To suggest that this book might
have had problems in selling since 1988 when it was published, is probably
reasonable, given a brief look at the chapter titles.  They are:

Ch 1: The practice of brief therapy

Ch 2: Initiating brief therapy

Ch 3 Common foci in brief therapy and some basic assumptions

Ch 4: Losses

Ch 5: Developmental Dysynchrony (your spell check will find
this one)

Ch 6: Marital and Family Conflicts: early treatment issues
and assessment

Ch 7: The brief therapy of marital and family conflicts

Ch 8: Symptomatic presentations: the uses of clinical
hypnosis

Ch 9: Treating personality disorders

Ch 10: Time limited group therapy

Ch 11; Time and termination

Ch 12: A case transcript

None of this is likely to get a
potential buyer to pay out the $27 at Amazon might want more than this grouping
of chapters to entice them.  Freud after all did his initial therapies over
very short spaces in time, Sandor Ferenczi took him six weeks, but others,
towards the end of his life, took longer (page 1).  It all depends on the goals
of therapy.

Today we would easily accept
periods of 8-12 sessions, goal directed and client focused, with the therapist
dictating approaches from a manual, and with the evidence base suggesting that
all can be dealt with, therapeutic goal by therapeutic goal, in a handful of
weeks or months.  Most of the lay public would see a long series of meetings
over months and years as probable, but most professionals today would see
Motivational Interviewing, done with in a matter of hours, as more feasible,
affordable and effective.

Brief interventions are now
acceptable for even such albatrosses as alcohol addiction with family and other
therapies increasing used and brief. Gurman quotes his studies as showing that
less than 20 sessions was accompanying effective outcomes, by default, not by
design.

Length, after WWII was increasing
not seen as ‘strength’, or in our terms, necessarily indicative of the ‘depth’
of therapy, as many had found themselves intervening briefly in wartime for
battle fatigue and stress.  By design, such as those from Butcher and Koss
(names seen in the MMPI-2), showed no differences in the measures of
effectiveness used between time limited and time unlimited therapies.  The
difference is asserted by the authors here to be in the planned, focused use of
time in psychotherapy.  The goals are different, and they contrast the
long-term desire to change basic behavior to the short-term pragmatic,
parsimonious intervention that will do the trick. Here, psychological change is
seen as inevitable, strengths and resources are emphasized, accepts the ripple
effect of perturbation, with change antedating the interventions into the
future, and values the world experience over the therapeutic.  So the therapist
values the least costly, the least radical intervention, a prompting to change
rather than an endless journey with the therapist.  Cure is thus inconceivable
as we are at core designed to experience anxiety and fear as protective
mechanisms.  Humans are seen as never static, and always in flux. Orientation
is thus to health and wellness, not illness and cure.  It is clear that 16
years later we are still struggling with these models, and consumers (or rather
‘users’) of our services, are less than happy with our viewpoints on who is
what and why and what helps and how.

Further exposure to therapy in the
media and elsewhere has also come a long way, and hence preconceptions and
suppositions around what we do as professionals are also likely to play their
part in the interface.  This interface is then negotiated with by the provision
of homework tasks for the real world outside therapy, involvement of others in
the therapy, use of groups or resources outside of therapy, inextricable links
between evaluation and treatment, greater flexibility of interventions and
time, as well as planned follow up of outcomes.  All of this revolves around
the idea of an interpersonal-developmental-existential (IDE) domain as focus,
and many of the names I studied to get my degree are mentioned here, Watzlawick,
Fisch, Segal, Steve De Shazer, Yalom, McGoldrick, Carol Gilligan, Milton
Erickson, Jay Haley, Prochaska and DiClemente, all targeting the IDE
developmental line.  In essence, this is again a forerunner of the
biopsychosocial approach, Why this client?€¦..Why these symptoms?€¦..Why now?  In
this way, therapists exploring the IDE continuum of developmental lifespan
issues are concerned with the context of losses, developmental dysynchronies,
interpersonal conflicts, symptomatic presentations, and personality disorders. 
People therefore seek therapy at a time when there is a particular conjunction
of IDE events or issues. The IDE approach thus allows for focus and
clarification, as the symptomatic presentation may obscure the issues
underlying the presentation.

I use my own example here: A couple
approach for marital therapy, and argue endlessly in the first session.  I
prescribe to them that they should go to the newsagent and buy the cheapest
book on sale irrespective of what the title or content is.  They are to take
the book home, and then flip a coin.  The winner gets to sit in the bath with
the loser that night, reading aloud the first two pages of the book, ripping it
out, and then dictating to the other, the deep hidden message this has for
their relationship.  They then carry the pages around with them for the rest of
the week and when they think of the other person, they can then ponder on what
transpired around the pages now in their possession, and reflect on the hidden
message.

After buying Henry the Hippo, my couple
return a week later.  They have discovered that any issue between them follows
a prescribed path: she attacks him on one level, he replies on another, and
different level of abstraction and vice versa, hence they are never able to
resolve any issues.  They each have resolved to stay with the level of attack
from the other, and they find they resolved all arguments without me.  Therapy
terminated.  Henry the Hippo of course forced them into a neutral argument
devoid of their normal context, and the IDE issues came together in a neutral
debate, allowing them some vision or meta-perspective on losses, developmental dysynchronies,
interpersonal conflicts, symptomatic presentations, and personality disorders

In chapter three, the five frequent
or common foci mentioned above (losses, developmental dysynchronies,
interpersonal conflicts, symptomatic presentations, and personality disorders)
are discussed in more detail.  Particular note is made here of the
complications of substance abuse, which will then take precedence over all the
other treatment foci.  The decision tree thus runs Why now: is this visit
related to any of the following, loss, DD or IP? If not, then symptoms are focused
on, and if not successful, one moves on to character, again with the caveat
that substance abuse must be addressed before or currently with any of the
above.

In these contexts, basic
assumptions are clearly evident.  The authors assume the patient has been
subjected to faulty learning at some point early on in life, and in a systemic
way, the patient and his or her environment are in constant interaction with
the context and environment of the problem formulation, and this interaction is
reciprocal.  This environmental interaction can be buffering or perhaps
exacerbate the problem, and although personality, character, social supports
etc. play an important part in contributing to an individual’s life pattern,
chance factors and encounters are also seen as contributory in shaping the life
course as opposed to the things psychologists usually regard as
deterministically active, such as the self, or object relations with
significant others only, with reference to Bandura and others.

The next chapter, on Losses, calls
on attachment theory (see the review of Treating
Attachment Disorders in Metapsychology August 2004)
in order to illustrate both interpersonal and existential losses.  There is a
closer look here at brief therapy approaches to I-P and existential loss, with
the overall goal to transform the patient from victim to survivor.  Special
attention is giving to regrieving, using photos, films, diaries and tapes, as
the strategic therapists or brief directive therapists would do, finally
drawing on Kushner’s 1981 work, when bad things happen to those of us
considered unworthy of such suffering (see page 95-96) avoiding the hostile or
the rescue the victim response.

Chapter
five concentrates on developmental dysynchrony, a feeling of being
"off-time" with a sense of "dis-ease".  This would include
leaving home therapies, not having found a partner in the expected age zone,
aging without having had kids, losing a partner to death early on, aging with a
feeling of lack of closure on career or marriage, or finding oneself aging
whilst children still are dependant.  Again, the brief therapy is described. 
Typical skills involve complex reframes and advanced accurate empathy being
used to define and specify the ‘dd’ here, with some focus on the narrative.  A
combination approach, a) to achieve goals or b) to adjust to limitations is
also described.  The chapter is helpful in that it tries to protect therapists
from fundamental attribution errors, and steer us towards seeing the problem as
developmental.

Chapters
6 and 7 are more extensive, as the idea of therapeutic neutrality and the
formation of coalitions is vital to the treatment of family and marital issues,
and Ch 7 is devoted to the brief therapy of marital and family conflict, and
the concept of reframing the therapeutic ‘crisis’ in change. Stage theory, in
other words managing divorce in stages, is part of this pursuit. 

Chapter 8
discusses hypnosis in the context of symptomatic presentations and conducts a
nice historical look at hypnosis and the state/trait dilemma with its strategic
components.  Smoking, obesity, anxiety, and pain, all receive special attention.

Chapter 9
deals with personality disorders, and again the design is developmental rather
than attributional, designed to help the patient experience and realize
patterns of interaction, conceive of the possibility of other modes of
interaction, and enable the testing of these.  Corrective emotional experience
(somewhat akin to Linehan’s ‘wise mind’) and the intervention sequence are the
focus here, with disconfirmation of the expected response from the therapist. 
The focus narrows somewhat mid chapter to specify specific approaches to
specific clusters of disorder, and refers to interminable brief therapy as a
concept.

Chapter
10 shifts to time limited groups, as opposed to individuals, around core
competencies such as establishing and maintaining a focus in the group,
preparing and screening for the group, maintaining group cohesion, and dealing
with the existential and time factors that create problems in the group
setting. Several tables with examples of disruptive behaviors are useful here.

An issue
of time and termination take up chapter 11, and 12 is an extended case study.

Anyone
who was trained in the mid to late 80’s will recognize many of the words,
phrases, and authors referred to in this book, reminiscent of the era. 
Psychodynamic theories were being challenged, pathology was moving out of the
intra-psyche and into general systems theory applications and the
neo-biological determinism of the partly open, partly closed biological systems
of Maturana and Varella. Margaret Mead and Gregory Bateson were divorced, Bateson’s
daughter struggling on, and the Milan School was breaking up or using psychotropic medication.

This book has dated well however.  The mix of
pragmatics and aesthetics that warmed Paul Dell’s heart, the provision of an
alternate epistemology and ontology, the advent of heuristically useful
devices, all impacted on freeing the client and their family from blame, and
allowed the interaction to become systemic rather than linear, all live on and
return to many of the modern books I have recently reviewed.  Mainstream
psychiatry is moving to a biopsychosocial model, neuropsychiatry has an
evolving ecosystemic view of the chemistry of the brain as an emerging neuro-epistemology,
and one is falling through the roof of a second order neuro-epistemology to
land in a changing and complex ontology, to paraphrase Dell.

So this 1988 work still allows us a
pragmatic view, a method of delivering brief, and certainly directive therapies
in many settings, and Milton Erickson’s tomato plant-style of delivering
metaphor is still valuable in maintaining the therapist’s freedom.

The book could do with an update
and a new foreword, and some bits are looking cranky, but not nearly as much as
the Haley-Watzlawick-Milan school texts do, and I enjoyed the refresher course
in this style of doing the work of psychotherapy.  It’s worth the $27, and
there are cheaper, second hand versions in both hard and soft cover available
too.

 

© 2004 Roy Sugarman

 

Roy Sugarman,
PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist:
South West Sydney Area Health Service, Conjoint Senior Lecturer in
Psychiatry, University of New South Wales, Australia.

Categories: Psychotherapy