Short-Term Treatment: An Overview
Mental health professionals in a variety of disciplines are using short-term methods in their practice more than ever before. Although brief treatment always has been part of the therapeutic repertoire, it received little positive attention in mental health circles until the 1940s. The first wave of interest in short-term and crisis intervention occurred during and just after World War II as a result of several concurrent developments: efforts to make traditional psychoanalytic psychotherapy more efficient, experiences with soldiers under battle conditions, attempts to help soldiers and their families when the former returned to civilian life, and work with the victims of disasters and those undergoing stressful life events. Despite the interest in short-term approaches, they were not widely assimilated into mainstream mental health services at that time.
Even after the revival of interest in brief treatment that occurred in the 1960s, it continued to be relegated to a second-class status in comparison to long-term treatment among psychodynamically oriented clinicians. Showing a prejudice in favor of so-called deeper and more intensive treatments, which were thought to be essential for the achievement of personality change, many psychotherapists viewed short-term intervention as shallow and superficial (Shechter, 1997; Wolberg, 1965).
THE RISE OF SHORT-TERM TREATMENT
Numerous factors have contributed to the diminished status and use of long-term treatment and the increased use of short-term and crisis intervention (Budman & Gurman, 1988; Parad & Parad, 1990b; Shechter, 1997). Beginning in the 1960s, optimism about the ability of mental health treatment to help people led to efforts to make treatment accessible to greater numbers of individuals at earlier points in the emergence of their difficulties and for help with problems in living, as well as severe emotional disorders. The short-lived community mental health movement, ushered in by the Community Mental Health Centers Act of 1963 during the Kennedy presidency, was heavily weighted toward emergency and brief treatment. Even psychodynamically oriented clinicians experimented with short-term treatment, and new interventive models proliferated, including those that were cognitive and behavioral.
Another contributing factor to the changing nature of treatment was the criticism of traditional forms of intervention on the part of numerous special populations who sought greater opportunities for self-expression, freedom from oppression, and respect for their diversity. Among these groups were those reflecting counterculture lifestyles, people of color, women, and gays and lesbians, who tended to perceive long-term, psychodynamically oriented treatment as a form of social control, a means of blaming the victim, and a way of labeling difference as pathological. Self-help, consciousness-raising, and rap groups, along with other types of alternative helping methods, gained popularity and eroded the dominance of more traditional therapies.
As mental health treatment became more available, individuals sought help for a host of concerns that previously would not have been thought to warrant treatment. Less motivated for long-term treatment, clients expected treatment to focus on more here-and-now, reality-oriented problems. Often they possessed more knowledge about treatment options and were more vocal in questioning the utility of seemingly ill-defined and open-ended approaches with unspecified goals.
The accumulation of findings from practice research also supported the use of short-term approaches since many studies failed to show that more open-ended treatments were superior to brief intervention (Koss & Shiang, 1994; Wells & Phelps, 1990). Moreover, the use of long-term treatment was associated with high dropout rates. For example, in one study, as many as 80 percent of patients in mental health clinics and family service agencies, who were offered more ongoing intervention, were seen for six or fewer sessions (Garfield, 1986). Thus, despite clinicians' stated preferences for long-term treatment, intervention turned out to be short term by default rather than by design (Budman & Gurman, 1988, pp. 6-7). Additionally, as Wells (1990, p. 13) notes, there is some evidence to show that even for those who actually received long-term treatment, improvement occurred early, with 75 percent of clients making considerable progress within six months.
The economic climate of the past several decades has been another major cause of the dramatic increase in the use of briefer forms of treatment. New, more cost-conscious and seemingly efficient forms of delivering mental health care have proliferated, and reimbursement for, allocation of, and accessibility to mental health services have been greatly curtailed and circumscribed. Social agencies and hospitals, which have been the mainstays of service delivery in their communities, have been forced to slash their budgets, rearrange their priorities, downsize their staffs, engage in reengineering their operations, and offer more short-term intervention, sometimes to the exclusion of other types of treatment. Practitioners in these settings, as well as those in private practice, are being forced to reexamine their customary and preferred ways of helping others.
For all the reasons cited, social workers, among other mental health providers, are using time-limited treatment with ever greater numbers of clients. Some practitioners are embracing this development enthusiastically, while others are resigning themselves to it out of necessity. On the positive side, short-term approaches may be highly responsive to what clients want and expect. Consumers seek or are mandated to seek help for a wide range of problems, many of which can be addressed appropriately by brief forms of intervention. For example, a young adult may enter treatment after the breakup of a relationship and may benefit from supportive work aimed at assisting him in dealing with issues of loss and blows to self-esteem. Similarly, a mother who seeks help in disciplining an acting-out youngster may be able to benefit from brief, educative work focused on parenting skills, and a truant adolescent boy may benefit more from a simple change in his school setting than from open-ended ongoing treatment of his personality problems.
Even if clients present with more complex treatment issues that might warrant a more open-ended approach, they may not want or be amenable to such intervention. Proceeding when the goals of the worker and client are divergent runs the risk of causing the client to withdraw from treatment. It is preferable to try to meet the client's expectations if possible, as illustrated in the following example.
Mrs. Pierce, a twice-divorced, recently remarried 40-year-old woman, came for help because of marital problems that were leading her to want to separate from her new husband. She recounted incidents in which he had ignored her needs and wishes and gave evidence of her concerns that he was seeing another woman. Although the worker accepted the client's view of her husband, she learned that Mrs. Pierce had a history of repetitive instances in which her suspiciousness of men's motives led her to distance herself from them and she thought that she was contributing to her unsuccessful relationships. Concerned that the client might leave her current husband, only to repeat her pattern again and again, the psychodynamically trained worker thought that it would be advisable for Mrs. Pierce to get help in understanding the origins of her long-standing feelings of distrust, her sense of inadequacy, and her fears of rejection so that she could modify her ways of perceiving and relating to her husband and other men. The client, however, expressed an interest only in getting help in summoning the courage to leave her spouse.
Recognizing that she could not involve the client in a more insight-oriented and modifying long-term treatment unless she saw its benefit, the worker explained the reasons behind her thinking that the client would benefit from looking into her characteristic relationship patterns. The client missed the next session. In the following meeting, in response to the worker's inquiry about her feelings after their last meeting, the client indicated that she was not going to return at all because she did not want to dwell on the past but she realized that the worker meant well and was probably right. She said that she did realize that she had made a mess of her marriages but needed help in extricating herself from her current relationship, adding that she felt too upset to deal with her other issues at the present time. The worker accepted the client's wishes to focus on her present concerns and abandoned her agenda.
Despite the rationale for briefer forms of intervention, many practitioners remain skeptical, if not overtly negative, about the proliferation of short-term methods. Although their opposition may reflect bias against brief intervention, many clinicians also believe that the current emphasis on short-term treatment is misguided and ill conceived as a result of philosophical, political, and economic reasons.
Whether viewed from a positive or negative perspective, the use of short-term approaches challenges practitioners to expand and change their attitudes about the nature of the treatment process, learn new interventive strategies, and address greater external demands for accountability.
SHORT-TERM TREATMENT MODELS IN MENTAL HEALTH PRACTICE
There are three main types of short-term treatment models that are being used extensively in mental health practice: (1) the psychodynamic model, (2) the crisis intervention model, and (3) the cognitive-behavioral model. The table on pp. 20-21 compares the major characteristics of these models.
The Psychodynamic Model
The short-term psychodynamic treatment model consists of a variety of approaches that modify some of the basic assumptions of traditional psychoanalytic theory and treatment and embody more contemporary psychodynamic theories. Short-term psychodynamic psychotherapy generally is used with clients who have circumscribed problems that are embedded in either mild or moderate long-standing conflicts and maladaptive personality traits and patterns. Although their goals are restorative and supportive in some instances, most time-limited psychodynamic models aim at selective personality change and resolution of underlying conflicts. They have clearly defined selection criteria that favor highly motivated and well-functioning clients who have circumscribed problems and tend to exclude a wide range of individuals whose difficulties are more severe, pervasive, and chronic.
Despite the fact that each of the psychodynamic short-term models to be discussed below has somewhat different origins, goals, foci, selection criteria, and practice principles, they share common assumptions and features:
Common Features of Psychodynamic Approaches
1. The belief that early childhood experiences are a major contributor to adult dysfunction
2. The view that presenting problems generally are embedded in long-standing personality conflicts and patterns
3. The use of selection criteria such as a history of adequate adjustment, problems of acute or recent onset, strong motivation, and ability to relate easily
4. A quick and focused assessment
5. Setting of treatment goals that include either selective or more global personality change
6. The early establishment of a working alliance
7. A focus on core conflicts or relational themes that are manifested in the client's history and the treatment relationship
8. The utilization of active techniques such as clarification, confrontation, and interpretation
9. The use of time limits that can be negotiated fiexibly in some instances
Although the classical psychoanalytic model has been associated traditionally with in-depth, long-term treatment aimed at restructuring the personality, many authors have commented on the short-term nature of Freud's early cases and the fact that initially psychoanalysis was not long term (Flegenheimer, 1982; Shechter, 1997; Stadter, 1996; Wolberg, 1980). Nevertheless, the techniques that are characteristic of Freudian psychoanalysis are geared to helping the patient undergo a controlled regression in which early memories and childhood experiences are explored. The patient's revival of important aspects of his or her relationships with significant others in early life in the treatment or transference to the analyst or therapist provides the basis for therapeutic work. The patient's distorted perceptions of the therapist can be analyzed and interpreted in order to help the patient gain insight into the nature of his or her problems and their roots. Traditionally, the analyst was to remain neutral, anonymous, and abstinent or nongratifying so as to maximize the patient's transference.
Interested in making psychoanalysis more efficient and available to a greater range of patients, Ferenczi and Rank (1925) were the first psychoanalysts to address the issue of time in the treatment process. Rank believed that setting and adhering to a time limit in treatment would prevent regression and force the patient to deal with reality. Ferenczi emphasized the importance of using active techniques, such as suggestion and direct advice, in order to maintain the client's level of functioning, help the patient focus on his or her difficulties, and foster motivation (Flegenheimer, 1982, p. 27). Ferenczi and Rank's views were radical for the time and were neither endorsed nor accepted by the psychoanalytic community. Their work fell into disrepute for some time.
Two decades later, Alexander and French (1946) published a pioneering book, Psychoanalytic Therapy, the first systematic presentation of short-term psychodynamic psychotherapy. As Koss and Shiang (1994, p. 665) point out, Alexander and French believed that psychoanalytic principles could be beneficial, irrespective of the length of treatment, and sought to adapt selective psychoanalytic techniques in order to "give rational aid to all those who show early signs of maladjustment" (1946, p. 341). Drawing on the earlier work of Ferenczi and Rank, they also questioned some of the basic assumptions of the traditional psychoanatytic approach: that depth of treatment was related to length; that brief treatment was temporary and superficial while the resuits of long-term treatment were stable and profound; and that it was necessary to prolong treatment in order to overcome the patient's resistance to change (Budman & Gurman, 1988, p. 2).
Alexander and French tried to avoid techniques that fostered regression and emphasized therapy over real-life experiences. Among the more directive and active techniques that they advocated were (1) the manipulation of the frequency of sessions in order to confront the patient's dependency on the therapist; (2) the utilization of temporary interruptions to determine the patient's reactions to termination; (3) emphasis on the patient's affective experience in the here and now, with attention to relevant historical material; (4) direct encouragement of the patient to face conflicts and problems and to put what he or she learned in therapy into practice; and (5) the therapist's assumption of a role that was diametrically opposed to the earlier parental roles in order to promote an emotionally corrective experience that would foster the patient's functioning and ability to engage in more satisfactory interpersonal relationships.
Like Ferenczi and Rank, Alexander and French were ahead of their time and provided the foundation for all later psychodynamic short-term approaches. Nevertheless, their work was controversial at best and minimized and denounced at worst within the psychoanalytic community. In social work, however, it found a more appreciative audience.
Following is a summary of the salient characteristics of the better-known and more recent psychodynamic short-term models.
MALAN'S INTENSIVE BRIEF PSYCHOTHERAPY. In two books based on his studies at the Tavistock Clinic in London, Malan (1963, 1976) outlined an approach to short-term treatment that relied heavily on the technique of classical interpretation of a central conflict or important aspect of the patient's psychopathology. His research indicated that change included not only symptom relief but also modifying basic and entrenched neurotic behavior patterns. The number of weekly treatment sessions ranged from 10 to 40, and the best results occurred when patients showed (1) high motivation for insight, (2) good ego strength, (3) the ability to formulate a specific focus, (4) the ability to establish a quick transference to the therapist, (5) favorable reactions to interpretation, and (6) the ability to deal with their emotional reactions to termination. The therapist's enthusiasm was considered a major factor associated with good outcome.
SIFNEOS'S SHORT-TERM ANXIETY-PROVOKING PSYCHOTHERAPY. Like Malan, Sifneos (1972, 1979, 1987) developed a short-term treatment model that used interpretation of a patient's oedipal conflict as it appeared in the transference to the therapist as the major tool of therapy. In order to help the client focus on the main problem area, Sifneos relied heavily on confrontation and other anxiety-arousing techniques, which often created anger and resistance that needed to be addressed.
The duration of treatment ranged from 7 to 20 weekly sessions. Sifneos's selection criteria were among the most stringent and exclusionary of all the short-term psychodynamic models and stressed the presence of numerous patient characteristics, including (1) aboveaverage intelligence; (2) possession of at least one meaningful relationship in the past; (3) psychological mindedness; (4) ability to interact with the therapist in an affective manner; (5) motivation beyond symptom relief; (6) honesty, curiosity, and openness to self-reflection; (7) willingness to make accommodations and sacrifices; (8) receptivity to new ideas; and (9) realistic goals (Stadter, 1996; Wolberg, 1980).
Sifneos also proposed a brief treatment model, anxiety-suppressive therapy, for patients who showed weaker egos, impaired interpersonal relationships, and chronic difficulties. The goal was to reduce anxiety through more supportive measures, such as reassurance, advice giving, ventilation, environmental manipulation, persuasion, hospitalization, and medication (Wolberg, 1980).
DAVANLOO'S INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY. Davanloo (1978, 1980, 1991) was another proponent of a highly confrontational and interpretive approach, which had definite selection criteria. Stadter (1996, p. 72) views this model as the most forceful and persistent of the short-term psychodynamic approaches. Davanloo himself referred to his methods as relentless. The model also is the most ambitious in that it aims for complete personality or structural change.
The evaluation process can take up to six hours, usually during the course of one day. The length of the treatment depends on the severity of the patient's problems and rate of progress and can vary from as little as 1 to as many as 40 sessions. The emphasis of the treatment is on uncovering unconscious conflict through systematic challenging and interpreting of resistances, making the therapy process highly intense and affectively charged. Discussion of termination is kept at a minimum.
MANN'S TIME-LIMITED PSYCHOTHERAPY. A unique approach to short-term treatment is found in the work of Mann (1973, 1991). Like Rank, Mann made a conscious use of time and the struggle around separation and loss in his short-term treatment model. His approach is highly structured, with a rigid adherence to time limits. The approach consists of a formulation phase followed by 12 sessions, which may be spaced at varying intervals. Selection criteria include patients who can rapidly establish a therapeutic relationship and possess an ability to tolerate loss.
After determining the central issue to be addressed in the treatment during the assessment period, the therapist gives the patient the formulation of the problem, even if it is at variance with the patient's stated complaint, and how the work will proceed. All treatment deals with the theme of separation-individuation as a basic universal conflict that influences the resolution of all later conflicts. Despite the patient's presenting problem, the formulation always relates to the patient's negative self-image, which Mann believes is linked to unresolved separation and loss issues in a patient's life. Because of the treatment's time limit, the therapist helps the patient deal with the establishment of a dependent relationship amid the reality of the impending separation and loss. Presumably the therapy provides the patient with a more optimal setting in which to master separation anxiety and achieve autonomy.
STRUPP AND BINDER'S TIME-LIMITED DYNAMIC PSYCHOTHERAPY. The work of Strupp and Binder (1984) began at Vanderbilt University and drew on the work of Sullivan (1953). Their model, along with that of Luborsky, was among the first psychoanalytic approaches to employ a treatment manual, thus making it easier to implement and study systematically. It was used with patients who showed a range of functioning and personality traits, including resistance, hostility, and negativity.
The duration of the treatment is limited but flexible and ranges from 25 to 40 sessions in instances where personality problems are mild rather than severe. In this model, intrapsychic conflicts are redefined as interpersonal in nature. The therapeutic process relies heavily on the therapist's empathic responsiveness to and ability to address the patient's cyclical maladaptive patterns of relating as they appear in the therapeutic interaction rather than on the use of technical interventions in creating change. Thus, no particular techniques are emphasized. The research findings generated in the use of this model have shed light on the importance of the therapist's personality in treatment outcome.
LUBORSKY'S SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY. Luborsky's (1984) model incorporated ego psychological theory and practice principles to a greater extent than other models. It emphasized both the supportive relationship between the therapist and patient and the technical interventions in facilitating change. Although Luborsky suggested screening out the most severely disturbed and antisocial patients, as well as those who had environmental problems, he believed that the model could be used broadly.
Like Strupp and Binder, Luborsky thought that the duration of treatment was related to the severity of the patient's problems. He recommended 25 sessions that sometimes were spread over time rather than occurring weekly. In more severe cases, Luborsky (1984, p. 67) indicated that as many as 40 sessions might be necessary. Treatment goals are individualized and are supposed to be consistent with what the patient perceives as his or her main difficulties and needs. The therapist employs the full range of psychotherapeutic techniques. A major component of the model is its focus on a patient's core conflictual relationship theme as it is reexperienced in the relationship with the therapist. A manual of procedures that Luborsky developed in conjunction with this his model has been used extensively.
OBJECT RELATIONS AND SELF-PSYCHOLOGICAL MODELS. As psychodynamic frameworks that differed from classical Freudian theory and psychoanalytic ego psychology have gained a wider audience, some theorists have begun to apply their principles to short-term treatment. For example, Stadter (1996) has drawn on object relations theories in his perspective, and Baker (1991) and Seruya (1997) have put forth a selfpsychological model of brief treatment. Although similar in some respects to the other models discussed so far, these newer approaches are important in their alerting the practitioner to a different and broader range of past and existing factors that give rise to certain types of dysfunction than do either Freudian theory or ego psychology. They emphasize the importance of the therapist's ability to provide a holding environment and/or an empathic selfobject experience for the patient.
There are several important limitations associated with the use of psychodynamic approaches. First, as noted by Koss and Shiang (1994, p. 671 ), the majority of individuals who seek help from mental health settings do not meet their selection criteria and thus would not be considered suitable for brief treatment. This fact would not constitute so much of a problem if other types of treatment were readily available. Given the constraints of services, however, an exclusive reliance on a psychodynamic model may result in inappropriate treatment. A second problem in the use of psychodynamic approaches is that they are not suited to patients who are beset by environmental difficulties or seeking help with more concrete needs and immediate concerns. A third difficulty in using these models is that they often employ techniques, such as confrontation and interpretation, that may be contraindicated with some individuals.
The Crisis Intervention Model
Crisis intervention is a form of brief treatment, but not all short-term intervention is crisis oriented. Because all individuals, regardless of their particular personality and strengths, are potentially vulnerable to having their equilibrium disrupted by extremely stressful life events, crisis intervention can be used with a wide range of clients so long as they have been thrown into a state of crisis.
The crisis intervention model originated in part from the study and treatment of soldiers who developed so-called war neuroses and combat fatigue during World War II (Grinker & Spiegel, 1945). Psychiatrists and other mental health professionals, who were charged with the task of helping soldiers return to their battlefield assignments quickly, used emergency interventions that seemed to be effective in many instances, particularly when treatment occurred at or near the front lines. Treatment was based on the belief that soldiers could regain their equilibrium and return to active duty if they were given immediate, supportive help. It was observed that such prompt attention prevented regression, secondary gain, guilt, feelings of failure, stigmatization, and loss of peer support (Parad & Parad, 1990a, p. 13). Additionally, the return of soldiers to civilian life after the completion of their military service necessitated readjustment of both the veterans and their families. Many sought help for transitional difficulties that seemed to respond to brief interventions.
Concurrently, other investigators became interested in the reactions of individuals to disasters and stressful life events. Lindemann's classic paper, "Symptomatology and Management of Acute Grief" (1944), delineated identifiable stages of the grief process of the survivors of the tragic Coconut Grove nightclub fire in Boston, in which hundreds of individuals lost their lives or were injured. According to Lindemann, an important component of grief resolution is the survivor's ability to master various affective, cognitive, and behavioral tasks. He observed that people could resume and even improve their precrisis level of functioning after a crisis, or they could deteriorate. Lindemann believed that those who showed more maladaptive solutions to their grief could be helped to cope more effectively with their mourning through intervention, and he developed an interventive approach of 8 to 10 sessions.
Lindemann's work, along with that of Caplan (1964), led to more systematic study of how people cope with disasters and other stressful life events and to the establishment of community-based crisis intervention services. Caplan, in his work at Harvard University in the 1950s, was instrumental in the development of programs that provided early intervention to those experiencing acute situational stress in an attempt to facilitate crisis resolution and to forestall more serious problems.
In the 1950s and 1960s, crisis theory expanded greatly. One of the hallmarks of this period was a greater delineation of different types of crises -- for example, those resulting from developmental and maturational stages, life and role transitions, and traumatic events. Others who contributed to this body of knowledge were Hill (1958), Janis (1958), Kaplan (1962, 1968), Langsley and Kaplan (1968), Lazarus (1966), Le Masters (1957), Parad (1971), Parad and Caplan (1960), Rapoport (1962, 1967), Selye (1956), Strickler (1965), and Tyhurst (1958).
Crisis theory is based on the assumption that an individual strives to maintain equilibrium through an ongoing series of adaptive measures and problem-solving techniques. A crisis represents an upset in that equilibrium in which the person's customary coping strategies are inadequate to deal with the task at hand. Although some crisis theorists suggest that all people who experience a similar event will respond in a similar manner, others have focused on the unique meaning that the individual attaches to a particular situation. For example, Jacobson, Strickler, and Morley (1968) differentiate between generic and individual intervention, the former focusing on the common reactions of all the people who experience the same event and the latter emphasizing the more unique reactions of each person. Although the active state of crisis is time limited, usually lasting four to six weeks, intervention can facilitate crisis mastery, prevent more maladaptive solutions, and allow for the reworking of underlying conflicts. It is crucial that crisis intervention be undertaken as near to the stressful event in time and proximity as possible. Due to the client's state of helplessness and vulnerability, he or she is more open to influence and change during a crisis.
Crisis intervention usually occurs in 4 to 12 sessions. The therapist attempts to convey an empathic understanding of the patient's state of disequilibrium and establish a working alliance with the patient. The therapist becomes a benign authority figure who provides a sense of safety and strength.
The goals of crisis intervention usually are limited to the resolution of the crisis, but this is not always a simple matter. For example, Langsley and Kaplan (1968, pp. 4-5) suggest a recompensation type of crisis intervention that helps the client return to his or her precrisis level of functioning and a limited psychotherapy model that deals with the underlying conflicts that have been reactivated. There may be instances, however, when it is not possible to help an individual resolve a crisis without dealing with these underlying issues since it is the triggering of these past conflicts and experiences that transformed the stressful current situation into an actual crisis.
Jacobson, Strickler, and Morely (1968) identify four levels of crisis intervention: (1) environmental, where the therapist serves as a referral source; (2) general support, involving ventilation, active listening, acceptance, and reassurance; (3) generic, in which the therapist deals with the common reactions that individuals who experience the same type of event are likely to show; and (4) individual, in which the therapist uses his or her understanding of the patient's personality dynamics to foster the development of insight into why the crisis event has been so disruptive.
The greatest strengths of the crisis model -- its specificity and clear methodology for working with individuals who are experiencing a state of acute disequilibrium -- become potential limitations in certain situations. Although all persons who seek help are uncomfortable in some way, most are not in a true state of crisis. Problems may have existed for a long time before the person seeks help, or they may be chronic. Sometimes individuals show a pattern in which being in crisis has become a way of life. In these and other instances, crisis intervention is not an appropriate model.
The Cognitive-Behavioral Model
Although behavioral and cognitive theories and treatment methods originated independently, in today's practice arena they overlap to a great extent and often are referred to as cognitive-behavioral approaches (Koss & Shiang, 1994, pp. 666-667). The cognitive-behavioral model focuses on modifying clearly defined ways of thinking and behaving and the current factors that are sustaining them rather than uncovering or exploring the past origins of the behaviors.
Not developed specifically as a short-term treatment, the cognitive-behavioral approach nevertheless is used frequently as a part of time-limited treatments, and results can be achieved in 12 to 20 sessions (Wright & Borden, 1991, p. 424). Cognitive-behavioral methods have been shown to be helpful in the treatment of anxiety disorders and phobias, obsessive-compulsive disorders, weight problems, smoking, somatic disorders, eating disorders, alcohol and drug abuse, and some aspects of schizophrenia (Goisman, 1997; Koss & Shiang, 1994). More recently, cognitive therapy has shown some promise in work with borderline personality disorders over a longer time frame (Beck, Freeman, & Associates, 1990; Heller & Northcut, 1996; Linehan, 1993).
The field of behavior therapy and behavior modification emerged after World War II and drew heavily on experimental psychology and social learning theory. Pavlov's work on classical or respondent conditioning, in which existing patterns of stimulus and response are associated with new stimuli to create new responses, and Skinner's experiments based on operant conditioning, in which rewards and punishments were used to create and modify behavior, were seminal (1953). Additionally, social learning or learning through observation, imitation, role playing, and rehearsal became an important part of the behavioral repertoire (Goisman, 1997, p. 4; Thyer & Myers, 1996, pp. 27-28). Other major contributors to the behavioral model were Wolpe (1958, 1969) and Lazarus (1971, 1976).
Cognitive treatment had its roots in the work of Adler (Adler & Ansbacher, 1956) and gathered renewed interest through the development of Ellis's (1962, 1973) rational emotive therapy and the later cognitive therapy of Beck (1976). In the 1970s, behaviorally oriented clinicians and researchers began to incorporate aspects of cognitive theory into their work (Craighead, Craighead, Kazdin, & Mahoney, 1994). As Thyer and Myers (1996, p. 29) point out, cognitive theorists accepted many aspects of behavioral theory but stressed additional elements that they felt were essential to understanding behavior and planning treatment, such as the importance of the cognitive representation of events rather than the events per se and the role of cognition. and thinking in determining behavior and emotions.
Behavior therapy emphasizes the consistent implementation of techniques with the goal of altering self-defeating or maladaptive behaviors and undesirable traits. The primary foci of the treatment are (1) identifying target behaviors, that is, those that need to be changed; (2) the antecedents of the behaviors; (3) the consequences of the behaviors; and (4) the interactions of both the antecedents and consequences of the behaviors (Bandura, 1976). Efforts are made to reinforce new behaviors and to modify, punish, or extinguish maladaptive behaviors through systematic desensitization, respondent and operant conditioning, flooding, and observational learning.
Cognitive therapy attempts to modify the patterns of thinking that are at the root of dysfunctional behavior and troubling emotions by (1) correcting misconceptions, unrealistic expectations, and faulty ideas; (2) modifying irrational thoughts that relate to the self; (3) improving problem solving; and (4) improving self-control and self-management (Fischer, 1978, pp. 177-178). The therapist helps the patient bring into focus the thoughts, beliefs, and ideas that are creating and maintaining his or her problems. The approach is reality oriented and educational. It uses such techniques as clarification of thinking, reeducation, and homework assignments.
Cognitive-behavioral therapies are well suited to addressing specific and circumscribed target symptoms, traits, and behaviors that the individual is highly motivated to change. Although there is some indication that these techniques can be used to modify certain ways of thinking and behaving in those who show more deep-seated personality problems, generally they are not as helpful in dealing with complex individual, interpersonal, and person-environmental difficulties. Further, the exclusive focus on altering thinking and behavior overlooks more dynamic aspects of the person and often leads to a mechanical application of technique.
SOCIAL WORK PRACTICE MODELS AND SHORT-TERM TREATMENT
Social workers are part of a unique profession and are particularly well suited to serve clients in the current climate. From the profession's inception, they always have been on the front lines in working with clients from diverse backgrounds and with clients who faced problems in living as well as more severe and persistent personality and environmental difficulties. Moreover, much of social work practice over the years has been short term in nature.
Social workers intervene with clients presenting a staggering array of problems in a variety of facilities and in private practice -- for example, Vietnam veterans and their families; persons with HIV-related illnesses and their caregivers; survivors of physical and sexual abuse and other types of trauma; individuals suffering from mental illness and other forms of emotional disorder; substance abusers; victims and perpetrators of child abuse and other forms of domestic violence, rape, and crime; individuals and families coping with death, divorce, physical illness, disability, aging, unemployment, homelessness, and other types of life crises; and those struggling with family difficulties, interpersonal, school, and occupational problems, and life cycle transitions.
When social work originated in the nineteenth century as a result of the activities of the Community Organization Society and, later, the settlement houses, the focus of intervention was the person in interaction with his or her environment. Early caseworkers, or friendly visitors as they were called, as well as settlement house workers attempted to help those in lower socioeconomic circumstances, many of whom had recently emigrated to the United States. They confronted problems that were immediate, sometimes concrete, and often related to family, situational, environmental, and cultural issues.
The Early Diagnostic Model
As social work became professionalized, Mary Richmond's pioneering book, Social Diagnosis (1917), became the foundation of casework practice. Relying on a medical model, Richmond advocated an exhaustive study process. Only after a formal diagnosis of the client's problem was made could treatment be implemented. In keeping with Richmond's emphasis, the "diagnostic school" or "differential" approach emerged in the 1920s, taking its name from the fact that it regarded diagnosis as the foundation of all intervention. This model developed in the aftermath of World War I, which brought social workers in hospitals and clinics into greater contact with psychiatric principles and practices. During this period, Freudian theory, which emphasized the role of intrapsychic conflict in causing client problems, gained acceptance among a large segment of social caseworkers, particularly in the northeastern United States. It seemed to explain why it was so difficult for clients to change certain behaviors and their seeming resistance to intervention (Hollis, 1963, pp. 7-23).
Many practitioners adopted the Freudian view that it was necessary to modify clients' underlying conflicts in order to help them improve their current functioning, and they incorporated psychoanalytic techniques into their practice. The focus of treatment shifted away from the more here-and-now, concrete manifestations of clients' problems and their environmental component to emphasize the personality dimensions of the clients' difficulties and their childhood origins. Because the process by which a client developed insight into the true nature of his or her personality difficulties and altered their basic patterns of functioning was time-consuming, treatment became lengthier. For a time, diagnostic casework and individual long-term psychotherapy seemed to be synonomous.
The Functional Model
In response to what some have argued were excesses in the use of the diagnostic model during this early period (Hamilton, 1958, pp. 11-37; Meyer, 1970, pp. 36-53), a schism developed between the diagnostic caseworkers and those who called themselves functional caseworkers. As early as the 1930s, Robinson (1930) recognized the importance of time as a propelling factor in treatment, and she, along with Taft (1937, 1950), made it a central component of functional casework practice.
Taft and Robinson rejected Freudian theory and the diagnostic casework approach associated with it because they felt it was too pathology oriented in its view of clients' problems, robbed them of taking responsibility for change, created undue dependence, and led to an unrealistic, never-ending process of exploration of the past (Yelaja, 1974, pp. 151-152). They drew instead on the theories of Rank, who viewed individuals as more active and creative in seeking health, capable of changing themselves and their environment within the limits of their capacities, and able to use relationships to move toward their life goals (Smalley, 1970, pp. 90-91). In fact, Robinson stressed the use of relationships as a major force in helping to empower the client to make necessary changes. Further, she viewed the client, rather than the worker, as having the major responsibility for his or her life.
As described by Yelaja (1986, pp. 52-53), the functionalists rejected the concept of diagnosis as it was being used at the time and the need for in-depth and time-consuming exploration of the client's personality difficulties. In large part, the agency's function organized and directed the interventive process. Workers attempted to engage clients in a relationship process designed to release the client's own power for choice and growth. The use of time was a crucial factor in functional casework since it presented the client and worker with the need to accept constraints and endings. The helping process was partialized and linked to the client's use or rejection of the agency's services within a specified time limit. This focus on time led to greater attention to the present and a more conscious use of the phases (beginning, middle, and ending) of the helping process. The functionalists viewed the ending phase, which involved separation from the worker, as a major force in helping the client take responsibility for his or her own life. The functionalists believed that the client would benefit from and become more self-actualizing, empowered, and self-sufficient as a result of this process, irrespective of his or her particular problem.
Like the diagnostic model, functional casework had its critics, many of whom argued that it created rigid conditions, ignored the client's view of the problems, misused agency and worker authority, and engendered a relationship struggle between worker and client in which the client's problems were lost.
Ego Psychology and the Evolving Diagnostic (Psychosocial) Model
At the end of the 1930s (although it became more significant in the post-World War II period), ego psychology gained recognition in the United States and had an important impact on social work practice (Goldstein, 1995a; Woods & Robinson, 1996). Followers of the diagnostic school used ego psychological concepts to help correct what some considered to be the model's narrow intrapsychic focus, reliance on psychoanalytic techniques, lack of specificity of goals, and openended nature. In 1940, Hamilton published the widely used Theory and Practice of Social Casework, which put forth the principles of the evolving diagnostic approach. Hamilton began to use the term psychosocial, which was incorporated by Hollis, who was responsible for continuing and expanding the model after Hamilton's death (Hollis, 1964, 1972; Hollis & Woods, 1981; Woods & Hollis, 1990).
Among ego psychology's contribution were (1) its more optimistic and humanistic view of human functioning and potential; (2) its view of environmental and sociocultural factors as important in shaping behavior; (3) its focus on clients' rational, problem solving, adaptive capacities, and strengths; (4) its conception of development as a lifelong process; (5) its expanded view of change processes to encompass learning, mastery, corrective relationship experiences, and environmental supports rather than only insight; and (6) its view that it is possible to enhance, sustain, or modify functioning without reworking the client's underlying personality difficulties (Goldstein, 1995a).
Diagnostic caseworkers used ego psychological concepts to reconceptualize the casework process. Some of the desired modifications included (1) shortening of the study phase; (2) assessing clients' ego functions, including their strengths and the degree to which the external environment was creating obstacles to successful coping; (3) focusing on more current issues, particularly the degree to which clients were coping effectively with major life roles and tasks; (4) appreciating the key developmental issues affecting the clients' current reactions and addressing them in the interventive process where feasible; (5) attending to goal setting, greater structuring of the interventive process, and more active focusing; (6) classifying types of intervention more clearly (for example, supportive, experiential, insight or modifying, environmental modification); (7) expanding interventive procedures to include more supportive and environmental measures; (8) recognizing the importance of the helping alliance between client and worker; (9) emphasizing the reparative, enhancing, and sustaining impact of the casework relationship; and (10) using crisis, short-term, and long-term methods (Goldstein, 1995a; Parad, 1958; Parad & Miller, 1963).
During the 1940s and 1950s, there were many attempts to define the goals and techniques of social casework, differentiate social casework from psychotherapy, and enlarge its range of application (Austin, 1948; Cockerill & Colleagues, 1953; Garrett, 1958; Hollis, 1949, 1964, 1972; Stamm, 1959; Towle, 1949, 1954). In codifying and refining the psychosocial approach, Hollis described and studied a group of techniques that can be used flexibly in the interventive process. In addition to those used primarily with the individual, including sustainment, direct influence, exploration-description-ventilation, person-in-situation reflection, pattern-dynamic reflection, and developmental reflection, Hollis also classified environmental intervention according to the type of resource employed, the type of communication used, and the type of role assumed (provider, locator, creator of a resource, interpreter, mediator, or aggressive intervener) (Goldstein, 1995b).
Those involved in the evolution of the psychosocial approach have shown an openness to new knowledge over the years and a willingness to discard ideas that are not useful. Nevertheless, it has remained associated with its earlier and more psychoanalytic and long-term thrust. It is beyond the scope of this chapter to discuss all the reasons for this. It can be said, however, that although many social workers incorporated important changes in the model, others either did not understand how to use these newer ideas in their direct practice, or they continued to be invested in using the more traditional approach.
The Problem-Solving Model
Efforts to assimilate ego psychological concepts and emerging cognitive and social science theories also led to a distinctive problem-solving casework model developed by Perlman (1957). Among the factors motivating her work were a desire to heal the split between the diagnostic and functional caseworkers and a wish to offer correctives for practices that she viewed as dysfunctional and believed were responsible for long waiting lists, high dropout rates at family agencies and mental health clinics, unfocused and lengthy treatments, and the pathologizing of clients.
Although Perlman viewed herself as diagnostically oriented, she also saw the value of many of the principles of the functional school (for example, partialization and attention to the phases of the helping process) and incorporated these into her approach. In her seminal book, Social Casework, Perlman evolved a casework model based on the premise that all human living is effective problem solving. She described the casework process as a series of problem-solving operations that were carried out within and given impetus by the client-worker relationship.
Perlman (1957, p. 17) referred to the ego as the problem-solving apparatus of the personality system. Interested in cognitive theory, she emphasized rational thinking processes. Drawing on Erikson's (1959) views of the life cycle and White's (1959) theory of competence, Perlman thought of the individual as always striving toward growth and having an inherent thrust for self-actualization. Her optimism and belief in the positive impact of current relationships and experiences played an important role in her understanding of the casework process.
Two major contributions of the problem-solving model were its sharp focus on the client's presenting problem and its recognition of the importance of partialization in deciding how to intervene. The process consisted of three phases: the beginning phase of the work centering on understanding the facts of the problem; the middle phase focusing on engaging the client's thinking and feelings about the problem and establishing a focus; and the third phase including ongoing discussions of options, alternatives, and consequences of actions and emphasizing decision making and doing.
Unlike the diagnostic approach, which required a period of study and diagnosis before treatment could begin, the problem-solving approach stressed the importance of immediate engagement in which the client is supported and sustained and encouraged to think and talk about the various aspects of the problem and begin to explore possible solutions. Assessment of the client's motivation, capacities, and opportunities (Ripple, 1964) occurred simultaneously.
Although Perlman's model achieved considerable success in many circles, it failed to overcome the division between the diagnostic and functional caseworkers, both of whom criticized Perlman for abandoning too many important features of their respective approaches.
The Crisis Intervention Model
During a period in which there was an expansion of knowledge in the social sciences and experimentation with new practice models, Golan (1978) brought together much of the burgeoning crisis theory literature discussed earlier in the chapter. In Treatment in Crisis Situations, she put forth a crisis model specifically geared to social work practice. Additionally, Parad (1965) and Parad and Parad (1990b) compiled numerous important articles that applied crisis intervention to a broad range of special populations.
According to Golan (1978, pp. 62-63), the crisis situation encompassed a total sequence of events, "from equilibrium to disequilibrium and back again," and contains five components: (1) the hazardous event, (2) the vulnerable state, (3) the precipitating factor, (4) the state of active crisis, and (5) the state of reintegration or crisis resolution. Assessment must include an understanding of the nature of the crisis, the individual's precrisis level of functioning, the coping capacities of the individual or family, and the presence of inner and outer resources.
Rapoport (1970, pp. 297-298), another important social work crisis theorist, described the minimum goals of crisis intervention as (1) relief of symptoms, (2) return to previous level of functioning, (3) understanding of what precipitated the crisis, and (4) identification of the remedial measures that clients can take or that are available through community resources. She also indicated that the more ambitious goals of connecting current stresses with past life experiences and conflicts and helping the client develop new coping mechanisms might be undertaken when the client's personality and social situation were favorable and the opportunity existed.
Practice principles of the crisis model include (1) time-limited interventions, (2) worker flexibility, (3) high level of worker activity, (4) circumscribed specific goals, and (5) the identification of tasks to be mastered. The interventive process emphasizes ventilation, clarification, reassurance, direct influence, supporting strengths, and the mobilization of inner and outer resources.
The crisis intervention model has been used increasingly among social workers and occupies a crucial role in social workers' armamentarium of approaches. However, it has a restricted range of application and cannot be relied on exclusively.
The Task-Centered Model
The task-centered approach (Epstein, 1980, 1992; Reid & Epstein, 1972) had its origins in research conducted by Reid and Shyne (1969) in which planned short-term treatment of an unspecified nature, consisting of 8 to 12 interviews over a three-month period, was compared to more open-ended and extended treatment at the Community Service Society in New York. The findings showed that clients who received short-term intervention did as well in a briefer period of time as did those receiving continued service. A major component of intervention that differentiated the two forms of treatment was the degree of worker activity, which was much greater in the short-term process.
In Task-centered Casework (1972), Reid and Epstein presented a more structured and systematized model of short-term treatment that drew on problem-solving, cognitive, and crisis theories. Like those who used crisis intervention, Reid and Epstein believed that the client's presenting request for help usually reflected problems in living and a temporary interference with customary problem-solving abilities. Further, they argued that the client would seek to restore his or her equilibrium and that time limits would accelerate the helping process.
The task-centered approach has a number of important features: (1) the delineation and use of a problem topology, (2) a stress on the worker and client's coming together in identifying the goals and focus of intervention; (3) the organization of the helping process around specific client tasks, and (4) the specification of modes of intervention (Reid & Epstein, 1972, p. 25). Diagnosis centers on target problems rather than personality functioning, treatment goals are specific and limited, and the treatment process encourages clients to carry out a specified course of action related to the client's own perception of the problem and its possible solution. The relationship process is deemphasized in favor of more specific case planning and technical interventions.
Originally, Reid and Epstein enumerated certain target problems or areas that they felt were amenable to task-centered practice, including (1) interpersonal conflict, (2) dissatisfaction in social relations, (3) problems with formal organizations, (4) difficulties in role performance, (5) problems of social transition, (6) reactive emotional distress, and (7) inadequate resources. In addition, they felt that clients must recognize and show motivation to work on the problem, that the problem must be solvable, and that it must be limited in scope (pp. 42-53). Later, Epstein envisioned an even more inclusive approach, suggesting that all problems are appropriate for task-centered intervention and that the worker's responsibility is to help the client define target problems and specific foci that can be addressed by means of the model's techniques (Epstein, 1992, p. 103).
The task-centered approach underwent considerable testing and development during the 1970s and 1980s (Epstein, 1992, pp. 114-115). In Brief Treatment and a New Look at the Task-Centered Approach (1992), Epstein outlined a more methodical, detailed, and prescriptive approach to the model and described four sequential but overlapping steps: Step 1, in which the client's target problems are identified; Step 2, in which the contract (the agreed-on goals, focus, tasks, scheduling of interviews, and time limits) is established; Step 3, in which problem solving, task achievement, and/or problem reduction are implemented; and Step 4, in which termination occurs. Although time limits were established at the beginning of treatment, they could be modified by mutual agreement between worker and client.
The task-centered approach, used widely in social work, is more suited to work with very concrete and specific problems and highly motivated clients. Some criticisms of the model include its almost total lack of attention to personality functioning and dynamics in assessment, its narrow and mechanical application in goal setting and intervention, its simplistic view of human problems and their amelioration, and its limitations in work with more complex difficulties.
The Cognitive-Behavioral Model
When psychodynamically oriented treatment came under attack in the 1960s, some social workers embraced cognitive and behavioral theories, which view patterns of thinking and behaving as leading to problems in functioning. Although each of these models has a distinctive focus, in that the cognitive approach tends to be educative, centering on altering the ways clients think and behavioral intervention emphasizes the client's overt behavior, the models overlap and share common characteristics: (1) a systematic assessment in which presenting problems are redefined in terms of current thoughts, observable behaviors, and environmental factors that are contributing to the problem; (2) a clear prescription for how to correct distorted thinking and self-defeating behavior, create new ways of perceiving the self and others, and develop more desirable behaviors and skills; and (3) the use of objective measurements of progress and outcomes.
These models do not make use of time in the interventive process explicitly, but the duration of treatment tends to be short term. Often intervention takes place in 25 to 30 sessions or more. In fact, the seeming rapidity with which positive outcomes were attained was a controversial issue when the models were first used (Wilson, 1981, p. 131). Cognitive-behavioral approaches tend to envision the worker as an expert who is going to direct the change process. It advocates the use of more active rather than reflective techniques -- for example, education, direct influence, logical discussion, rehearsal, homework assignments, behavioral reinforcement, self-monitoring through the use of record keeping, and a variety of other techniques aimed at modifying concrete behaviors and irrational or distorted ways of thinking.
Like the task-centered model, cognitive-behavioral approaches have been shown to be effective in addressing very specific types of target problems and symptoms with clients who show strong motivation. Their limitations center on their narrow focus and range of applicability.
The Ecological Perspective and Life Model
Attempting to correct for what they perceived as casework's lip-service attention to the environmental component of client problems and continuing reliance on psychodynamic theory and psychotherapeutic techniques, a number of authors proposed that general systems theory become an overarching framework that would provide a distinctive and unifying conception of social work practice (Bartlett, 1970; Gordon, 1969, pp. 5-11).
In an effort to go beyond general systems theory's more theoretical, mechanistic, and abstract characteristics, Germain (1979) and Germain and Gitterman (1980) used concepts from ecology, ego psychology, particularly the work of Erikson (1959) and White (1959), and theories of stress and coping in evolving their ecological perspective. Germain redirected attention to the transactions and mutual and reciprocal impact of people and their environments in the process of adaptation. She regarded adaptation as involving either the individual's attempts to change himself or herself in order to cope more effectively with the environment or efforts aimed at making the environment more responsive to people (Germain, 1991, p. 17). Germain also emphasized the "goodness of fit" between people and environments as essential to individuals' well-being and viewed problems as stemming from the "discrepancies between needs and capacities, on the one hand, and environmental qualities on the other" (Germain & Gitterman, 1980, p. 7).
In keeping with the ecological perspective, Germain and Gitterman (1980) put forth the life model, which provided an alternative to a disease-oriented approach. It assessed clients' problems in three interrelated areas of living: (1) life transitions and traumatic life events, (2) environmental pressures, and (3) dysfunctional interpersonal relationships. The life model advocated interventions directed at improving the quality of the person-environmental fit.
The life model aims to release the potential for growth, health, and adaptive social functioning and to make the social environment more responsive to human needs, goals, and capacities (Germain & Gitterman, 1986, p. 628). It focuses on strengths rather than pathology and combines a focus on helping the individual with an emphasis on organizational and social change. Thus, it encompasses both micro- and macrosystems intervention.
Although not developed as a distinctively short-term model, the life model can be used on a short-term basis. The assessment process is ongoing and interactive rather than constituting a clearly defined diagnostic phase conducted solely by the worker. In the interventive process, the life model stresses (1) the mutuality of contracting between client and worker with respect to problem definition, objectives, planning, and action; (2) engaging the client's decision making and cognition and enhancing the sense of self-direction, self-esteem, and competence; and (3) the importance of mutuality and authenticity in the client-worker relationship in order to promote the client's competence and reduce social distance and power differentials (Germain & Gitterman, 1986, p. 632). In the area of techniques, the life model is not prescriptive; it is thought to be composed of common and generic practice skills directed at improving the person-environmental fit.
As an alternative to the psychosocial model of practice, the life model has gained considerable adherents, particularly in academic social work circles. It has been criticized, however, as abstract and difficult to use, minimizing the personality system in assessment and intervention, leading to more superficial interventions, and creating a new division between more clinically oriented social work and "real" social work (Goldstein, 1996).
The Proliferation of Practice Models
When direct practice reasserted its importance in the 1970s and 1980s after being eclipsed by a focus on macrosystems intervention, the awareness of the pressing needs of clients for individualized services led to many new theoretical developments and practice models. In addition to those already discussed, psychodynamic theory expanded to embrace newer developments in ego psychology, object relations theory, and self psychology, which are more interpersonal and transactional in nature; couple and family approaches became popular; group treatment gathered more adherents; more affirmative and empowering models for work with women, people of color, and gays and lesbians were put forth; empirically based practice models were advocated; and practitioners began to experiment with hypnosis, biofeedback, gestalt techniques, and other newer forms of intervention. A popular social work text cites over 25 different frameworks for practice and does not include some of those that have developed since
An Integrative Perspective
Short-Term Treatment and Social Work Practice
An Integrative Perspective
In Short-Term Treatment and Social Work Practice: An Integrative Perspective, Eda G. Goldstein and Maryellen Noonan take the best of theories that social workers have relied on for decades, including ego psychology, other psychodynamic and psychosocial frameworks, and the cognitive-behavioral approach, to create a new short-term practice model for social workers. Short-Term Treatment and Social Work Practice introduces the authors' integrative short-term treatment (ISTT), and demonstrates in detail each aspect of the approach. Their book is replete with case examples that illustrate ISTT's principles and techniques and their use in a variety of situations -- including crisis intervention, family- and group-oriented therapy, treatment of clients with emotional disorders, and treatment of nonvoluntary and hard-to-reach clients.
As the first social work textbook describing an integrated framework for short-term treatment and practice, Short-Term Treatment and Social Work Practice fills a void the mental health field. Offering a comprehensive, practical, in-depth discussion, this book promises to become a vital new resource for students and practitioners alike.