General Principles of Time-limited Psychotherapy
The hallmark of TLP is its specified treatment duration. Because of this compression, TLPs share attributes that both link them to one another and distinguish them from long-term treatment mo-dalities. These general principles are summarized in Table 68.1.
Table 68.2 groups psychotherapies commonly administered in a time-limited format by treatment approach and lists representa-tive examples of strategies and typical treatment durations.
TLPs differ from truncated long-term treatments that are interrupted by attrition, noncompliance, or the pressures of man-aged care organizations. The duration of these latter therapies may coincide with that of a TLP, but they do not constitute fully formed brief treatments. TLPs have distinctly defined beginnings, middles, and ends – regardless of their absolute duration. Knowl-edge from the outset that therapy has a defined end-point indeed may constitute a key active ingredient of time-limited therapy. It suggests that relief may be near at hand. Marmor speculates that this approach “counters the patient’s impulse to see him-self as helpless, inadequate, and in need of dependent support”. Our experience with IPT as a treatment for depression in individuals who are HIV-seropositive suggests that these individuals, despite shortened life spans, use the brev-ity of treatment as an impetus to effect radical, rapid changes in their lives (Swartz and Markowitz, 1998). The time limit, in a variety of ways, seems to provide an important motivation to speed the patient toward health.
A meta-analysis of many psychotherapy studies (none of them TLPs) found that most (75%) patients achieve symptom relief within 26 sessions of an open-ended treatment (Howard et al., 1986). Most treatments included in this meta-analysis were naturalistic (e.g., not controlled) studies of patients suffering from very heterogeneous symptoms (diagnoses are not specified). This finding suggests that many patients may respond quickly, even if psychotherapy is open-ended. Although no studies have com- pared prospectively response rates of TLPs to open-ended treat-ments, we predict that treatment response would be more rapid for patients receiving time-limited interventions because of ex-plicit expectations that therapy will conclude within a specified time frame. TLPs are generally dosed with a frequency of once a week, although this varies as well.
The optimal duration and dosage of TLP, although em-pirical questions, remain largely unanswered to date. In practice, treatment duration is often defined by convention, the exigencies of a research protocol or managed care organization, or even the inclinations of the therapist.
IPT was originally designed as a 16-week intervention so that it could be administered over the same period as an acute course of pharmacotherapy, allowing an assessment of the relative efficacy of the two interventions (DiMascio et al., 1979). IPT is also administered as a 14-session intervention (Markowitz unpublished data), a 12-session intervention (Mufson et al., 1999; O’Hara et al., 2000) and an eight-session intervention (Swartz et al., 2002), but there are no data comparing the relative benefits of varying doses of acute IPT.
An important characteristic of TLP is careful definition of treat-ment goals, which are usually agreed upon by the patient and therapist, and often specified at the beginning of treatment. Because therapy is brief, the scope of the treatment is circum-scribed and focused. TLPs do not attempt sweeping changes in character. Rather, treatments target a specific diagnosis, set of symptoms, or a narrow aspect of character. Typical and appro-priate treatment goals for TLPs include remission of depressive symptoms, reduction in frequency of binge-eating, and resolu-tion of a specific interpersonal conflict.
Most TLPs define treatment goals by diagnostic criteria, in much the manner of pharmacotherapies. IPT focuses on two discrete goals: remission of depressive symptoms and resolu-tion of an interpersonal problem area (Weissman et al., 2000). Cognitive–behavioral therapy for panic disorder focuses on reduction in frequency of panic attacks and relief of general anxiety symptoms (Barlow, 1997). Motivational interviewing, a brief intervention designed to facilitate behavior change, is often administered for the sole purpose of helping patients reduce or eliminate their alcohol consumption (Miller and Rollnick, 1991). Thus, although the treatments vary in their focus, in all cases their treatment goals are narrow and usually specified from the outset.
Treatment focus is closely allied with the broader concept of case formulation. According to Eells, psychotherapy case for-mulation is “a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interper-sonal, and behavioral problems…. It should serve as a blueprint,
guiding treatment” (Eells, 1997, pp. 1–2). In TLP, because time is short, the process of generating a case formulation is also com-pressed. The therapist must identify the most important compo-nents of the patient’s narrative, balancing the urge to learn more about the patient’s life circumstances with the time constraints of the TLP. Thus, the TLP therapist typically conducts an overview of the patient’s psychosocial circumstances and then selects a few “hot” topics – relevant both to the current complaint and the nature of the therapy – to consider in greater depth. This ap-proach allows the therapist to develop an informed, timely case formulation. The ability rapidly to develop and deliver such a for-mulation is for many therapists among the more difficult but also most valuable aspects of learning a TLP.
Case formulation in IPT builds on two core IPT concepts: 1) de-pression is a treatable illness and 2) events in one’s psychosocial environment affect one’s mood, and vice versa. The IPT thera-pist defines depression as a medical illness that, like asthma, is both treatable and affected by the patient’s circumstances. The therapist notes that, in a biologically vulnerable individual, when painful events occur, mood worsens and depression may result. Conversely, depressed mood compromises one’s ability to handle one’s social role, generally leading to negative events. IPT thera-pists use the connections among mood, environment and social role to help patients understand their depressions within an inter-personal context, and to teach them to handle their social role and environment so as to both solve their interpersonal problems and relieve their depressive syndrome.
The therapist’s formulation includes a diagnosis of depres-sion as a medical illness, the provision of reassurance and hope, the assignment of the sick role and, most importantly, the identi-fication of one (or at most two) interpersonal problem areas that become the agenda for the remainder of the treatment. The thera-pist directly states this case formulation to the patient and elicits his or her agreement with the proposed strategy before moving ahead with the next phase of treatment. Thus, in IPT, case for-mulation constitutes an important treatment tool that links the patient’s mood symptoms to life events and introduces a specific interpersonal problem area as the focus of treatment for the ensu-ing sessions (Markowitz and Swartz, 1997).
The brevity of treatment leaves little room for error in for-mulating the IPT case – or any TLP case, for that matter. The therapist must use the initial treatment sessions aggressively to pursue all potential areas and to determine the treatment focus prior to embarking on the middle phase of treatment. If a cov-ert and imposing problem area should arise in the middle phase, however, the therapist would have to renegotiate the treatment contract to address it.
In TLP, the structure of the intervention is clearly delineated and referenced throughout the treatment period. The therapist will often call the patient’s attention to important landmarks in the treatment: “Today we’ve reached the halfway point” or “We only have three sessions left”. In manualized treatments, each of these time intervals has specified tasks or strategies. For instance, in IPT, the initial phase can last up to three sessions. During that time, the therapist has spe-cific tasks (viz., obtain a psychiatric history and interpersonal inven-tory, offer a case formulation). Similarly, the middle and end phases of treatment have a specified duration and associated tasks.
In support of the treatment structure, TLP requires the therapists to make formal or informal “treatment contracts” in which the patient and therapist explicitly or implicitly agree to goals, duration and other parameters of treatment. The thera-pist may discuss with the patient the exact number of sessions planned, rules for missed sessions or rescheduled sessions, fees and so on. Although some aspects of treatment contracts are common to all psychotherapies, TLPs tend to specify more ele-ments in the contract from the outset, including expected treat-ment responses (e.g., “At the end of 16 weeks, your mood will likely be much better”) and specific requirements of the patient (e.g., homework assignments in Prolonged Exposure and CBT). Patients often find the transparent structure of TLPs reassuring, removing some of the unnecessary mystery (and perhaps stigma) historically associated with psychotherapy.
Most TLPs call for serial assessments of symptoms. In clinical practice (and in clinical trials), it is often practical to administer a self-report measure such as the Beck Depression Inventory (Beck and Steer, 1993) or the Beck Anxiety Inventory (Beck and Steer, 1990). Regardless of the instrument chosen, it is important to build into the weekly therapy session time to complete and review a standardized symptom measure and track change over time. Serial symptom assessment provides the pa-tient with additional psychoeducation (i.e., symptom recognition) and a reliable means of tracking improvement (or lack thereof).
In order to maintain the treatment focus, the therapist must be ac-tive in TLP. He or she must move the treatment process forward under the pressure of an inexorably ticking clock. This demands constant attention to the treatment focus and redirection of the patient if the focus falters. The therapist gently keeps the patient on task, shaping the treatment rather than simply following the patient’s lead. A challenge in TLP is to balance strict adherence to the treatment focus with an empathic stance that supports the treatment alliance. Although it is important to attend to the agreed upon problem area in IPT, it is also important that the pa-tient feel “heard” and that the therapist allows time in the session for the patient to express his or her feelings unimpeded.