The ways in which most clients use therapy has long been at odds with the most popular theories of therapeutic change.  As anyone who has been in therapeutic practice knows, clients tend to come to therapy in much distress and leave therapy after just a few sessions.  Many theoretical paradigms have suggested that such clients cannot possibly be getting substantial benefit from their therapeutic encounters, arguing that change comes about through processes which require more time and effort than such brief encounters can provide.  Recent research, however, has confirmed that therapy is remarkably effective and that treatment modality contributes very little to the positive change which clients experience.(Wampold, 2001)  This same research clearly demonstrates that the most important components of therapy, primary among them, the expectation for change, can be reasonably mobilized in very few session, indeed, validating the sense that the many patients who enter therapy for very brief periods are truly benefiting from their therapeutic investments.

Rubin Battino has written a lucid introduction to the craft of very brief therapy which makes a virtue of the necessity of working with clients in very brief therapeutic encounters.  The book is arranged as both an introduction to the research which validates the approaches behind brief therapy, and as a primer to the many techniques different clinicians have developed for working with patient expectation for improvement.  As he makes clear in his introduction, Battino recognizes that what the field calls "brief therapy" has changed over the years, first denoting fifty sessions of treatment, then fewer, until it now tends to be in general currency as a description of treatments lasting 8-12 sessions.  Battino, in contrast, refers throughout his book to "very brief therapy," by which he means treatment encounters lasting 1-2 sessions, in which patient expectations of rapid change are used to facilitate immediate therapeutic work.

The most useful part of Battino's book is the first four chapters.  In them he marshals the research that forms the basis of his argument, and discusses the general shape of a brief therapy encounter.  Appropriately he does this by first examining Bruce Wampold's crucial book, The Great Psychotherapy Debate, in which Wampold uses meta-analysis to prove not only that psychotherapy is remarkably effective, but that that effectiveness comes from general rather than specific factors.  Battino does a good job of extracting the most salient points from Wampold's argument, highlighting the freedom from a medically dogmatic approach to treatment which results from Wampold's data.  Battino also takes from Wampold validation for his project, as Wampold's data clearly shows that client expectation, or hope, for improvement is a determining factor in subsequent change.

Battino also uses the first chapter to introduce the work that Duncan, Miller, et al. have done on the role of client expectations and resources for change.  One of Battino's central theses is that clients enter therapy with not only the expectation for change, but the wherewithal to pursue that change themselves once the clinician has helped to facilitate such self-healing.  Battino refers to the work that Duncan, Miller and their colleagues have done to bolster this contention, and the argument is persuasive.

Battino goes on to further discuss the importance of expectation in the role of change.  He properly links the notion of expectation to medical discussions of the placebo effect, and shows how integral to the client experience of therapy the hope for change is.  This segues into a discussion of basic strategies for working with clients that mobilize expectation as their core approach.  Among these, using "as-if" thinking and reframing are outlined at some length.  Both contribute to a larger introduction to the centrality of focusing client thought and attention on the positive aspects of their lives and the positive change that they want to see occur.  Whether used in solution-focused therapy, or narrative therapy (both discussed later in the book), or in some other modality, attention to the positive aspects of a client's experience is central to helping to bolster hope and foster an expectation of change.

Chapters three and four focus on the ways in which clinicians foster rapport with their patients.  Chapter three examines some of the linguistic and physical cues that indicate to patients that we are in alliance with them, while in the fourth chapter Battino talks about some of the language and language strategies that he has found most helpful in working with clients during very brief therapy encounters.  Battino here demonstrates his allegiance to Eriksonian hypnotic techniques, which forms the backdrop for much of this book.  While his understanding of the technique seems thorough and laudable, that very understanding introduces the major weakness of this book, which is that it's introductory, and in many places cursory, nature does not leave room for adequate explanation.  His chapter on the language of brief therapy describes over 30 different techniques for using language in under 15 pages, providing the merest gloss on many of them.  The reader unfamiliar with these techniques is unlikely to gain any real understanding from their treatment here, although the extensive citation makes it clear that the issue is that Battino is too familiar with these techniques to realize that he may not be imparting enough information.  (An example of this:  Introducing his discussion of these techniques, Battino writes "Much is owed to NLP for this organization," (p.38) as if it were transparently evident that NLP refers to Neurolinguistic Programming.  Granted, there is a chapter devoted to NLP later in the book, but this first introduction of the material is not properly fleshed out.)

The rest of Battino's book is fascinating and frustrating in equal measure.  In about 15 brief chapters he covers twice as many sets of therapeutic techniques, ranging widely through the work of Bill O'Hanlon, Jay Haley, Milton Erickson, and Ernest Rossi.  He also covers metaphor therapies, NLP, some aspects of hypnosis, as well as several other approaches.  While these chapters provide some interesting introductions, they are written more as refreshers on the techniques he finds so helpful, and as such, suffer from not explaining in adequate detail the methods that they recommend.  Overall, however, these chapters form a valuable and remarkable compendium of some of the techniques best suited to helping clients make significant shifts in the way they are conceptualizing the problems which have brought them into treatment.  Coupled with Battino's extensive bibliography, they serve as an invitation to further study.

Battino does not discuss the ethics of solution focused brief therapy techniques, which is a shame.  A strong argument can be made for the clinical ethical imperative for facilitating change for our clients as quickly as possible.  Therapeutic techniques which place a premium on time spent versus change engendered may be not only doing a disservice to client expectations, but may be actively getting in the way of our clients living the lives which they desire and are entitled to live.  While the research presented by Wampold suggests that all therapeutic techniques are about equal for helping clients to improve during therapy, that same research should force us to question whether or not all techniques are appropriate for all clients.  Rubin Battino's book, despite its brevity and some of the flaws which that engenders, is a welcome reminder that there are as many ways to work quickly for client change as there are clients.

© 2007 Andrew Pollock

Andrew Pollock, Baltimore, MD

Categories: Psychotherapy