Short-Term Psychotherapy

I admit I was not expecting a lot from Alex Coren's 2002 book Short-Term Psychotherapy, but I was very wrong. I picked it up at the urging of one of my recent supervisors who encouraged me to investigate resources on brief or time-limited therapies. I'm glad I took his advice, for reading Coren has forced a major re-think on this question and that is always a bit of an exhilarating and chastening experience. But I am very glad to have read this book and benefited from the reconsideration. 

One of the most interesting things I learned from the moral philosopher Alasdair MacIntyre, on whom I wrote my MA thesis, is the concept of an "epistemological crisis." That is when two rival traditions encounter one another with different answers to the same questions, and one of those traditions experiences a crisis of confidence in what it has hitherto believed. The resolution of such a crisis may take one of three forms: collapse and defeat; stubbornly and willfully blind and cult-like denial of any answers (or even challenges) from the rival; or a reconfiguration in which the weakened tradition learns from the rival and incorporates the latter's wisdom into a new synthesis. 

I admit that for more than twenty years I have been a stubborn defender of long-term therapies for two reasons. First, the simple reason is that my life has benefited enormously from one such long-term therapy, a fairly classical psychoanalysis (four times a week on the couch for seven years). Second, my automatic suspicion of capitalism and its so-called healthcare systems--especially in the absolute worst of them, which is of course here in the US, where the pressure to be "efficient" is relentless and heartless in equal measure--ensures that I would oppose the externally imposed demands for people to be given a handful of sessions of therapy on their "healthcare insurance" plans to get their "behavioral health" (as it is revealingly and increasingly called today) back into line. I loathe capitalist conformism (one must always have compliant citizens, employees, and consumers!) and all its pomps and works, and so I loathed any idea that short-term therapies were to be regarded, as they seem everywhere to be in this country, as normative or superior to the long-term ones. 

Such views of mine were, I now see, fairly unreflective prejudices of long-standing that I have had to put to the question thanks to Coren's useful little book. In fact, if the book had no other virtue than to force me to consider "Where is the evidence for the belief that longer is always better?" and "What about the early history of Freud and psychoanalysis, when short treatments were very much the norm?" it would be well worth it. We'll come back to both questions presently. 

For now, let me just record my gratitude to him for describing how "therapists can have transferences to concepts" (119) as I clearly did to the concept of short, time-limited therapy! Let me also record my gratitude for his reminding me of what I've seen elsewhere but not yet integrated sufficiently: the fact that "all research suggests most therapeutic benefits occur early in treatment for the majority of clients" (163)--before what is often called the "therapeutic plateau" sets in. One final benefit here--though not as well established in the literature--is the limited "evidence to suggest that premature terminations, or drop-out rates, are reduced when clients were offered a circumscribed time-limited therapy" (164). 

Why this Book?

This book has as its goal an examination of the role played by time in therapy, and of time-limited therapies not externally imposed (by some bureaucracy, whether public or private) but as deliberately designed and chosen. Along the way, Coren also offers some helpful insights into the kinds of patients and problems most likely to be helped by time-limited therapies, and the kinds of people and conditions who will not be helped by such an approach, some of whom might actively be harmed  by offering only a few tightly focused sessions.

Some History: 

The first chapter is invaluable in reminding us that the first generation around Freud, including the great man himself, were all themselves analyzed over a short period, and often analyzed patients for brief times--sometimes a handful of days, sometimes of weeks, occasionally some months ("the early Freud was an often extremely brief therapist" [p.26]). 

This is also true of others. For Otto Rank, Sandor Ferenczi, and perhaps especially Alfred Adler, inter alia, short therapies were the norm. So too did Alexander and French insist on shorter treatments (one feature of which was, of course the "corrective emotional experience" which was then controversial but today taken for granted) in their famous 1946 book, where they saw the danger that longer therapies might drift into intellectualization. 

Still others, especially attachment theorists like Bowlby, saw that time is relative, and that in some relationships it is "less a question of the amount of time a caretaker (or therapist) spends" with the child/patient than "the nature and quality of how the time is spent" (98). A little later this is phrased differently in recognizing that a short experience of the therapist may be more beneficial than a long explanation from the therapist. 

Only much later did it come to be accepted as something of a self-serving orthodoxy (whose enforcement Coren compares to "fundamentalist sects") that one must be in analysis for five, ten, or fifteen years. How often one now sees that that long period of orthodoxy has done untold damage to psychoanalysis in a variety of ways, not least by estranging itself from its own rather socially radical roots as uncovered recently in such hugely important works as Elizabeth Ann Danto's Freud's Free Clinics: Psychoanalysis and Social Justice, 1918–1938 and more recently still by Daniel José Gaztambide's People’s History of Psychoanalysis: From Freud to Liberation Psychology. (I have sent questions to Gaztambide for an interview about his magnificent book.) 

It is to Coren's considerable credit that, having unearthed this history, and called out the orthodoxy of long therapies, he does not turn around to become an unthinking partisan of shorter therapies alone. He several times recognizes that in some conditions (see below) longer therapies are absolutely indicated and are essential. Equally praiseworthy is his recognition of the necessity of not giving in to the demands for short therapies merely because impudent insurance companies demand them. They can only be recommended because that is what seems best in the considered clinical judgment of the therapist, not some outside busybody inflicting the "corporatization of psychotherapy" on the rest of us. 

The middle chapters of Coren review brief therapies in a variety of schools--analytic getting the most attention, but also CBT therapies and some ecclectic approaches. Kohut's self-psychology gets a look-in here as well, along with other analytic reconfigurations at the hands of Davanloo (and his more recent disciples, including Patricia Coughlin, whose books I have and hope to write about on here later). Coren notes where each of these may specify a certain number of sessions as part of a pre-conceived definition of time, though he himself seems to prefer leaving things a bit open-ended, saying late in the book that he will often propose, especially to ambivalent patients, "Let's meet X times and review." This is a useful way forward that I have recently seen used in community mental health to good effect. 

Pre-Transference:

One person one does not expect to find here--as Coren explicitly recognizes--is D.W. Winnicott. As that link indicates, I've read a good deal of Winnicott and profited thereby enormously, but I have not read everything, and it is to Coren's credit that he brings forth an especially useful bit of DWW previously unknown to me: the notion of the pre-transference as well as what Coren later calls "transference to the setting." These are useful concepts to think about: what are our patients, even before walking in or making first contact, transferring on to us? What are their transferences to the consulting room and surrounding environs? It bears thinking about these things as one is setting up shop. 

Later on Coren will note that given the limitations of time, the therapist does not need to wait for a full-blown transference to emerge, but can begin using whatever materials might manifest in the pre-transference as well as the transference to place. Given those limitations, he also notes that in some, perhaps most, cases, one cannot presume that the patient will know how to begin, or how therapy should unfold. Do not take this for granted, but instead offer some explanation of how the process typically unfolds. 

One other useful insight from Coren I appreciated hearing, and it ties into something Nina Coltart also says: "There is growing recognition that there are times when the prescription of no therapy is the (non-) treatment of choice." (I saw this done very skillfully in recently shadowing a very experienced therapist, who, during an intake, very quickly perceived that the person had other issues to deal with, whose resolution would almost certainly take away the present unhappiness, thus obviating the need for therapy.)   

For Whom are Time-Limited Therapies Indicated?

Coren suggests that as a general rule of thumb, the farther back the trauma, the more long-term therapy will be required, and thus such patients are generally not going to benefit from time-limited therapies. In general, the following are good signs that patients might be a good fit for this form of therapy: psychological mindedness, a capacity to reflect/introspect, capacity for forming the working alliance, capacity to know one's history and problems but take some distance from them. Additionally, he later says that patients presenting with problems connected to "recurrent interpersonal patterns" will do best with time-limited approaches, not least because such approaches foreclose the possibility of "therapeutic drift" (139). 

The central factor he repeatedly highlights is the working alliance, stressing that it will be the key to the success of time-limited therapy. Interestingly, he suggests that in the dyad both parties reflect on the relationship as the "third" in the room, looking somewhat objectively at their relationship. This, he says, will help prevent an over-dependence on the therapist from arising, making termination of a short therapy difficult.  

Beyond all this, both need (to borrow Winnicott's famous phrase) to be prepared for a "good enough" outcome to the therapy, content to leave some issues unexamined, and the resolution of others ambiguous if 

How Might Time-Limited Therapies Work?

Coren has a model of a Triangle to conceive of the three crucial components of a successful treatment, which works within, and on, the Present Complaint, Transference, and Personal History. Quickly tuning into what he also called the patient's idiom is another crucial component for him (and here he draws on Christopher Bollas). He goes into useful detail about each and all of them. I will not relay that here, but encourage those who are interested to track down and read a book that usefully challenged me and changed my mind in some important ways.

For all that, though, I am not in the least suggesting that all therapy should be short or time-limited. I still do very much think people should be free to pursue it for as long as they need without corporate minders interfering in a process they have no business being involved in. But for some people who would benefit from this approach, and perhaps this approach alone, I have new-found respect and a desire to work with them, too.