Time-Limited Counselling

Colin Feltham

• Publisher: SAGE Publications Ltd
• Year: 1996
• Print ISBN: 9780803979758, 9780803979741
• eBook ISBN: 9781446239186
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

`Excellent... [the book] explores the "provision of effective counselling with limited resources and under strict time pressures"... with some excellent writing on the nature of time and attitudes to time in counselling and psychotherapy... the evidence in favour [of short-term counselling] is put strongly. Colin Feltham favours it as an approach of choice for certain clients, which should co-exist with (rather than adversarially seek to oust and replace) longer-term therapy... he draws from a wide range of literature, while identifying those key ingredients, skills and strategies that he has found especially significant. He also discusses some of the different contexts in which this work operates... Many of the questions and issues he poses... will be picked up most productively in training and supervision sessions? - Counselling, The Journal of the British Association for Counselling and Psychotherapy

Time-limited counselling - that is, the provision of effective counselling with limited resources and under strict time pressures - is becoming increasingly important as the demand for counselling increases, and the management of waiting lists and costs becomes a crucial concern.

In this clearly written book, which incorporates useful, illustrative examples, Colin Feltham outlines the specific practical and technical skills, strategies and knowledge counsellors must have in order to undertake time-limited counselling. Following an examination of the client?s induction into counselling, he describes the most appropriate models for different clients and problems. Further chapters assess the management of time-limited counselling in different settings - including private practice - and look at research, training and supervision issues.

Squarely addressing the objections to the use of, and real problems in, the practice of this short-term therapeutic paradigm, the author argues that time-limited counselling can be justified not only on economic grounds but also ethically, philosophically, clinically and with reference to consumer preferences. He also identifies the common factors in successful short-term work that span different theoretical orientations.

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Introduction: the Nature of Time

Some explanation for the title of this book is called for at the outset. Since my own view is that counselling and psychotherapy are largely synonymous, the title could as well be Time-Limited Psychotherapy’. It is not titled ‘Brief Therapy’ because, although I will mainly refer to quite short-term therapy and counselling, ‘brief in the context of psychotherapy tends to refer to both counselling by design and counselling by default and has been used to refer to anything up to 40 or 50 sessions. Time-limited counselling, for the purposes of this book, mainly refers to therapeutic counselling which is usually designed to be of a predetermined number of sessions, usually not more than 20 at most, and including single session therapy. In agencies where actual limits are set – for example, by employee assistance programmes or American Health Maintenance Organizations (HMOs) – the number is usually between about 6 and 20 (see also Barten, 1971). This book takes individual counselling as its focus but many issues are transferable to work in other therapeutic modalities or arenas. (See Freeman (1990) on couple counselling; Budman (1981) on group therapy; de Shazer (1991), Boscolo and Bertrando (1993) on family therapy.)

Having said this, I must now alert readers to my belief that effective time-limited counselling, indeed all counselling, benefits from an exploration of its temporal assumptions. A major assumption in this book – and in many brief therapy approaches – is that time is both a linear affair in which our familiar personal narratives are embedded and, simultaneously, an illusion behind which lies the ever-present possibility of many different ways forward. Counselling that is time-sensitive is a pragmatic venture but also raises the fundamental question of how we understand time – how it shapes our problems and solutions. Whitrow (1988) has discussed the rival concepts of duration and instant, and this is an excellent way of understanding the tension existing in counselling that is sensitive to the use of time. We have expected therapy to be a somewhat extended process but simultaneously we know that dramatic breakthroughs and unexpected endings may happen at any time in the process.

Time-limited counselling is not, in my view, a hurried and superficial activity – as its critics like to suggest – but is simply one way of doing counselling differently, based on questions about the meaning and use of time, and the aims and scope of counselling and therapy. Readers may note that time-limited counselling can be rendered as TLC which also stands for tender loving care. I have avoided using TLC in the text but I believe that as much tender loving care can be conveyed in brief as in lengthy therapy! Certainly, time-limited counselling as a title has some problems, connoting as it does perhaps a sense of negativity and shortage. Some writers prefer to speak of time-sensitive therapy or time-efficient therapy; Elton Wilson (1996) has coined the term ‘time-conscious psychological therapy’. We might try time-centred counselling, time-informed therapy or, simply, timed counselling but none of these feels wholly satisfactory. ‘Counselling based on an awareness of time factors, including consideration of therapeutically optimal temporal dosage’ perhaps captures the essence of it.

Let us now look briefly at some of the universal issues contained within the concept of time, so that we can then proceed to ask what temporal assumptions are embedded within the concepts of mental health and dysfunction, human development, problem solving and personal growth. Even as you read this, you may be aware of your own attitudes towards time and its use: do you read the text in a leisurely or hurried way, in a methodical linear manner, or do you skip certain sections to get to what seems most useful to you? Do you read it in one sitting or over many weeks?

What is time?

For most of us time means the daily passing of morning, afternoon, evening and night; it entails a sequence of events and a sense of past, present and future; we may think of our lives in terms of a linear narrative between birth and death, and of history as a linear progression. Time is measured by the clock and calendar so that we know what to expect at certain times, when to be somewhere and how long we have got. Time seems to be ubiquitous, taken for granted, as the medium in which we live; time seems to move ever forward, naturally and without needing to be examined. Yet philosophers, theologians, physicists, biologists, anthropologists, poets and others have puzzled over what it really means, whether it really exists and what the relationship is between our subjective sense of time and what time might objectively be.

It does not take much thought to realise the illusory or problematic nature of time: the past, now gone, no longer exists, except as memory traces; the future, always still to come, doesn’t yet exist, except as anticipation; we might say, then, that the past and future have no objective reality, existing only in our minds as memory and expectation. That leaves only the present. Yet what is the present except a fine dividing line between past and future, and exactly what reality does this fine line have? From a historical perspective, the present may be defined as the late twentieth century (although this historical structuring of time may itself be regarded as entirely arbitrary). From the personal perspective, the present may be defined as this year in my life, this week or day. The now in which I write this is over, however, as soon as it is mentioned and the moment in which you read this is sometime in the future (from my now), yet it will be in your present that you read it, many months or years after I have written it. Where the writer and each reader of this book is ‘coming from’ – in terms of our exact interests in time-limited work, our individual histories and psychological differences, theoretical orientations, and so on – colours our understanding of the text and its subject matter. This almost inevitable temporal imbroglio has serious conflictual effects in human relationships, as family therapists know (Boscolo and Bertrando, 1993).

If you have any difficulty or frustration considering the elusive concept of time, you are in good company. Hawking (1988) attempts to understand and explain the origins of time with reference to the Big Bang and black holes. Coveney and Highfield (1991) examine the physicists’ and biologists’ preoccupations with time, focusing on the notion that time, whatever it is, is clearly irreversible. Shallis (1983) explores scientific, mystical and subjective elements of time. Physicist David Bohm commended a dialogue between science and mysticism, and regarded human thought as the mechanism responsible for the creation of the illusions of time and all personal and social problems (Krishnamurti and Bohm, 1985). Post-modernist social theorist Baudrillard (1994) challenges the concept of the purposeful linearity of time on a historical scale. Adam (1995), writing from social and feminist theory perspectives, urges us to make consideration of time central to social analysis.

Thomas (1991), calling on mystical, musical, bioenergetic and Jungian concepts, argues that a radical analysis of time is necessary to the development of true human potential. Rawlence (1985) has presented many fascinating views on time, including factors of gender difference in perception of time, the meaning of rites and holidays, and so on. Graham (1990) weaves together the concepts of time and energy in her examination of health and complementary medicine. Counsellors and psychotherapists have until recently shown little zest for analysing time, but McGrath and Kelly (1986) have looked at the social psychology of time and Slife (1993) examines time from the perspective of theoretical and philosophical psychology, with some reference to psychotherapy and its temporal assumptions.

While cyclical time was and still is taken for granted by Hindus and others, the Judaeo-Christian tradition has always promoted a view of linear and directed time. Other traditions have sometimes argued for the coexistence of at least two modes of time; the ancient Iranians, for example, recognised both an indivisible time (a creative, eternal now) and the time of the long dominion which brought decay and death (Whitrow, 1988). The discrepancies between concepts of reincarnation and one earthly life followed by either a heavenly eternity or eternal damnation must also be contrasted with the existentialist view that each human life is purely and simply the 70 or 80 years that it usually is, without survival, repetition or mystery. Statistics available to us now suggest that Western men can normally expect to live into their 70s and women into their 80s. Not so long ago, however, life expectancy was considerably shorter. Obviously the culture and era in which we live influences our perception of time and the way in which we use time. Other factors also affect how we perceive time: if you have a terminal illness, time may be very precious; if you are in prison time will drag and hang heavily on you; and so on.

The notion of time schedules and punctuality has been traced to the original Benedictine monks, for whom each day was passed in a strictly accountable, efficient way (Adam, 1995). The Industrial Revolution too emphasised schedules and erected artificial boundaries between times of work, rest and holiday. Psychoanalysis helped to promote the importance of punctuality, not only as a convenience but also as a marker of commitment or resistance to treatment. Insofar as time is money and efficiency, we seem in the West to be inescapably hooked into time schedules, appointments, deadlines and the accompanying stress. A combination of contemporary hurry sickness, uncritical attachment to clock time and alienation from natural body rhythms has led to physical illness as well as psychological ailments (Adam, 1992). American psychotherapist Kottler (1993) argues that Latin cultures have greater respect for the present. Hence, in Peru Kottler reports experiencing among his students a healthy, almost complete, disregard for punctuality.

The invention of the pendulum clock in 1657 ensured that time could be accurately tracked. Time is plastic; it can be and has been changed overnight by government decree. Our language is full of references to time: time flies, time drags, time is money, time and tide wait for no one, time heals, only time will tell, there’s no time like the present. We say that we have a lot of time for someone, or no time at all, meaning that we do or do not like and respect them. We often have certain unexamined assumptions about how long things should or do take. How long does it take to build a house, to sell a house, to write a book, to learn a language? Members of certain religious organisations have been known to build a church in a weekend. Although property conveyancing in Britain often takes months, when necessary it can happen in a matter of hours. It is not only at novel-writing competitions, where complete novels are written in 24 hours, that creative speed is exhibited. Stephen King wrote his novel The Running Man in 72 hours; Samuel Johnson wrote the novel Rasselas in the evening of one week in 1759. Various television shows have demonstrated how much can be achieved within, say, 48 hours, such as the conversion of a derelict building into a playcentre or the transportation of animals across continents and the building of humane living quarters for them. Whatever the motivating factors, there is evidence that our assumptions are based on a norm that can be challenged.

Temporal assumptions in the psychological world may need as much challenging as assumptions about time requirements in the physical world. It has been said that nothing lasts, neither tragedy nor triumph. Our problems themselves do not last forever, and neither do our solutions. We are currently seeing through the pseudo-triumph of much high-dose Gong-term) psychotherapy and turning our attention to low-dose, time-limited counselling and therapy. We might try to remember that today’s attempted solutions will themselves not last forever and that probably there is a time for time-limited counselling and a time for long-term counselling. While we are considering this issue, we might at least fleetingly give attention to the place time has in the way we construct our human problems and attempt to overcome them, although this larger question is mainly outside the scope of the present book.

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Attitudes to Time in Counselling and Psychotherapy

It is important to consider quite broadly clients’ and counsellors’ attitudes to time, how time is used, how it might be better used, which aspects of time may be negotiable or non-negotiable, and what time means for personal problem solving or personal growth.

Aspects of developmental psychology

Certain aspects of human development are beyond dispute. Pregnancies, for example, normally last about nine months. The human infant is vulnerable, cannot fend for itself and needs to be fed, cleaned and cared for for a considerable time. Most germane to our discussion are questions about the timing of developmental changes and malfunctions. Most counsellors would agree that a great deal of our habitual behaviour – comprised of our scripts, our defences and so on – is laid down in the earliest years of life. Many believe that the earlier we suffer traumas and deprivations, and the more of these events we suffer, the greater the impact these have on us and the harder they are to change, even within therapy later in life. There are differences of opinion about the degree of freedom of choice we had as children (to react one way or another to adversity, for example) and the extent to which behaviour stemming from childhood is reversible. Even within the psychoanalytic tradition there are differences of opinion about the extent to which we are afflicted by innate drives and the conflicts between them as opposed to damaging ruptures in early relationships.

The picture is complicated still more by the fact that some therapists (and millions of Hindus and Buddhists) believe that many of our problems stem from experiences in previous lives. Certain Jungians, for example, practise a form of past lives therapy which aims to acquaint people with, or liberate them from, the detrimental effects of ignorant acts or accidents in previous incarnations (Woolger, 1990). However sceptical you may be about this (and you may not be sceptical at all), it introduces a wholly different timescale into our discussion. The prospect of future incarnations, too, affects the way in which we interpret our lives (and our clients’ lives) now.

If you believe that adult life is largely predetermined by the events, circumstances and ravages of childhood, this is quite different from believing that adulthood, and indeed mid-life and old age, present not only crisis points but also immense opportunities and freedoms of their own. Remember too that our perceptions of time often alter according to our stage of life. Thus, Brundage and Mackeracher (1980) argue that children and young adults measure their lives from birth to the present, while those aged about 40 or over are inclined to measure time as something left before death. Rowe (1994) does not share this rather gloomy view of the latter half of life. Each of us decides to what extent we regard life as a repetition of early conflicts, as a series of exciting new stages, or as a perpetual blank page. Also, certain debates remain unresolved about periodicity in human life. Are astrological influences at work which affect our development? Are seasonal affective disorder and premenstrual syndrome real, imagined or not yet fully understood? There may be some facts of human development but there are opinions and choices too. There is even the view that developmental psychology itself rests on mythical foundations (Morss, 1995).

Lifespan psychologists may be confounded by exceptional cases. The following case illustrates humorously how our best-founded expectations can sometimes be way off. It was reported in 1995 that the world’s oldest woman, Jeanne Calment of Aries, France, was 120 years old and still going strong. When she was 90, a lawyer had offered to pay her rent for the rest of her life on condition that he inherited her house when she died. He was at that time 47 years old and had, therefore, made a reasonable (apparently rock-solid) bet. In fact he died, aged 77, in 1995, having paid more than three times the value of the house. If there is any moral for therapists in this wonderful story, it may be that we should never totally rely on our usual lifespan expectations and always leave room for surprises.

Consider, too, contrary to our conditioned tendency to dwell on negative early experiences, the impact of positive earlier experiences. A man who had a religious experience spoke of it in these words: ‘The vision lasted a few seconds and was gone; but the memory of it and the sense of the reality of it has remained during the quarter of a century which has since elapsed’ (Happold, 1963: 136). Many people who have been subjected to near death experiences report that they retain a vivid memory of the experience which exerts a powerful positive influence on how they live their lives thereafter. Often a brush with death sensitises people to the precariousness and preciousness of life. In a study of survivors of one maritime disaster it was found that 71 per cent thereafter claimed to live life to the fullest (Joseph et al., 1993). There are of course many Christian texts highlighting the importance of the eternal now or the valuing of the present moment (e.g. Goldsmith, 1965). It can also be argued that early deprivation and suffering is often character-forming. McCord (1978) followed up on the treatment (various kinds of formal social support, including counselling and academic mentoring) of a group of youths after 30 years and found that they compared negatively with an untreated control group in terms of illness, career development, dependency and other factors.

The point I am making here is that there are many interpretations of human development; perhaps too many of them derived from or associated with psychotherapeutic theory emphasise psychopathology and negativity generally. Brief therapists such as Budman and Gurman (1988) present an adult developmental model which challenges this. Elton Wilson (1996) incorporates a life stage rationale into her model of time-conscious psychological therapy. In time-limited counselling the counsellor is bound to consider whether and how his or her favoured theory – and its implications – fits with short-term work.

Psychoanalytic perspectives

While many of Freud’s early clinical cases were in fact of very short duration, psychoanalytic theory suggests that therapy must be either temporally indeterminate or long term. According to Freud unconscious processes are timeless, which means that ‘they are not ordered temporally, that time does not change them in any way and that the idea of time cannot be applied to them’ (Freud [1920] 1985: 299). What is repressed, in other words, cannot be de-repressed by the passage of time; early conflicts remain intact until dealt with psychoanalytically. Broadly speaking, the Freudian primary processes, governed by the pleasure principle, operate outside of space and time considerations and it is only the secondary processes, governed by the reality principle (concerned with logic and adaptation), that are amenable to temporal pressures and constraints. As Rycroft (1972) points out, psych...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• 1 Introduction: the Nature of Time
• 2 Attitudes to Time in Counselling and Psychotherapy
• 3 Kinds and Models of Short-Term and Time-Limited Counselling and Psychotherapy
• 4 The Appropriateness of Time-Limited Counselling for Different Clients
• 5 Key Ingredients, Skills and Strategies
• 6 Case Examples: Learning from Experience
• 7 Problems and Troubleshooting
• 8 Management of Time-Limited Counselling in Context
• 9 Training, Supervision, Evaluation and Research Issues
• Appendices
• References
• Index