Placing Short-Term Psychotherapy First
London, Robert T., Clinical Psychiatry News
Recently, I read about a survey showing that almost half the patients who begin psychotherapy quit--against their therapists' recommendations.
According to the article, some of the reasons for this high dropout rate are patients' unwillingness to open up about themselves, disagreement with the therapist about the nature of their problem, and a lack of confidence in the therapist. In addition, some patients do not think they are improving fast enough. Others have unrealistic expectations.
Regardless of the reasons, one fact is clear: Psychotherapy with a clear or negotiable end point has a much lower dropout rate than traditional, long-term therapy, which has a 50% or higher dropout rate (Harvard Mental Health Letter September 2005;4).
For the last three decades, I've been teaching that psychotherapy has a beginning, a middle, and an end, a theory consistent with the short-term psychotherapy program I ran at New York University Medical Center/Bellevue Hospital in New York. Jonathan D. Brodie, M.D., Ph.D.--the new chairman of the psychiatry department at NYU Medical Center--says that as a resident rotating through the program, he remembers my pointing out that therapy can be effective after 3-6 months, and that the same person can return years later for additional short-term work.
He further reminded me that psychotherapy should have a beginning, a middle, an end--an idea that clearly made an indelible mark on him. This is a critical point. And it is one that new patients should know from the start.
For far too long, traditional open-ended, no-end-in-sight psychotherapy providers have failed to implement the ideas for improvement mentioned in the Harvard newsletter. Chief among those views is to define what the psychotherapy aims to accomplish, with goals and time constraints.
Sometimes, traditional psychotherapists dismiss short-term therapy as shallow or as missing the "real" issues that surround emotional problems or maladaptive behaviors. These therapists abide by the "sword of Damocles" model of psychotherapy, warning patients that "if you stop now, you'll get worse."
Part of the problem is that many psychiatrists and psychotherapists know little about how short-term therapies work. As a result, they don't realize how successful these therapies can be. The reality is that often the dropout rate is attributed to patient problems because that fits into the therapists' model--not the model needed by the patient for problem resolution. This is a cardinal error in talk psychotherapy.
When Outdated Models Prevail
For many reasons, therapists continue to use traditional psychotherapy, but primarily because these are the approaches with which they are most comfortable. Rarely in medicine has this been an acceptable rationale for patient care: I like the theories I've learned. I'll continue to use them. This attitude prevails despite advances in knowledge and techniques.
What makes traditional approaches even more problematic is that therapists seem unable to integrate the patient's psychiatric and economic needs. In contrast, that's what short-term therapists have done all along: Describe the process of psychotherapy, determine the problem, and negotiate a therapeutic plan for improvement with the patient's finances in mind.
Psychotherapy is a service that must be paid for, which means that patients who get it are essentially consumers. But I would guess that often the therapist fails to recognize the significance of cost to that consumer.
The ambivalence that pervades much of traditional therapeutic process is puzzling. For example, as the newsletter points out, most health care professionals remind patients of upcoming appointments. But psychotherapists avoid doing so--because they want to promote responsibility in patients or explore the meaning behind cancellations. It's interesting; I don't know many therapists willing to go a year without pay while they explore the inner meanings behind issues surrounding responsibility or avoidance. …