CognitiveBehavioral And Psychodynamic Models For College Counseling

Essay, Research Paper

Short-term or Brief Counseling/Therapy:

Cognitive-behavioral and Psychodynamic Models for College Counseling

Abstract

?Short-term? or ?Brief Counseling/Therapy? and the current mental health system

seem to be inexorably linked for at least the foreseeable future. This paper discusses

the history, objectives, appropriate clientele, efficacy, and the other benefits, and

short comings, of this therapeutic/counseling modality and its relevance to my

present career direction, College Counseling. Cognitive-behavioral, Psychodynamic,

and Gestalt applications of brief therapy/counseling methods will be addressed.

For a working definition of short-term or brief therapy/counseling I would like to quote a

couple of authors on the subject. Wells (1982) states that, ?Short -term treatment, as I shall use the

term, refers to a group (or family) of related interventions in which the helper deliberately and

planfully limits both the goals and duration of contact?(p. 2). Nugent (1994) says that, ?In contrast

to traditional therapies, brief counseling and therapies (or time-limited therapies) set specific goals

and specify that the number of sessions will be limited.? He then adds that, ?Counselors using brief

therapy approaches help clients develop coping skills that will enable them to anticipate and manage

future problems more effectively?(p. 96). In short, brief counseling/therapy is more directive and

time-limited, regardless of the particular therapeutic theory being employed. The counselor assumes

an active instead of a passive role in his relationship with the client. Due to budget constraints, the

rising cost of mental-health care, and a growing demand for services over the last decade, a large

number of counselors, in a large variety of different work environments, have been using brief

counseling and short-term therapy approaches (Nugent, 1994; Steenbarger, 1992). Short-term therapy

and counseling have consistently proven to be a powerful, efficient, and effective approach for

resolving human emotional and behavioral problems, and it is a major force in the field of

psychotherapy and counseling today (Saposnek, 1984).

Although the overwhelming emphasis on brief counseling/therapy in the mental health

system is a relatively recent phenomenon, the concept itself is at least as old as Freud. Freud

originally viewed psychoanalysis as a research tool that had powerful therapeutic applications.

Although he tried to limit his early analysis to six to twelve months, he had hoped that in time it

would be superseded by more efficient methods (Saposnek, 1984; Nugent, 1994; Phillips, 1985).

According to Small (1979), ?Historically, it is clear that Freud first sought a quick cure; when he

began he could not foresee the developments that would lengthen the psychoanalytic process.? Who

would have believed that Freud would have preferred a brief therapy over the open-ended, time-

unlimited therapy process that classical psychoanalysis had become.

Social changes brought on by the pressures of World War II led to a great demand for short-

term interventions. ?The stress-related emergencies of World War II necessitated the development

of early forms of crisis intervention aimed at symptom reduction, strengthening of coping

mechanisms, and prevention of further breakdown? (Saposnek, 1984). Brief therapy had found a

niche and was made accessible by government funding through the Veterans Administration. One

of the ironies of war is that it often creates large market niches and economic boon at the expense

of humanity.

In 1963, due to an increasing need for services, President Kennedy and the Congress passed

the Community Mental Health Centers Act. This Act required an emergency service in every

community mental-health center and increased the demand for brief therapy services (Small, 1979).

?The community mental health concept was intended to eliminate waiting lists from clinics (which,

not infrequently, were up to two years long!) and to get services out to the truly needy.? (Saposnek,

1984). To date, with our current emphasis on managed health care and an ever increasing need for

mental health services, the demand for efficient, effective and accessible intervention has increased

even more, making brief therapy all that much more popular and necessary in the ?80’s and ?90’s

(Nugent, 1994).

Short-term or brief therapy refers to more than just the length of time or duration of

counselor-client contact. It also incorporates the use of sophisticated directive skills on the part of

the counselor. According to Richard Wells, author of Planned Short Term Treatment, ?The

therapist?s activities throughout the helping process are directed toward (1) making problems and

goal definitions as clear as possible, (2) supporting the client in systematic, step-by-step problem

solving, and (3) using the pressures of an explicit time limit as a key factor towards change?(Wells,

1982, p. 9). Garfield (1989) states that, ?The specificity of the goals of brief therapy, the active role

of the therapist, and the expectations concerning the length of therapy all help to facilitate the process

of therapy and to avoid some of the pitfalls that occur in long-term psychotherapy? (p. 12). From

these statements we can conclude that the concept of brief therapy incorporates a strategic,

systematic frame work for intervention as well as the element of time-limitation.

Although brief therapy has been adapted to the majority of intervention theories that exist,

it generally stems from either psychodynamic or cognitive-behavioral theories of which

psychodynamic approaches are the most abundant. For short-term psychodynamic therapists the

focus is on the analysis of transference and countertransference, but unlike long-term analysts, the

short-term therapist is more concerned with the client?s present circumstances rather than with issues

of childhood. The majority of cognitive-behavioral short-term therapists are concerned with setting

specific goals, de-emphasizing past events, teaching new skills, and emphasizing the practice of new

and adaptive behavior (Nugent, 1994).

The question of who is or isn?t an appropriate client for brief therapy seems to point to

anybody who is not suffering from serious disorders such as psychoses, major addictions, etc..

According to a review of approaches by Butcher and Koss (1978), they concluded that there were

four kinds of patients considered to be best suited for brief techniques: ?(1) those in whom the

behavioral problem is of acute onset; (2) those whose previous adjustment has been good; (3) those

with a good ability to relate; and (4) those with high initial motivation.? (Saposnek, 1984). Garfield

(1989) states that, ?With the exception of very seriously disturbed individuals …., brief therapy can

be considered for most patients who are in touch with reality, are experiencing some discomfort, and

have made the effort to seek help for their difficulties.? This sounds like a fairly average person fits

the criterium for brief therapy/counseling. Long-term therapies are generally elitist by nature. Those

who can afford the unlimited-time frame and expense involved are not in the average, mainstream,

working class population.

The empirical evidence in support of short-term therapy approaches is overwhelming. It has

been shown in reviews of studies that there are essentially no differences in outcome between short

and long-term psychotherapies but short-term therapies are significantly more efficient. This is also

the case when comparing varieties of short-term therapies among themselves (Saposnek, 1984). In

fact, the whole concept of long-term psychotherapy may be a myth based on the actual numbers of

long-term cases. Studies over the last four decades have consistently shown that the average number

of therapy sessions attended per patient across a wide variety of psychiatric clinics, ranged from four

to eight (Garfield, 1986). Even in psychoanalysis, clients tend to drop-out before ten sessions over

half the time and before twenty sessions more than 70% of the time (Garfield and Kurtz, 1952;

Gurman and Kniskern, 1978 ). The reasons for these high drop out rates among long-term therapies

vary. However, Saposnek (1984) gives a good overview of the potential reasons stating:

While some patients do drop out of therapy dissatisfied, because of a mismatch of values and

expectations with their therapists, it has also been found that those who leave therapy early

seldom go for therapy elsewhere. No doubt, in some of these cases, the clients may well have

been turned off to therapy forever. However, it appears more likely that the clients felt that

the problems for which they came had been resolved to their satisfaction (p. 1033).

A study by Butcher and Koss (1978) stated that improvement was reported in about 70% of cases

in various modalities of short-term therapies. This is a strong testimony to the efficacy of short-term

therapy especially when you consider the time factor. This is not to say that all long-term therapy has

no valid place in the mental health system (it does!), but if outcomes are equal between short and

long-term therapies in general, then that shows that the majority of clients (that are not suffering

from the before mentioned serious disorders), can be served well by short-term therapy.

In relationship to my present career path, college counseling, brief counseling/therapy

approaches have particular significance. Due to budget and logistic constraints, most college

counseling centers are overburdened and understaffed with a ratio of counselors to students of

1:1,765 (Galagher, 1991). These conditions are a specific example of a situation where short-term

therapy/counseling can play an invaluable role. Obviously students are in need of counseling

services. If not for time-limited intervention, I wonder where and how they would get the help that

they need. Referring to a review of the literature by Stone and Archer (1990), Nugent (1994) states

that, ?Stone and Archer recommend that counseling centers should maintain their emphasis on

developmental concerns of the students, offer career counseling as a major service, focus on outreach

programs for personal and psychological growth, and emphasize time-limited counseling.? Nugent

also refers to a study by Gage and Gyorky (1990) and states that, ?College students with specific

developmental concerns related to academics, careers, relationships, and loneliness are most

appropriate for time-limited counseling. Those clients who have mild disturbances and strong egos

and are capable of focusing on specific goals are most likely able to benefit from brief therapy.? By

this criterium, college campuses appear to be a perfect setting for the use of brief therapy/counseling

approaches. With the recent influx of older students returning to college, the diversity of presenting

problems among the college client pool should be rather large. This provides the counselor with a

rich and varied source of clients with which to hone his/her skills.

Although my long term goals are to become a clinical psychologist and author, I have chosen

?College Counseling? as an interim step in order to be able to work my way (financially) through

a PhD/Psy.D program and gain valuable counseling experience along the way. My hope is to land

a job as a college counselor at a university where I plan to complete a Doctoral program in clinical

psychology. Another motivation for this interim short-term strategy is that I am already forty years

old and I want to make damn sure that I have an employable credential in the event that I should not

complete my long term goals of a PhD/Psy.D. The bills are stacking up and I want to know that I

have a means of paying them.

On a less selfish note, I also chose college counseling because I have direct experience in this

arena and feel I will be able to relate to many of the problems I will be presented with by students.

I myself received abundant counseling while an undergraduate for vocational as well as

psychotherapeutic reasons. I know what it?s like to have and be treated for clinical depression, while

being a full time student. This kind of empathy and insight is hard to learn from less than first hand

experience and can be a most valuable asset when working with someone who is suffering with a

problem or condition that you know about from first hand experience. If not for the help I received

from counselors and therapists, I really don?t think I would be in this class today.

Although short-term approaches can be found based on any of the current therapy theories

that exist today, the two most common are psychodynamic and cognitive-behavioral based

approaches to brief therapy and counseling (Nugent). I would integrate both of these approaches and

also some Gestalt techniques (especially for group work) into my own eclectic/integrative style of

brief therapy/counseling.

Of the several mainstream cognitive-behavioral short-term approaches (all based upon the

previous works of Ellis, Beck, Meichenbaum, Haley, M. Erickson, etc.), I believe that Donald

Genter?s ?Solution-focused? model, is the best suited for the majority college student population

(Nugent).

In ?Solution-focused? short-term therapy, the counselor ?defines the problem, establishes

goals, designs an intervention, assigns a strategic task, emphasizes positive new behavior changes,

and then before termination, helps clients gradually incorporate new behaviors into their everyday

living.? (Nugent). This is very directive. The main reason I like this approach is because it clearly

fulfills the criterium mentioned earlier for effective time-limited interventions, and like all cognitive-

behavioral approaches it is psychoeducational, structured, and focuses on specific target problems

(Nugent). Although it can be especially effective in dealing with most normal developmental and

academic issues, it is not a panacea, and may not be as effective in dealing with more intrapsychic

long-term presenting problems, where I would prefer a more psychodynamic or humanistic approach,

but it will probably help most of the client populations (college students) presenting problems most

of the time.

The limitations of this specific approach are the same as those for all cognitive-behavioral

models. ?Cognitive therapy has been criticized as focusing too much on the power of positive

thinking; as being too superficial and simplistic; as denying the importance of the client?s past; as

being too technique-oriented; as failing to use the therapeutic relationship; as working only on

eliminating symptoms, but failing to explore the underlying causes of difficulties; as ignoring the

role of unconscious factors; and neglecting the role of feelings.? (Corey, 1996 p.356). Also, because

the underlying premise/techniques of all cognitive-behavioral therapy is challenging the client?s

beliefs/values and behaviors, this has potentially harmful implications for culturally diverse

populations/client?s. It is especially important that the counselor make himself aware of the cultural

context and values of these client?s before attempting to confront or change their way of thinking or

behavior (Corey).

When dealing with clients that have issues that are more of a emotional, long-standing,

intrapsychic nature, I would choose a short-term psychodynamic approach possibly coupled with

some gestalt techniques to help bring past issues into the ?here and now.? In short-term

psychodynamic therapies, the focus is on the analysis of transference and countertransference in the

therapeutic relationship, but unlike long term psychodynamic therapy they associate this analysis to

present circumstances instead of focusing on childhood traumas. This analysis of patient-therapist

interactions can then be generalized to interactions with others outside of therapy. The past may be

explored, but only in the context of the client?s present circumstances (Corey, Nugent). I like this

approach because unlike cognitive-behavioral methods, it allows the client and therapist more room

to explore the role of unconscious factors, feelings, and other underlying causes of difficulties

instead of just being symptom oriented. I would use Gestalt techniques (such as role-reversal, etc.)

in both individual and group sessions when appropriate (Nugent, Corey).

Some of the limitations of this approach (Psychodynamic), revolve around ambiguity and the

intrapsychic nature of these therapies. Some ethnic minority cultures, such as many Asian

Americans, may not be comfortable with this focus and prefer a more structured approach to

counseling. Corey states that, ?….intrapsychic analysis may be in direct conflict with some client?s

social framework and environmental perspective.? (Corey, 1996 p.128).

Gestalt, and Holistic therapies both have qualities/characteristics that fit well within the

college counseling arena. Gestalt techniques such as ?role play/reversal, etc.? would be particularly

good for group sessions. And I think that bringing the health of the physical body and spirit into play

is an essential aspect to overall health and well-being as emphasized by Holistic practitioners. I

would choose an integrative/eclectic approach combining particular aspects of all the previously

discussed therapy/counseling theories depending on the individual case before me.

In review, although brief therapy/counseling is by no means a panacea for all the presenting

problems in the world of mental health, it is in fact a great therapeutic tool for the majority of the

more normal developmental life issues or problems that present themselves in the lives of the

average population. Severe addictions, and psychoses may require long-term interventions and the

use of psychoactive drug therapies. Although its present wide spread use and acceptance is a rather

recent phenomenon, the concept of brief therapy is well rooted in historical foundation. From the

early formative days of psychoanalysis Freud was looking for a quick cure for neurosis and did not

intend on the long drawn-out process that psychoanalysis eventually became. I think he would have

liked the brief psychodynamic therapies of today. The research shows that there is no significant

difference in outcome between short and long-term approaches, but short-term is much more

efficient when used with appropriate clients. In effect, even the majority of long-term therapy

approaches are short (by default, not by design), when you consider the actual number of sessions

the average patient attends.

In conclusion, with the pressures of an ever increasingly fast paced society such as ours, the

need for an effective, efficient, and accessible therapy/counseling approach is obvious. Short-term

or brief counseling/therapy is that approach. Brief therapies have been adapted to most of the major

therapy/counseling theories so there should be an approach that suits just about every one. It seems

inhumane to treat people for long periods of time at huge expense if they can be effectively and

efficiently be helped with short-term approaches. Classic Psychoanalysis, among other long-term

approaches, need to be more honest with themselves about who is really being served in the majority

of time-unlimited interventions. Old habits and attitudes often die hard, and this is especially true

when they are linked to individuals professional identities and bank accounts. When long-term

intervention are truly needed, it?s great to know we have them, but in the face of the evidence,

professionals should not make, or maintain, generalized questionable claims about the efficacy and

merits of open-ended therapeutic practices at the expense of the best interests of their clients.

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