Expectation

The Very Brief Therapy Book

Rubin Battino

• Publisher: Crown House Publishing
• Year: 2006
• Print ISBN: 9781845900281
• eBook ISBN: 9781845906030
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

It is the author's contention that creating an environment where the client expects change is the foundation of doing effective very brief therapy. His own private practice is one where he rarely sees clients more than one or two times. Clients know in advance that this is the way that he works, and so their expectation is that during this session they are going to get down to the hard stuff. This means working as if each session were the last one. So, this book is about all of the things that are designed to work in a single-session mode.

Chapter 1

Introduction to Very Brief Therapy

1.1 Introduction

My introduction to brief therapy came from examining the literature on the subject a number of years ago. I was intrigued by finding a book that was enthusiastic about brief therapy being conducted in one year (rather than five or more), and in under fifty sessions (rather than hundreds). The book, of course, was psychodynamically oriented. In recent times, “brief” has come to mean something like six to twelve sessions, much of this mandated by managed care systems. In fact, many of these managed care systems will tie a number of sessions to a particular diagnosis. This is carrying the intrusion of the medical model into psychotherapy to what I consider to be ridiculous extremes, so I am being explicit about this at the outset of this book. The medical model works well when prescribing a particular drug for a specific infection for a set number of days. But people who seek the help of psychotherapists are not diseased, they are troubled and stuck and seek some guidance for their unique concerns. A diagnosis such as “depression” is manifested uniquely by each person, and their individuality and history must be taken into account in any work done with them. It is in this sense that Milton H. Erickson’s Utilization Principle is primary in determining how you work with a client. This principle simply states that every client is absolutely unique, and that the treatment needs to be specific to that client (and not some abstract diagnosis). The client’s uniqueness is utilized in working with them.

I came to the central theme of this book via something I heard Steve de Shazer report in one of his presentations. This was about the results of a study they carried out at the Brief Therapy Family Center of Milwaukee. The receptionist was told to randomly tell each new client, after looking at their intake form, that their particular concern usually took five or ten sessions. The center’s staff did not know what the client was told. Later analysis showed that the five session clients started doing significant work around the fourth session, and that the ten session clients started doing significant work around the eighth or ninth session. In essence, the clients were told when to expect change to begin, and they responded appropriately. My reasoning then was, why wait for the fourth or eighth session, why not have the expectation be that significant work can be done in the first session and, further, why not imply that one session was all that was usually necessary? So, that is what I do. Very brief therapy to me means that I rarely see clients more than once or twice, with one being the most frequent number of sessions. Of course, I tell each client that I will see them for as many sessions as they feel are helpful.

The essence of what will be the content of this book is how to use expectation in psychotherapy. In a sense, this is akin to the placebo effect, and there is much evidence on how well placebos work in a variety of areas. This chapter introduces a number of related concepts and research. In particular, the work of Wampold, Hubble, Duncan, S. D. Miller and others is discussed in some detail as it directly impacts on the nature of psychotherapy and how it is practiced. In this book I am presenting how I work in the field. Are my methods and my approach significantly better than the hundreds of other approaches out there? Is any one approach better than any other? Why bother reading this book, especially when you are already certain that what you do is the best way to do this work? After all, I am eclectic and pragmatic in how I work—if what I am doing is not working, then I switch to something else. I do have a bunch of preferred things that I do, and I do generally function out of an Ericksonian perspective. These preferred methods are described in the remainder of this book, yet they are presented so that you can read about many different ways of operating effectively and efficiently. What about the research evidence supporting how I work? In effect, I have personally done no research on this subject—as in many books, the evidence is anecdotal, i.e., I really do see my clients only one or two times. Since I do have a background as a “hard” scientist (I have spent most of my adult professional life as a professor of chemistry, and I am still actively functioning in that capacity), it is incumbent upon me to present some research in the field. Therefore, I am going to do that in this chapter by first citing (in the next section) the work of a qualified academic researcher (B. E. Wampold). This is followed by a description of the ongoing research being carried out by B. L. Duncan and S. D. Miller and colleagues. Finally, the seminal work of Talmon on single session therapy is discussed. It is my hope that the remainder of the book proves useful to you.

1.2 The Great Psychotherapy Debate

This is the title of Wampold’s book (2001) summarizing an enormous amount of research on psychotherapy. This book is a solid example of a scholar at work, and it is replete with relevant references—the interested reader is urged to consult them. This section sets the stage for the rest of this book to whet the reader’s appetite. At the outset, Wampold (p. 2) states, “The pressures of the health care delivery system have molded psychotherapy to resemble medical treatments.” Then, he states categorically (p. 2), “In this book, the scientific evidence will be presented that shows that psychotherapy is incompatible with the medical model and that conceptualizing psychotherapy in this way distorts the name of the endeavor.” To start off, he offers the following working definition of psychotherapy (p. 3):

Psychotherapy is a primarily interpersonal treatment that is based on psychological principles and involves a trained therapist and a client who has a mental disorder, problem, or complaint; it is intended by the therapist to be remedial for the client’s disorder, problem, or complaint; and it is adapted or individualized for the particular client and his or her disorder, problem, or complaint.

Wampold contrasts the medical model with the contextual model. They are both summarized here before continuing with describing his results (see pp. 13–20).

1.2.1 Five Components of the Medical Model

1. As the first component of the medical model of psychotherapy, a client is conceptualized to have a disorder, problem, or complaint. DSM-IV (American Psychiatric Association, 1994) is one way of categorizing (mental) disorders, but these diagnoses are not necessary for the application of the medical model to psychotherapy.

2. For the second component, a psychological explanation for the client’s disorder, problem, or complaint is proposed. Since there are many approaches to psychotherapy, there are also many alternative explanations for a given disorder. This is generally not the case for medical disorders.

3. In the medical model of psychotherapy, it is stipulated that each psychotherapeutic approach incorporate a mechanism of change. That is, each theory or approach of psychotherapy implicitly or explicitly involves a mechanism, such as making the unconscious conscious in psychodynamic approaches.

4. There are specific therapeutic actions prescribed, often in treatment manuals. That is, a diagnosis of X requires a treatment of Y.

5. With regard to specificity, which is the critical aspect of the medical model, there is an implication that there are specific therapeutic ingredients which are remedial for a particular disorder, problem or complaint.

The medical model has, of course, worked quite well for medical problems. Yet, impressing that model with its empirically supported treatments (ESTs) and its diagnostically related groups (DRGs) into the radically different situation of psychotherapy requires a leap of faith worthy of the most fundamentalist religions.

With respect to the contextual model, Wampold writes (p. 27):

The contextual model states that the treatment procedures used are beneficial to the client because of the meaning attributed to those procedures rather than because of their specific psychological effects. [Emphasis added.]

That is, in this model it is the common contextual factors that are emphasized. Wampold cites Frank and Frank (1991) with respect to the components shared by all approaches to psychotherapy:

1. Psychotherapy involves an emotionally charged, confiding relationship with a helping person (the therapist).

2. There is a healing setting in which the client talks to a helping professional the client believes can help him or her.

3. There exists a rationale, a conceptual scheme, or a myth that provides a plausible explanation for the client’s symptoms, and also provides a ritual or procedure for resolving them. In this wise, the client must believe in the treatment, or be led to believe in it. [RB comment: this involves an element of the placebo effect.]

Wampold then cites (p. 25) six elements discussed by Frank and Frank (1991) as being common to the rituals and procedures used by all psychotherapists:

First, the therapist combats the client’s sense of alienation by developing a relationship that is maintained after the client divulges feelings of demoralization. Second, the therapist maintains the client’s expectation of being helped by linking hope for improvement to the process of therapy. Third, the therapist provides new learning experiences. Fourth, the client’s emotions are aroused as a result of the therapy. Fifth, the...

Table of contents

• Cover
• Title Page
• Acknowledgments
• Table of Contents
• Foreword
• Introduction
• Chapter 1 : Introduction to Very Brief Therapy
• Chapter 2 : Expectation and As-If
• Chapter 3 : Rapport
• Chapter 4 : Language for Very Brief Therapy
• Chapter 5 : Hypnosis and Very Brief Therapy
• Chapter 6 : Solution-Oriented Approaches
• Chapter 7 : Bill O’Hanlon’s Approaches
• Chapter 8 : Lucas Derks’s Social Panorama
• Chapter 9 : Erickson and Very Brief Therapy
• Chapter 10 : Jay Haley and Ordeal Therapy
• Chapter 11 : Ambiguous Function Assignments
• Chapter 12 : Burns’s Nature-Guided Therapy
• Chapter 13 : Metaphoric Approaches
• Chapter 14 : Rossi’s Rapid Methods
• Chapter 15 : NLP Approaches
• Chapter 16 : Narrative Therapy
• Chapter 17 : Rituals and Ceremonies
• Chapter 18 : When All Else Fails
• Chapter 19 : Brief Final Thoughts
• References
• Index
• Copyright