A Brief Beef

by Marc G. Schramm, Psy.D., C.G.P.

Given my interest in group dynamics, one historical trend I find particularly disturbing is the weakening of group supports available to us as individuals. Families--both nuclear and extended--are more fractious than ever, with blurred boundaries on the one hand and geographic dispersion on the other. But declining family support systems wouldn't be as problematic if other support systems weren't also declining. Our various social and communal institutions often have smaller and less stable membership than in recent generations, and are unable to pick up the slack.

In some cases the vacuum is filled by groups whose cohesiveness is enforced by violence and intimidation. The depth, breadth, and quality of our multi-interpersonal bonds, of our social support systems, are steadily deteriorating for too many people, and such supports that are available all too often tend to be cold, impersonal--and fleeting.

At first glance it may seem ironic that at such a time brief psychotherapy is becoming (perhaps already has become) the psychotherapeutic norm. Of course this is really not a matter of irony at all, since some of the same factors effecting the decline of supportive institutions are at work here as well. The weakening of confidentiality by third party payors, and limitations on treatment by managed-care providers both have a lot to do with changes in the structure of the economy, and such changes impact on family and institutional supports as well. While there is a greater need than ever for long-term psychotherapy to fill the gap, its declining availability is simply further symptom of the problem.

Let me make clear before I go any farther that I am not one who fulminates against the modality of short-term psychotherapy. I feel quite fortunate to have received training in brief psychotherapy before there was anybody breathing down my neck telling me I had to, and I received that training from no less a mainstream figure than Leopold Bellack. Short-term psychotherapy is an important part of my repertoire, and I have little sympathy for hide-bound traditionalists who sneer at brief psychotherapy, especially those unaware of its long historical pedigree.

Not having learned brief psychotherapy "under the gun," my attitude is not colored by a sense of compulsion. Nevertheless, when I see an increasing minority of psychotherapists advocating brief psychotherapy as *the* approach of choice, I can't help but feel that they are making a virtue of a necessity. My first experience with managed care was in community mental health. Our clinical director (a man for whom I otherwise tend to have a great deal of respect) offered us his own rationale (rationalization!) for the requirement to limit sessions: since the modal number of sessions in community mental health is one, and few patients stay in treatment beyond a dozen or so sessions, brief psychotherapy must be what patients want. I hope the fallaciousness of this argument needs no exposure by me.

Sometimes the argument for brief psychotherapy consists of casting aspersions upon long-term psychotherapy and its advocates. The idea that therapists typically keep patients in therapy interminably with motives of monetary exploitation may be quite cynical. The cynicism of the charge does not defend against the kernel of truth behind it, however. Certainly patients often stay in therapy longer than needed, and in some cases the therapist's need for productivity plays at least an unconscious role. Such problems occur, and are no less objectionable than patients receiving less therapy than they need due to financial motives on the part of insurers. Abuses of brief and long-term psychotherapy do not invalidate either approach.

Let me propose a thought experiment, eliminating some of the peripheral factors that can cloud the issue. Let us assume that a steady stream of patients are available, but that no patient in need ever has to go on a waiting list for psychotherapy. Let us further assume that all therapists are well-trained in both brief and long-term psychotherapy. What modality would most psychotherapists choose under these circumstances? I would like to hear your personal reactions to this thought-experiment, your expectations for how most therapists would respond, and your reasons for both. Please let me know how the modality of group psychotherapy fits into all this. In a later column I will share the reactions I receive, as well as the results I came up with when I asked myself these questions.

4/17/98

Marc G. Schramm, Psy.D., is a Founding Certificant of the National Registry of Certified Group Psychotherapists, a clinical member of the American Group Psychotherapy Association, and President of the Tri-State Group Psychotherapy Society. He is currently Cincinnati-Dayton Regional Director for Counseling Consultants, Inc. Call Dr. Schramm at 513-984-9222

 

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