Practical Issues in Time-limited Therapy
Because of their limited focus, TLPs are ideally suited to patients with acute symptomatology and relatively favorable baseline functioning. Resource availability may also influence decisions to use a time-limited or open-ended approach. Most evidence-based treatments are designed for and have been tested in sam-ples of patients who meet DSM-IV criteria for Axis I disorders (predominantly mood and anxiety disorders, as well as specific behavioral problems such as substance abuse or eating disorders). Thus, it is important to conduct a thorough diagnostic interview, identify target diagnoses and symptoms and select, if possible, a TLP that has been empirically validated for that population. It would be inappropriate to treat a patient with a primary diagnosis of a specific phobia with IPT, as IPT has not been tested in this population; a behavioral approach would be preferable. A patient suffering from major depression, however, might reasonably be treated with CBT, IPT, or brief dynamic therapy.
The closely allied concepts of engagement and treatment alliance respectively refer to the patient’s commitment to the treatment enterprise and the relationship between therapist and patient. Positive treatment alliance typically correlates with better treat-ment adherence and engagement. Given the brevity of treatment, one challenge of TLP is to establish rapidly a relationship with the patient in order to facilitate engagement in treatment. Main-taining this alliance throughout treatment is also important be-cause nonattendance, while disruptive to any psychotherapy, is particularly costly in a time-limited treatment.
While many of the so-called “common” factors of psychotherapy function to facilitate this process, in IPT the therapist’s stance is specifically intended to create a positive relationship with a de-pressed patient. The IPT therapist maintains a warm, encourag-ing stance that counters the depressed patient’s pessimism with an equal and opposite optimistic realism. In psychodynamic terms, the IPT therapist cultivates a positive transference. He or she handles negative transference as illness-derived, treatment-inter-fering behaviors: for instance, tardiness or lack of participation would be defined as sequelae of depression. The therapist might intervene by saying, “It’s hard to feel enthusiastic about therapy when your depression makes it hard to enjoy anything”. In addi-tion, the therapist might address it on a practical level, saying, “We only have five sessions left. We need all the remaining time to get to the bottom of your problem with your wife and to treat your depression”. These strategies both promote the therapeutic alliance and enhance treatment engagement.
As previously discussed, it is imperative that the TLP therapist identify clear treatment goals and maintain focus during the brief treatment period. It can be challenging to keep the patient on task and manage material that emerges in sessions unrelated to the primary treatment goal. To address this important issue, the therapist must clarify from the outset the goals and potential limitations of treatment.
In IPT, treatment goals are specifically stated during the initial phase of treatment. The IPT therapist might say, “The goal of this treatment is to help you with this depression and your un-resolved feelings about your mother’s death last year. At the end of 16 weeks, we can discuss whether you need additional treat-ment for your bulimia, but let’s first see how you feel when the depression has lifted”. It is important that the patient explicitly agree to the stated treatment goals. In the case described above, the patient would need to agree to defer treatment for a possible eating disorder, focusing on her depression and grief for the im-mediate future.
In IPT, a clear treatment contract helps the patient and therapist remain focused. For instance, if the patient brings up feelings of dissatisfaction in the workplace during a therapy de-signed to address problematic relationships with a spouse (role dispute), the therapist may first briefly explore whether these complaints relate to the treatment focus. Thus, if demands from the spouse lead the patient to accept an unsatisfactory job, or if a dispute at work parallels that at home, the therapist can refocus the comments in light of the ongoing marital dispute. However, if there is no obvious connection to the main treatment focus, the therapist might gently redirect the patient by saying, “Although your work concerns are important too, at the beginning of ther-apy we agreed that we should spend these few months working through your problems with your spouse. I wonder how that has been going”.
As the end of treatment nears, the therapist reiterates the date and time of the final session, actively eliciting responses to the end of treatment if the patient does not spontaneously offer them. Termi-nation provides an opportunity to review treatment gains (which are often impressive), support the patient’s sense of competence and independence, grieve the end of treatment and identify un-addressed problems. The termination phase is more crucial and more complicated in psychodynamic psychotherapies because of their emphasis on the importance of the therapeutic relationship.
In IPT, termination is handled as a graduation or role transition. In the termination phase of IPT (typically the last two to three sessions), the therapist helps the patient express expectable sad feelings (which are distinguished from recrudescent depres-sive affect) about the end of treatment, but underscores patient progress in having treated the depressive episode and problems at work, love relationships, and so on. While concerns about the patient’s ability to manage without the therapist’s help are inevi-table, the therapist counters with examples of the patient’s hard therapeutic work outside of the office. The therapist commends the patient’s “real world” victories, reminding the patient that IPT has helped him or her to develop new skills that he or she will continue to use after treatment ends. Termination promotes patient independence while grieving the loss of the treatment re-lationship. The therapist and patient also review the symptoms of depression and identify “warning signs” which might lead the patient to a reevaluation in the future.
In the event of partial response or nonresponse, the thera-pist suggests alternative treatments and makes appropriate refer-rals for follow-up. If the therapist judges that additional treatment is warranted for management of persistent symptoms, it is criti-cally important that the therapist blames the therapy rather than the patient for failing to bring about a full remission. The thera-pist can gently point out that all of our treatments for depression are imperfect and that we cannot yet predict which treatments will work for any individual patient. The therapist confidently reassures the patient that there are other options (i.e., medication, other forms of psychotherapy), helping the patient select follow-up treatment that fits his or her needs. Another reasonable strat-egy (though not backed by any empirical data) would be to extend the treatment duration of IPT by a fixed number of sessions (e.g., six or eight additional sessions). This option would probably be best for a patient who has had at least a partial response to IPT and may need a few extra sessions to complete therapeutic work that is already underway. In keeping with the spirit of IPT, it would be important to explain this rationale to the patient ex-plicitly and to set a second termination point to help maintain the focus of treatment.
When the patient experiences a remission of symptoms by the end of 16 sessions, it may be tempting to refer the patient for additional psychotherapy such as marital treatment or an insight-oriented psychotherapy to address residual interpersonal issues or longstanding personality problems. However, it may be prefer-able to encourage a treatment-free period of 3 to 6 months to help clarify and consolidate treatment gains, particularly if the pa-tient has presented with a first episode of relatively acute illness. Greater symptom chronicity and number of episodes suggest the need for continuation and maintenance treatment.