Doing Therapy
Briefly
Professor Robert Bor
Consultant Clinical, Counselling & Health Psychologist
Family and Couples Therapist
Royal Free Hospital, London
Director, Dynamic Change Consultants
www.dccclinical.com
Related themes
Goals?
Aims?
Expectations?
Needs?
What affects or informs practice?
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Core beliefs about psychological challenges
Life experience
Training and experience
Interests
Supervisor
Context or work setting
Wider issues and pressures (work
resources, profession, clinical guidelines
and protocols)
How many of us have been trained to
work briefly in the course of our basic
training?
How many of us have acquired skills
in 'brief therapy' since qualifying?
Literature refers to numerous 'schools' or
approaches in brief therapy
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Time-limited therapy
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Focal therapy
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Short-term therapy
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Solution-focused therapy
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Strategic therapy
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Brief therapy
This is not therapy lite
One size does not fit all in therapy
– one size fits no-one
Is it conceivably possible that particular
brands and schools fit with every problem or
person, whether CBT, Mindfulness,
Psychodynamic, Brief, Client centred etc?
Working briefly as a therapist is NOT about
abandoning your approach to therapy.
This is not a sales pitch on ‘brief therapy’; it
is about reflecting on how we engage,
viewing psychological issues differently,
expecting different outcomes and practising
more flexibly.
Working briefly is not ‘therapy lite’
Modern approaches are typically…
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Evidence-based
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Time-limited
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‘Branded’ (acronyms are common)
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Value the therapist’s unique style or
personality less
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Often involve ‘objective’
measurement
The ‘dose effect’ in therapy
When does change most occur in
therapy?
What are the points at which this is
most likely to occur?
Dose effect in therapy:
selected research
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Seligman 1995, Am Psych 50, 12, 965-74
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Kopta 1994, J Cons Clin Psych 62, 5, 1009-16
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Kopta 2003, J Clin Psych 59, 727-33
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Hansen 2002, Clin Psych, 9, 329-43
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Barkham 1996, J Cons Clin Psych, 64, 5, 927-35
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Kadera 1996, J Psychotherapy, 5, 2, 132-52
Dose effect in therapy:
summative outcome
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The most significant positive changes
occur within the first 12 sessions
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Measurable progress can be found in as
few as 1 or 2 sessions, irrespective of the
approach used
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78% of clients receive what they want
after a single session
What do most of our clients want
from therapy?
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Support; time; space
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A witness to their grief and pain
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An outsider to accompany them through
grief
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Validation of their feelings
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Reflection on their coping and solutions
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Escape from people who inflict
cheeriness
Grief is normal, but uncomfortable
and painful
But it should not necessarily lead into long
term therapy for personality change or
psychopathology
Pathological grief (enduring acute despair,
suicidal intent, dysfunctional behaviour,
resistant clients) is rare
Changes in therapy since
the economic downturn: the
impact on services
Changes in how
therapy is delivered
It is increasingly packaged,
and there is liberal use of
acronyms
Changes in what happens
in therapy
Less emphasis on listening, stillness,
reflection, engagement through empathy.
This is seen as ‘inactive’ and a less good use
of time in therapy. There is a premium on
‘doing something’ in therapy.
Changes in what clients
expect from therapy
An increasingly ‘app-driven’ culture gives
support to the idea that there is a solution
out there which is packaged, accessible
and akin to a commodity. There is a shift in
emphasis from the psychological problem
to methods.
Changes in what family members expect
to hear after the therapy session – they want
to see evidence of change or improvement,
and sometimes feedback
Changes in what therapy
supervision/management aims to
achieve
The economic downturn has put stress on
therapeutic services which, in turn, require
different methods of doing therapy. Therapy
needs to be protocol driven and outcomes
demonstrated.
Increasing presence of
managed care
Private medical insurers, the NHS,
and other organisations require
therapy to be delivered within a
specific timeframe and for
diagnosable/treatable problems (DSM
V and ICD 10).
Changes in protocols over
the delivery of therapy
Increasing use of formulations,
diagnosis, measurable outcomes,
questionnaires, client satisfaction
surveys, etc.
Problems being clearly
categorised, measurable and
definable
This means that problems are reified
and there is less attention given to
cofactors which may drive or maintain
problems. Linear versus circular
causality dominate. Grief is
categorised.
Changes in where people seek or
find therapy; changes in how
therapy is delivered
Face-to-face, online, packaged,
in groups, etc.
A de-emphasis on the person
of the therapist in favour of
following standardised protocols
The therapist is increasingly devalued
in relative terms and the method of
therapy receives greater attention.
Time and timing in therapy
Time and timing in therapy
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When the client contacts you
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When the session is scheduled for
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Length of session
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Interval between sessions/frequency
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When we 'intervene'
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Dealing with endings in therapy
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Dealing with missed appointments
What are some core beliefs about
therapy?
Beliefs by therapists about briefer therapy
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More is better than less
Less is shallow
It ignores the client’s emotional pain
It is too active; therapy is rushed and the client feels
‘coerced’ into change
 Buys into a ‘quick fix’ culture in therapy
 Working briefly is no way for a therapist to make a living
Working briefly requires a willingness to
re-examine:
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The role of the therapist in eliciting change
The role of the client in therapy
Beliefs about psychological problems and solutions
The nature of the therapeutic relationship, especially
with regard to the intake process and endings
The overall place of therapy in people's lives (a
permanent ‘cure’?)
Experience of therapeutic process; it may not always
be neat, orderly and predictable
Core beliefs about working briefly
in therapy
1. Therapy is mostly a conversation
between at least two people. It is the
quality, richness and intensity of the
conversation, rather than its duration,
that is most relevant to therapeutic
outcome.
Core beliefs
2.
Relationship (between client and therapist) is
at the core of working briefly. The therapist
listens intently to the client. Intensity is actively
sought from the outset through positive,
energetic and empathic engagement.
Maintaining emotional distance will not help to
achieve the levels of engagement and security
needed to work in a time-sensitive way.
Core beliefs
3.
Emotional distress and pain is acknowledged.
The therapist does not ignore the client's affective
response by steering the conversation to
solutions. This is the 'heart and soul' of therapy.
(Hubble et al. 1999)
Core beliefs
4.
Less therapy does not imply a shallower
or weaker form of therapy. The therapist
and client can 'dig deep' over a shorter
time span.
Core beliefs
5. Research has shown that most
change occurs early on in therapy
and this ‘window’ is seen as an
opportunity, but with limits.
Core beliefs
6.
Working briefly does not mean that clients are
seen only over a short period of time.
Sessions may be spaced apart at intervals
(e.g. fortnightly or monthly), and the judicious
and creative use of time within and between
sessions can positively further the aims of
therapy.
Core beliefs
7.
Therapy does not necessarily nor
specifically aim to 'cure' clients; the aim
is to help the client to move to not
needing therapy. The therapist is not
necessarily present for every step that
the client takes to resolve their problem.
Core beliefs
8.
Therapy is a co-partnership with clients
and is therefore not hierarchically
organised.
Core beliefs
10 The client is validated. The therapist
simultaneously assigns competence to the
client alongside the story of the problem.
Feelings of shame are addressed.
Characteristics of time-sensitive therapy
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The intention is to help move clients to an agreed goal in a timeefficient way
Number of sessions may or may not be specified
Time is limited and is used flexibly and creatively.
Therapist is active throughout - a positive, strong and
collaborative working alliance is developed
Effort is made to engage the client in the process from the outset
Clear and achievable goals are discussed from the outset
There is flexibility around goals which may change
Assessment is conducted early and rapidly and is ongoing until
the therapy concludes.
Characteristics of time-sensitive therapy
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Interventions are introduced promptly
Serious problems do not necessarily require profound solutions;
small changes may be sufficient
The client's strengths, abilities and resources are recognised and
encouraged rather than emphasising pathology
Different approaches may be used drawing on a wide repertoire of
skills
Change is expected to occur; this expectation may be self-fulfilling
Change mostly occurs outside of sessions and ALWAYS before
therapy starts and should be validated
There is a clear sense of ending right from the beginning.
Traditional versus brief therapies: Key concepts
Long-term insight oriented therapy Time-sensitive therapy
 Time in therapy is unlimited
and open-ended
 Time is acknowledged as a
therapeutic issue and
accordingly limited and
structured
 Therapist seeks an
understanding of the causes of
the problem and of underlying
or enduring traits
 Therapist facilitates a
conversation about solutions
and exceptions to the problem
 Mystique surrounding therapy;
the therapist is an expert
 Process is transparent; client
and therapist work
collaboratively
Traditional versus brief therapies: Key concepts
Long-term insight oriented therapy Time-sensitive therapy
 Focus is on the client's problem  Focus is on the client's
and limitations
strengths and competencies,
whilst also acknowledging the
client's distress
 Client is defined as having a
problem that 'resides' within
him
 Client is defined as temporarily
'stuck' in an area of his life,
which might, in fact, turn into an
opportunity for him to change
 The focus in therapy is on the
 The focus in therapy is on
past, the cause of the problem
change, applying different
and on gaining insight; the
solutions and a future
theme is 'what might have been
orientation; the theme is on
if things were different'
possibilities
Traditional versus brief therapies: Key concepts
Long-term insight oriented therapy Time-sensitive therapy
 In some approaches, goals are  The goals are set jointly by the
set by the therapist and may be
client and therapist and are
instructive; solutions are
measurable/observable;
outside the client
solutions are within the client
 Lack of progress in therapy is
a sign of resistance and is
either 'subconscious' or
intentional
 Lack of obvious progress in
therapy may be a sign of
collaboration difficulties or the
therapist 'misreading' the client
 Sessions may or may not
motivate one to change
 Sessions are empowering and
can energise both client and
therapist
The first therapy session
"If therapy is to end properly, it must
begin properly – by negotiating a
solvable problem and discovering the
social situation that makes the problem
necessary."
Jay Haley, 1976
Is there a client?
NO
YES
YES
Does the client want to be there?
NO
YES
Is this a problem which can be
dealt with in therapy?
Is there a problem?
NO
NO
You cannot do
therapy
Identify for whom there is a problem
before agreeing to see the client. Offer
an initial consultation to this person to
explore their ideas about the problem
and its resolution
Refer to another professional specialist
or look at objectives of therapy for the client/referrer
YES
Is there rapport with the client?
NO
Address incongruity. Establish whether this
is due to client, therapist or other factors.
Seek supervision or consultation
YES
No further
progress
Is there progress in therapy?
YES
NO
Terminate therapy.
Give feedback to referrer
Proceed
Algorithm for deciding whether therapy can proceed
Problems in therapy can always be
attributed to:
Therapy at the wrong time
Client motivation
Therapist sticking too rigidly to their ideas
The ‘wrong’ problem being treated
Therapy moving too quickly (or slowly)
Therapy too shallow (or deep)
The client wanting/expecting something else from therapy
No personal connection between client and therapist
Not a problem that can be treated in therapy
Therapist (in)competence
Orienteering the client to competencies and
solutions
'What made you decide to come today?'
'What is the smallest amount of change or progress that you
would need in order for you to feel that things were
moving ahead?'
'Can you tell me about a challenging situation which you think
you handled well, and in a way that made you feel good
about yourself?'
'How have you managed to keep things going in your life in
spite of these challenges and problems?'
Orienteering the client
'You have described things clearly from how you see the
problem and how you feel you have tried to manage it.
How might someone else who knows you view or
interpret what you have just described?'
'How did you manage to "read" and understand that awful
situation you described so clearly?'
'From how you see things, and as I understand it, you don't
see much future in that relationship. What might you gain
from moving away from it?'
'Have you been noticing and watching out for those times
where you didn't feel so anxious and managed to go to
the supermarket? Tell me about the exceptions you have
noticed to this problem.'
Orienteering the client
'Who else was pleased to see you act so decisively in that
situation?'
'What will you need to do to maintain and consolidate these
changes that you have described to me today?'
'How do you describe the problem to yourself?'
'Who has stood beside you as you face up to this problem?'
'I assume you have been having conversations in your mind
about this problem. Is this the first time you are 'going
public' about it?'
'How has our conversation so far helped you to think
differently about (a) yourself and (b) the problem?'
Checklist for the therapist:
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Look for exceptions to the problem (positives)
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Introduce a future orientation
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Work towards goals with a solution focus
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Invite the client to scale feelings/experiences
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Highlight coping and resourcefulness
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Validate change that has already occurred
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Keep a focus on the client’s problem
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Reflect on the systemic (relational) impact of their
difficulty
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Miracle question
Application of time-limited therapy will be
determined by:
 The context of work setting(s)
 Your control over the number of sessions you may
allocate
 The 'fit' between the your own style or personality,
and the nature of the presenting problem
 Your view of the onset, maintenance and resolution
of psychological problems
 Clients' expectations of what will happen in therapy;
and
 Opportunities for supervision in time-limited practice.
Common problems that interfere
with the viability of therapy
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Comprehension - mental or physical health
states
Coerced into therapy
Low motivation
Rigid expectation of therapy