Clients are also said to have a need for agency. Unlike in client-centered therapy, therapists may, at times, take the lead in guiding clients experiential processing while, at other times, clients’understanding of their own experience is paramount. The usual range of BET is 12–20 sessions.

Selection Criteria

Elliott (2001), a prominent exponent of process-experiential therapy, considers BET to be suitable for clients with mild to moderate distress and symptoms. Potential clients should also be able and willing to focus on their inner experience and to express emotions. In diagnostic terms, included are the adjustment reactions and the depressive and anxiety disorders. Other suitable problems, expressed in nondiagnostic terms, are low self-esteem, internal conflicts, and interpersonal resentments and difficulties. For those clients who tend to focus on external factors as the cause of their problems, the therapist must try to create an internal focus by, at first, empathizing with the client’s plight. More direct problem-solving tasks, which are a feature of BET, might be most appropriate for such clients. Because it would go against humanistic values to try to impose such a treatment (or any treatment) on clients, referral should be considered as well.

Watson and Greenberg (1998) point out that the quality of clients’introjects may affect their suitability for BET. That is, “Clients who are hostile and rejecting of themselves and who do not seem to have any complementary affirming, understanding, or nurturing attitudes towards themselves may not be good candidates for short-term therapy” (p. 140). In reviewing the research literature on brief dynamic psychotherapy and in agreement with this viewpoint, Messer (2001d) found that such clients, often considered to have personality disorders, require a longer therapy to improve.

Techniques of Therapy

In the space available, we can offer only an overview of the major techniques and methods of BET. Our discussion is based on several sources, to which the reader is referred for more indepth consideration (Elliott, 2001; Elliott & Greenberg, 1995; Greenberg, Rice, & Elliott, 1993; Watson & Greenberg, 1998). To begin with, there is a distinction made between general treatment principles and therapeutic task facilitation. We will start with the treatment principles expressed in the form of guidelines to the BET therapist:

• Enter and track the client’s immediate and evolving experiencing. The therapist enters the client’s world, trying to grasp what is most central at any moment in time. There is an effort at empathic attunement that requires letting go of preformed ideas about the client.
• Because the relationship is considered an important curative element in BET, the therapist conveys acceptance and prizing of the client.
• Facilitate mutual involvement in goals and tasks of therapy. The setting of goals should be a collaborative effort between client and therapist. The client should be helped to understand the specific therapeutic tasks that will be carried out in therapy, such as the empty chair or two-chair techniques described later.
• Facilitate optimal client experiential processing. The therapist should be flexible in recognizing that the client will be helped to work in different ways at different times. At one moment there may be the need for the client to tell his or her story and at another to work on emotional experiencing in connection with its more problematic aspects.
• Foster client growth and self-determination. Clients’ agency is important in choosing their actions and constructing their experience. “The therapist also supports the client’s potential for self-determination, empowerment, mature interdependence, mastery and self-development, by listening carefully for, and helping the client to explore ‘growing edges’of, new experience” (Elliott, 2001, p. 41).
• Facilitate client completion of key therapeutic tasks. The therapist helps the client, especially in brief experiential therapy, to develop a clear therapeutic focus and keep that focus in mind in every session. The client is helped to resolve the issues encapsulated in that focus by a gentle guiding process.

One of the major ways in which process-experiential therapy differs from its client-centered progenitor is in its willingness to define specific therapeutic tasks, sometimes drawn from Gestalt therapy. The main elements of the tasks are (a) a marker, which indicates that the client is ready to work on a particular issue; (b) a task intervention sequence involving client and therapist task-relevant actions; and (c) a desired resolution of the task worked on. These tasks can be described as falling into one of the three following categories: basic exploratory, active expression, and interpersonal. In BET there is more use of the active expression tasks, whereas in the open-ended treatment of more chronic personality or interpersonal difficulties, the other two task modes predominate.

Basic Exploratory Tasks

The therapist encourages clients to attend to and explore inner experience, and to verbalize it. That is, clients learn to symbolize their experience, constructing meaning out of it.This is probably the most frequent kind of activity engaged in by the experiential therapist. Examples of exploratory tasks are empathic exploration, experiential focusing (Gendlin, 1996)— used especially when clients feel overwhelmed or stuck—and facilitating retelling of traumatic or difficult experiences.

The therapist usually begins each session with empathic exploration, and the markers for other tasks eventually come into relief. Any experience that captures the client’s attention can be explored and parsed, especially if it is unclear. With the help of the therapist, the client moves from a more intellectualized stance to one of personal evaluation and then to the generation and integration of new personal meanings about the self (Elliott & Greenberg, 1995). Other basic exploratory tasks are systematic evocative unfolding for unexplained client overreactions to specific situations (Watson & Rennie, 1994), and meaning work for life crises that challenge cherished beliefs.

Active Expression Tasks

These stem from psychodrama and Gestalt therapy and are intended to bring hidden emotions to the fore. Best known among them are the empty chair (mentioned earlier) and two chair techniques. The former is used for unfinished business, when there are lingering bad feelings toward a significant other. “In the presence of a strong therapeutic alliance, the therapist suggests that the client imagine the other in the empty chair and express any previously unexpressed feelings toward him or her. The therapist may also suggest that the client take the role of the other and speak to the self” (Elliott, Davis, & Slatick, 1998, p. 265). Expression of strong feelings can lead to more positive views of self and other.

Whereas the empty chair technique is aimed at resolving conflicts between self and others, the two-chair technique is useful in resolving splits between two different aspects of the self, which are brought into dialogue with eachother. It allows rapid contact with strong emotions and is particularly useful for uncovering clients’ fears in anxiety disorders. Wolfe and Sigl (1998) give an example of how a person with panic disorder used it to reconcile one side of her self as “niceperson” and another side as “angrybitch” (p.287). The dialogue helped her to view her rage as based in legitimate grievances rather than as a totally unacceptable aspect of her self.

Interpersonal Tasks

These include a therapeutic relationship characterized by empathic attunement, prizing, genuineness, and collaboration. When a client presents a vulnerability marker, indicating the emergence of strong emotional pain, the therapist offers empathic affirmation. Complaints about the therapist or treatment are dealt with through alliance dialogue.

Therapists practicing BET need to “establish a focus early in treatment and actively work toward an agreement with their clients on the goals of therapy in the first few sessions” (Watson & Greenberg, 1998, p. 132). In their research on depressed clients, these authors found that where therapists had not set a focus early on in either BET or person-centered therapy, clients had the poorest outcome.

Theory of Change

The theory of experience-centered therapies is covered in detail in Greenberg and Van Balen (1998). Here we will highlight the most prominent current theoretical development in process-experiential therapy, which is emotion theory (Greenberg & Paivio, 1997; Greenberg & Rice, 1997). Emotions are seen as being important to peoples’ well-being to the extent that they enhance orientation, adaptation, and problem solving. Within the safe environment of therapy, negative affects are evoked in the session in order to explore them and to access core maladaptive emotion schemes such as basic insecurity or worthlessness. Emotion schemes are structures that serve as the basis for human experience and as a way of organizing the self. They are made up of situational, bodily, affective, conceptual, and action elements. Different kinds of client emotion reaction require different therapist interventions and can serve different therapeutic purposes. For example, anger at being infringed upon can lead a client to set firmer personal boundaries; or an emotion reaction can lead to the incorporation of new experience, as when insecurity is restructured by accessing pride and mastery motivation.

Bohart (1993) has suggested that experiencing is a core change process in all therapeutic approaches. It is not only the symbolization of internal experience, it results from doing things in the world, that is, from behaving in new ways. Empathy, which has typically been defined as understanding the position of the other, is currently conceptualized as affective resonance with the other, which also contributes to change by its encouragement of unfolding and reflection.

Supporting Research

Elliott (2001) conducted a meta-analysis of 28 studies (involving 20 treatment conditions) of BETs that consisted of individual, short-term (5–20 sessions), outpatient treatment of at least 10 clients. Seventeen of the studies were of clientcentered, nondirective therapy, while 12 were of contemporary process-directive experiential therapy. Eight of the latter were of the process-experiential variety. The clients mostly suffered from anxiety or depression or, in some studies, personality disorders. The pre- to post-treatment changes were substantial (about 1.1 standard deviations), and were maintained at follow-up.

Analyses of the studies that had wait-list controls showed a similar advantage of treated over untreated clients. Comparing across different treatments, clients in the BETs changed as much as those in the other treatments. The finding of equivalence of BET and other therapies is in accord with recent meta-analyses that showed no differences among the therapies studied (Wampold et al., 1997). In a subanalysis, Elliott found that cognitive behavior therapy was superior to experiential therapy but that this difference disappeared when researcher allegiance to one or another of the therapies was controlled for.

Future Directions

To attain research funding or insurance coverage, it has become increasingly important to gear treatment of any kind to the specific diagnostic categories encompassed by the DSM. Experiential treatment has been rising to the challenge by studying the kinds of therapist interventions that are necessary to treat a variety of disorders within this tradition. These include depression, posttraumatic stress disorder (PTSD), anxiety disorders, psychosomatic disorders, sexual abuse, and severe personality disorders such as borderline. Chapters on the treatment of each of these can be found in a volume edited by Greenberg, Watson, and Lietaer (1998). For example, commonalities in emotion schemes appear to exist in the depressive disorders and certain types of in-session states emerge in their treatments. Greenberg, Watson, and Goldman (1998) present a model of the depressive process that requires evoking emotional memories and then helping the client reorganize them.The maladaptive depression-producing emotion schemes are challenged.

Likewise, Elliot et al. (1998) has found experiential states in clients suffering from PTSD differing from those arising in depression. This requires different techniques within the experiential tradition to treat PTSD. In dealing with flashbacks, for instance, renarrating traumatic episodes is helpful in order to symbolize traumatic affective experience in words. However, unless trauma was involved, this would not be especially helpful in depressives.

In addition to continuing studies of different diagnostic groups by means of randomized clinical trials, there has been a call for use of newer research methods to study BET. These include discovery-oriented, qualitative, and descriptive methods. One approach being adopted within the experiential tradition is intensive single-case research to track changes in key client issues across the course of therapy. Single case records that combine qualitative and quantitative data are particularly promising in providing explanations for withinsession events. For example, Elliott (2000) has presented a hermeneutic single-case efficacy design that is systematic and self-reflective enough to provide an adequate basis for making inferences about what transpires in therapy. In his words, “The approach outlined here makes use of rich networks of information (“thick” description rather than elegant design) and interpretive (rather than experimental) procedures to develop probabilistic (rather than absolute) knowledge claims” (p. 3). For other emerging trends within the experiential therapy tradition, see Greenberg,Watson, and Lietaer (1998).

Strategic Therapy

Introduction

Strategic therapy is a brief, problem-focused psychotherapeutic approach developed by the PaloAlto Brief Therapy Group (Watzlawick, Weakland, & Fisch, 1974; Weakland, Fisch, Watzlawick, & Bodin, 1974). This mode of intervention is based upon the ironic notion that problems persist as a function of people’s attempts to solve them. Thus, the focus of strategic therapy is on ironic processes. Since this treatment strategy is intended to break the vicious cycle that develops when the potential solution aggravates the problem, the goal of the therapist is to identify and develop a plan to interrupt the patient’s well-intentioned solution efforts in order to resolve the presenting problem (Fisch, Weakland, & Segal, 1982). This psychotherapeutic model is considered strategic in that the therapist develops interventions to deliberately interrupt ironic processes based upon a specific case conceptualization. Frequently, interventions include counterintuitive suggestions (e.g., to have the patient engage in the behavior he or she wants to eliminate, such as staying awake when having a problem with insomnia, or thinking an unwanted thought he or she is trying to suppress; Rohrbaugh & Shoham, 2001).

Regarding its historical origins, during the 1960s a group of psychotherapists associated with the Mental Research Institute (MRI) in Palo Alto were investigating therapeutic approaches to rapid problem resolution. The team became interested in the work of Milton Erickson, who was utilizing methods that were quite different than long-term psychodynamic psychotherapy—the dominant psychotherapeutic approach at the time (e.g., Haley, 1973). Rather than viewing problems as a function of underlying psychopathology, as did psychoanalysis, Erickson conceptualized them as stemming from the mishandling of common, everyday difficulties (Haley). Treatment was not focused on understanding psychopathology, but rather on solving problems as they cropped up. The PaloAlto group began testing a brief 10-session treatment based on the ironic process approach and Erickson’s assumptions. From their clinical experience, a model of brief therapy emerged: focused problem resolution (Fisch et al., 1982; Weakland et al., 1974). This model was seen as strategic in that the clinician’s interventions are deliberate and based upon a careful plan, and the clinician assumes responsibility for the outcome (Fisch et al.).

Selection Criteria

Strategic therapy is considered appropriate for the entire range of problems for which people seek psychotherapeutic treatment. Thus, there are no specific selection criteria other than an individual presenting with at least one complaint (Rohrbaugh & Shoham, 2001). In fact, the clinical work that led to the development of this approach was based upon unselected cases seen at the Brief Therapy Center (BTC) and represented a wide range of problems. While almost half of the patients treated with strategic therapy at the BTC presented with an interpersonal problem such as marital discord or family conflict, many other individuals suffered from a range of problems, including anxiety, depression, procrastination, and eating disorders. Results from an archival study examining its effectiveness found that treatment outcome was not related to the presenting problem (Rohrbaugh, Shoham, & Schlanger, 1992). It is important to note, however, that given the limitations of the archival study (e.g., the lack of standardized diagnostic and assessment procedures and comparison group) one cannot be certain that strategic therapy is equally effective across all types and severities of presenting problems. Also worth noting, however, is that strategic interventions may be particularly useful for patients who are resistant to change, especially when compared to more straightforward skill-oriented approaches (cf. Rohrbaugh & Shoham).

Techniques of Therapy

As succinctly summarized by Rohrbaugh and Shoham (2001, p. 71), the format for conducting brief strategic therapy is as follows:

(a) define the complaint in specific behavioral terms; (b) set minimum goals for change; (c) investigate solutions to the complaint; (d) formulate ironic problem-solution loops (how “more of the same” solution leads to more of the complaint, and so on); (e) specify what “less of the same” will look like; (f) understand patients’ preferred views of themselves, the problem, and each other; (g) use patient position to interdict problem-maintaining solutions; and (h) nurture and solidify incipient change.

Once the therapist has defined the problem or problems in specific, behavioral terms (e.g., taking 2 hr to fall asleep each evening) and set a minimum acceptable goal for change (e.g., taking 1 hr to fall asleep each evening), the intervention phase of therapy begins. The initial focus is to elucidate the solution patterns that maintain the complaint by assessing what the individual or others have been doing to solve the problem. Since the ironic process approach assumes that attempts to solve the problem are in fact maintaining it, illuminating cycles of problem-solving (i.e., problem-maintaining) strategies will highlight areas for intervention. Although the focus of problem-maintaining solutions is on the current period, previously attempted solutions can provide insight into what has and has not been effective.

Based upon the information obtained while evaluating current attempts to solve the problem, the therapist can conceptualize what “less of the same” will look like. Specifically, the goal is to reverse the problem-maintaining solution by identifying specific changes that need to be made. Ideally ,this strategic objective constitutes a 180-degree reversal of what the patient has been doing (Rohrbaugh & Shoham, 2001). For example, if the problem-maintaining solution is the avoidance of social situations that cause anxiety, the objective of treatment might be for the patient to experience anxiety by entering a feared social situation, since the crucial element in planning an intervention is stopping the performance of the attempted solution (i.e., avoidance of social situations that cause anxiety). It is interesting to note that this strategy is similar to systematic exposure, a treatment strategy used within CBT. One of the marked differences however, is that in CBT the patient is typically given coping strategies to deal with the anxiety, whereas strategic therapy is not oriented toward providing such skills to patients.

To promote compliance, a hallmark of the Palo Alto strategic therapy model is framing therapeutic tasks and suggestions in terms compatible with the patients’ own language, worldview, or position. To accomplish this, it is essential for the therapist to listen carefully to patients’comments in order to assess the way they see themselves and others and to determine what is important in their lives. In addition, the therapist attempts to determine patients’ views of the problem, specifically, what they believe is causing it.

As part of setting the stage for effective problem resolution, the therapist not only elicits the patients’ views, but also attempts to mold them to increase patients’ receptivity to the intervention. For example, a therapist might accept a wife’s position that her husband is demanding and controlling, and then extend this notion to suggest that the husband’s behavior may indicate an underlying vulnerability. The therapist’s extension creates a different way of looking at the problem, and thus a different solution to resolving it. The husband is now seen as vulnerable rather than controlling, and solving the problem requires dealing with his vulnerability, not his controlling nature. As the wife takes into account and responds to the husband’s vulnerability, he becomes less controlling, and a positive feedback loop develops, leading to a resolution of the problem.

Theory of Change

As noted before, the patient’s presenting problem is believed to be maintained by his or her ongoing current attempt to control, prevent, or eliminate the problem. Thus, the focus of intervention and necessary condition for change is the interruption or elimination of the problem-maintaining behavior. From this viewpoint, resolving a problem does not require understanding or changing its antecedent cause, but simply the breaking of the ironic pattern of problem maintenance by promoting “less of the same” solutions (Rohrbaugh & Shoham, 2001). The theory of change is quite simple: If the problemmaintenance behavior can be reduced or eliminated, the problem will be resolved, regardless of its nature, origin, or duration. (Weakland et al., 1974).

Supporting Research

There is a dearth of research on the PaloAlto strategic therapy model in its pure form. The only controlled study that exists was conducted by Goldman and Greenberg (1992), who compared a treatment based on the PaloAlto strategic therapy model to emotion-focused couples therapy and to a wait-list control condition. Whereas both treatments were superior to the control condition at posttreatment, couples who received strategic therapy reported better marital quality and more change in target complaints than the emotion-focused therapy group at the follow-up assessment (4 months after treatment).

The bulk of research support for this approach (for relationship distress as well as a variety of other problems) comes from the BTC’s archives (Rohrbaugh et al., 1992; for a detailed description, see Rohrbaugh & Shoham, 2001). Since its inception, a standard procedure at the BTC has been for ateam member to conduct a follow-up assessment with patients via telephone approximately 3 and 12 months following termination. The assessor (never the patient’s primary therapist) evaluates changes in the presenting complaint, whether additional problems have developed, and whether additional treatment was sought elsewhere. On the basis of the patient’s response to these questions, each case was classified into one of three categories: success (substantial or complete relief of the presenting complaint with no new problems), significant improvement (clear but incomplete relief of the complaint), or failure (little or no change, negative change, or further treatment for the presenting complaint).

In an initial report published by Weakland et al. (1974), the first 97 patients treated by the BTC group were categorized based upon their 1-year assessment. Forty percent achieved success status, 32% were rated as significantly improved, and 28% were considered treatment failures. Since this study neither included a comparison or control group nor used standardized assessment or diagnostic procedures, results must be interpreted with caution. However, as noted by Rohrbaugh and Shoham (2001), these data are comparable to success rates reported in the literature for other forms of psychotherapy (e.g., Smith, Glass, & Miller, 1980).

Rohrbaugh et al. (1992) updated the tabulation of outcome data for BTC cases seen through 1991 (a total of 285 patients). The results of this study essentially replicated the original findings. Furthermore, treatment outcome was unrelated to type of complaint, age, gender, educational level, and whether the patient had prior therapy, had been hospitalized, or carried a psychiatric diagnosis. (Since this archival data set is not published, the interested reader can see Rohrbaugh & Shoham, 2001, for a more detailed account.)

Finally, it is important to note that although they do not test the strategic therapy model per se, studies have supported the efficacy of a range of psychological treatments that include essential components of strategic therapy. Examples are the techniques based upon ironic-process principles, such as paradoxical interventions, that have been supported in a metaanalysis by Shoham-Salomon and Rosenthal (1987).

Future Directions

Two areas stand out as requiring further attention. First, given the current emphasis on accountability in health care, if strategic therapy is to be a viable psychotherapeutic approach, treatment outcome data supporting its efficacy must be generated. As noted previously, to date only a handful of studies exist that support the effectiveness of strategic therapy. Collaborations between researchers and strategically oriented clinicians should be developed to generate research support for this approach (cf. Goldfried, Borkovec, Clarkin, Johnson, & Perry, 1999; Lambert, Okiishi, Finch, & Johnson, 1998). Second, research should be conducted to identify patients and problems particularly suited for this approach (e.g., Shoham, Bootzin, Rohrbaugh, & Urry, 1996).The existing research data suggest that strategic therapy is in fact quite effective for a reasonable proportion of patients.Thus, for some patients, interruption of the ironic process that is maintaining the problem behavior is effectively administered in a brief treatment. Identifying patients and problems most likely to benefit from strategic therapy would support its use in such cases in which a simple, parsimonious therapy may be the best first-line solution.

Brief Integrative-Eclectic Therapy

Introduction

Although most psychotherapists have been trained in one or more primary treatment approaches, the large majority of practitioners are eclectic or integrative in practice (Jensen et al., 1990). The terms eclecticism and integration have the common attribute of not using a pure approach to treatment, but have somewhat different meanings (Messer & Warren, 1995; Norcross, 1986). Eclecticism refers either to technical eclecticism (i.e., calling upon specific interventions from theoretically different methods) or to prescriptive matching (i.e., pairing the use of particular techniques with particular symptoms, syndromes, or patient personality types). Theoretical integration attempts to encompass different theories and the techniques deriving from them in one coherent theory. Finally, the common-factors approach to eclecticism emphasizes therapeutic variables and processes that are presumed to be common to all therapies and central to their efficacy.

Whereas most outpatient individual psychotherapy is eclectically brief, it is ironic that there are few explicit models of such therapy. Among the most influential are Bellak’s (1992) brief and emergency psychotherapy, Beutler’s (1983) systematic eclectic psychotherapy, Budman and Gurman’s (1988) interpersonal-developmental-existential approach, Garfield’s (1989) common-factors approach, Klerman, Weissman, Rounsaville, and Chevron’s (1984) interpersonal psychotherapy, Lazarus’s (1981) brief multimodal therapy, and Wolberg’s (1980) flexible short-term psychotherapy. A recent creative model is McCullough’s short-term anxiety-regulating therapy (McCullough &Andrews, 2001).

Selection Criteria

In the practice of some influential psychodynamic approaches to brief psychotherapy, discussed elsewhere in this research paper, the criteria for the selection of patients are quite exacting. In brief integrative-eclectic psychotherapy (BIEP), however, suitability criteria tend to be minimal and less stringent. Typically in BIEP, only the most severely disturbed candidates are excluded—for example, patients who are actively suicidal or dangerously impulsive, psychotic, drug abusing, or dealing with incapacitating chronic disorders such as schizophrenia. Even patients with personality disorders, especially those in the dramatic cluster and the anxious cluster, may be helped in brief treatment (Budman & Gurman, 1988). Generally, such diagnostic considerations aside, sufficient criteria for including a patient in BIEP are at least a moderate level of everyday psychosocial functioning, the capacity to form a working alliance with the therapist, and the ability either to identify a central focus (whether of the more symptomatic or thematic type, discussed later) or to agree upon such a focus with the therapist very early in treatment. Wolberg (1980, p. 140) captured the typical thinking of most BIEP-oriented clinicians about patient selection in urging that they “assume that every patient, irrespective of diagnosis, will respond to short-term psychotherapy unless he proves himself to be refractory to it.”

Techniques of Therapy

By its very nature, BIEP includes a very wide range of therapeutic techniques. Indeed, there are no techniques that are unique to BIEP. BIEP clinicians tend to be quite pragmatic in their choice and use of specific interventions, and regularly ignore the kinds of conceptual concerns expressed by clinical theorists about such indiscriminate borrowing. For example, Messer and Warren’s (1995) concern that using a given technique out of the context of its originating theory may change its meaning does not usually deter workaday clinicians from incorporating varied techniques despite their possible incompatibility at a theoretical or even clinical level.

More than anything else, BIEP-oriented clinicians lean toward technical flexibility, often attempting to match particular interventions to particular problems. They usually do so somewhat intuitively rather than systematically, as is done in Beutler’s (1983) and in Bellak’s (1992) approaches. Thus, BIEP may include such interventions as interpretations to enhance insight, experiential exercises to enhance affective self-awareness, role playing to promote interpersonal effectiveness, and hypnosis or relaxation training to decrease anxiety. Essentially, in BIEP, the therapist’s choice of techniques tends to be very patient-centered, in contrast to the more theory-centered choice of techniques usually found in pure approaches to therapy, including brief therapy. An increasingly important influence on the brief therapist’s flexible selection of techniques involves an appreciation of potentially relevant patient sociocultural factors, such as race, ethnicity, and social class. As McGoldrick et al. (1982) have made clear, the fit between different styles and techniques of psychotherapy and patients of different cultural backgrounds varies significantly.

Still, most BIEP approaches are predominantly aligned with one conceptual orientation more than another. Thus, Bellak (1992) and Wolberg (1980) emphasize a psychodynamic foundation to their case conceptualization, Budman and Gurman (1988) and Klerman et al. (1984) have a strong interpersonal and adult-developmental slant, and Lazarus (1981) adopts a cognitive behavioral stance. In contrast, Beutler’s (1983) approach is heavily influenced by social psychological theory, especially regarding interpersonal influence processes, and Garfield’s (1989) common-factors approach deemphasizes techniques as major change-inducing elements of treatment, relying instead on such factors as empathic listening, reflection and reassurance, suggestion and explanation, and opportunities for catharsis.

In addition to selecting techniques that seem to fit the particular patient, BIEP therapists tend to choose interventions that have certain attributes that foster therapeutic brevity. These choices tend to be present-centered; to attend more to conscious and preconscious than to unconscious experience; to address interpersonal relationships more than inner fantasy life; to encourage, or at least suggest, taking action as much as engaging in reflection; and to acknowledge and build upon patient strengths and resources more than exposing deficits and limitations. A particular style of technical eclecticism in BIEP that is quite common involves the combination of different modalities of therapy, such as individual plus family/couple therapy, or individual plus drug therapy.

In general, the choice of therapeutic techniques, as in all brief therapy, should reinforce and be consistent with the maintenance of a clear, explicitly agreed upon treatment focus.The focus agreed upon can involve almost any life domain and problem description that allows the specification of achievable goals. A useful distinction in the setting of a focus is that between a symptomatic focus and thematic focus. The former refers to rather readily specified symptom complaints, usually of the sort associated with psychiatric diagnosis (e.g., depression, anxiety, or alcohol abuse). A thematic focus involves a broader pattern of behavioral or affective difficulty, or what behavior therapists call response classes—for example, interpersonal conflict, self-criticalness, or fear of commitment in relationships.

Budman and Gurman (1988) have offered a frame of reference to help therapists more rapidly assess a number of possible foci that are phenomenologically meaningful to patients. The five foci they described are losses, developmental dysynchronies, interpersonal conflicts, symptomatic presentations, and personality disorders. Losses can include any time frame (past, present, future), and may involve people (e.g., loved ones), position (e.g., job), or potential (e.g., permanent disability). Developmental dysynchronies refer to an individual’s seeing him- or herself as being off track developmentally, and are often identified at nodal life-transition points (e.g., completion of formal education, marriage, etc.). Interpersonal conflicts commonly involve family and marital difficulties, although they may also center on friendships or workplace relationships. Symptomatic presentations, as noted, involve discrete symptoms such as anxiety or depression. Personality disorders may be gauged by chronic and constant loneliness, varied and repeated interpersonal conflicts, and anger and depression.

Budman and Gurman’s (1988) five foci are not biased toward any particular theory of psychopathology or psychotherapy, and thus may serve as a template for the kind of rapid assessment and treatment planning that brief therapy requires. Moreover, the identification of a particular focus in their schema neither precludes nor preordains the use of any particular method of brief therapy or the selection of techniques within any given method.

Moreover, the use of such a template for focusing does not dictate how time is apportioned in BIEP. It is the manner of distributing time for treatment, not the setting of finite limits on the amount of available time (e.g., fixed termination date, fixed number of sessions), that typically distinguishes brief therapy from its longer term cousins (Budman & Gurman, 1988). Brief psychotherapy, and certainly BIEP, is very flexible in its distribution of treatment time. This temporal attitude has led some to assert that brief therapy could be more appropriately dubbed time-sensitive or time-effective therapy (Budman & Gurman). That is, BIEP is not necessarily continuous therapy, conducted weekly. Nor is BIEP necessarily provided as a course of treatment that comes to a final end. Rather, patients may be seen intermittently for successive periods of therapy, especially as changing life circumstances dictate a need to return for additional focused work. It is in this most concrete of ways that a life-cycle developmental perspective on clinical presentations (the all-important “Why now?” assessment question) has practical relevance.

Supporting Research and Future Directions

BIEP, by its essential nature, lacks the panache to ever gain passionate adherents and become a therapeutic movement. Therefore, forces other than the conceptual and charismatic zealotry of BIEP’s leaders will be called upon to maintain the widespread practice of these approaches. The first force that is likely to sustain and enhance BIEP’s usage is the commonly encountered patient expectation that therapy should be brief and practical. Patients are generally not very interested in complex theories of treatment. They typically want to be offered what works, especially what is specifically likely to work for them. Likewise (although probably not with the same motivations), health care delivery systems and their administrators certainly favor whatever works, and whatever works the fastest.

The second major force that is likely to sustain the practice of BIEP is the corpus of existing research on psychotherapeutic outcomes. As noted earlier, the lion’s share of outcome research on individual psychotherapy, which typically shows positive results, has involved brief treatment by any temporal standard (cf. Bergin & Garfield, 1994), and has tended not to favor one approach over the others. Many clinicians feel that if research has supported several different therapeutic approaches, combining them may enhance the overall effect. Process research has demonstrated that what appear to be pure approaches often are quite integrative (e.g., Jones & Pulos, 1993).

At the same time, there exists almost no research on what may be called intentional integrative therapy, in which intervention methods from disparate schools of thought are synergistically brought together in a coherent fashion, with adequate training and monitoring of therapists in the emerging integrative model. (See Glass, Arnkoff, & Rodriguez, 1998, for suggested directions for integrative psychotherapy research.) Likewise, the body of research on eclectic approaches is not large. It is best represented to date by Beutler’s (1983) systematic approach, which attempts to match treatments to patients on the basis of potentially pertinent factors. A fundamental difficulty in studying eclectic treatments, of course, is that eclectic therapists typically use whatever techniques they think will benefit a given patient, rendering it difficult to standardize or manualize therapy for investigative purposes. Still, even in the face of these countervailing forces, brief integrative-eclectic styles of individual psychotherapy are likely to continue to quietly dominate the landscape of contemporary practice.

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