Brief therapies: approaches and applications

¶ … Therapy

Constructivist Perspective of Brief Therapy

Understanding the basis of theories and therapy is a necessary element of the therapist's trade. Without some knowledge of why certain therapies are practiced, or where they came from, it is difficult to develop a personal theory and a personal view of how to conduct therapy. Since one of the basic concepts presently is that of brief therapy, it is necessary to see how that concept was formulated by other concepts. Thus, this paper examines how constructivist perspectives underlie brief therapy. This paper also gives the author the opportunity to voice a personal statement about how these findings coincide with personal constructions of therapy.

Definitions

It is first necessary to understand the terms that are to be discussed. The two primary phrases to be discussed are constructivism and brief therapy. However, it is also necessary to grasp what brief therapies exist.

Constructivism

The definition here is not necessarily difficult, but there are many people who have both studied and thought about what the concept of constructivism is and that has led to some confusion. First, there are two different words used in the literature that are similar but they are not the same (it seems). It is easy to be confused for two reasons: both of the words look and sound the same, and one theory is based on the precepts of the other. The concept of constructionism is actually based on that of constructivism in that it is actually the same except for the fact that it discusses learning based on manipulation of objects which is not a part of constructivism. Thus, that part of the confusion is assuaged. However, that still does not explain what constructivism is.

A simple, and understandable, definition is that;

"Constructivism is a theory of learning based on the idea that knowledge is constructed by the knower based on mental activity. Learners are considered to be active organisms seeking meaning. Constructions of meaning may initially bear little relationship to reality (as in the naive theories of children), but will become increasing more complex, differentiated and realistic as time goes on" (University of Saskatchewan, 1999).

By way of illustration, a child will witness something and, via their limited experience, will develop an understanding of that event. It does not matter what the relative simplicity or gravity of the situation is in reality, the construct that the child develops comes from their own experience. But, as the experience grows, the construction of explanations also grows. That is why this is basically a learning theory. As an individual grows, their understanding of events increases and the person is able to get closer to actual reality than they were able to at first.

It is also noteworthy for the study of the concept in relation to therapy that the construct does not have to be based on what society views as reality. The "reality" that the person develops is based on their own interpretation of events. It can best be said then that this is a study of personal perception. As far as the psychotherapy community is concerned, it is important to understand the constructs the individual has built over time and how they can either reinforce those that are healthy or defeat those that are unhealthy.

Brief Therapy

The idea of brief therapy is not as simple as just taking the two words at face value and constructing a definition from that knowledge. As Levenson, Speed and Budman (1995) relate, "brief therapy, although it is customarily defined in terms of limited sessions, is not simply a shorter version of long-term therapy, but a different treatment modality requiring specialized training in its theory and techniques." Having fewer sessions is a part of the design of brief therapies, but it is not the totality of the process. Unfortunately, researchers have found that although therapists said that they were using the technique approximately 40% of the time, they actually had little training in the actual delivery of proper brief therapy.

It is also false to think that the entire practice of brief therapy comes from a need, due to insurance company imposition, that therapy take fewer sessions, again this is partly true for the current movement to these types of therapies, but it has little to do with the actual definition. The fact that researchers in the field, and therapists themselves have found evidence that this may be the best therapeutic solution for the majority of clients is the reason brief therapies have flourished.

The best way to define this type of therapy is to say that it is a combination of factors. Lisa Fritscher (2009) defines it as "A collection of therapy options that are focused on fixing the presenting problem in only a few sessions. Many brief therapy practitioners see their role as largely one of "educator," teaching the client strategies to manage their own conditions. Brief therapy has become popular due to the limitations of managed care." Thus, brief therapy is primarily a departure from the historical focus of psychotherapy from leading a consumer towards a solution that they devise themselves through therapeutic techniques, to a paradigm where the therapist actually teaches the consumer. This is a departure because it has seemed in the past that it was more responsible to allow discoveries to dawn on the client rather than have the therapist actually teach them. Teaching seems to go against some of the historical principles because it is akin to giving the consumer the knowledge that the therapist thinks they need rather than allowing the client to reach an understanding for themselves. However, forces outside of the therapeutic interaction fist helped determine the number of sessions, and there were studies that suggested that certain methods of brief therapy were actually more effective than allowing the client to arrive at a solution through a greater length of therapy.

Types of Brief Therapy

Therapists use many different types of therapy to achieve a meaningful outcome for a client. Usually, because there is a session limit (usually no more than 20, but often fewer), therapists will only work on one issue with a client. This means that there may be more sessions in the future, but they are not necessarily a part of the original issue. Traditional forms of therapy such as cognitive and behavioral types can be used but there are others that have proven affective as well. Hypnotherapy has been shown to limit the number of sessions that are needed for some problems (especially those such as smoking cessation and weight loss that have a physical component). A major type of therapy that is specifically brief in nature is solution-focused therapy. The client tells the therapist the issue that they are trying to solve and therapist assists the client in solving it. Solution-focused therapy in particular is based on assumptions made is social construction theory

How Constructivist Thinking led an Emphasis on Brief Therapy

As mentioned above, people are prone to gather experiences throughout their lifetimes and with the experiences they have had adopt a construct. The problem with this is that experience can be very narrowly focused. Individuals have different levels of experience, of course, and they will devise the solution to a problem in different ways based on what personal experience has taught them. Of course there is a base of knowledge that people gain throughout their lives also, but this is also flavored with the experiences gained.

For example, a person sees fire and they experience it in different ways as they develop. When that individual is an infant, there is probably a desire to touch the bright, moving flame which they may fulfill. Thus, the individual learns that the fire is hot and that it can burn them. The individual also learns that it is okay to look at fire, but that getting too close is painful. As that individual grows they learn that fire can be fun (fireworks), useful (cooking food), and that it can also be destructive. The person probably experiences variations of the utility, fun and danger of fire which helps to draw conclusions.

In the case of mental health, the same development can occur. Of course, there are mental illnesses that are the result of actual physical causes, but many are either exacerbated or caused by flaws during development. A child is not closely cared for, and is often left by herself. The parents go out of the house, sometimes for hours from the time the child is very young, and when they return they continue to take no notice of the child. As the individual grows, they have reinforcing experiences that deepen a sense of abandonment. As an adult, she seeks assistance from a counselor because of continuing problems as a result of the abandonment which started when she was a child. The construct she developed was that people will not respect her, and that no one pays any attention to her. This has caused a deep depression and a self-loathing that she sometimes relieves with cutting behaviors. The original construct has deepened to the extent that she sees everything from the prism of her abandonment issues, and the expectation that they will continue. It is no wonder that she has these thoughts because of the reinforcement she has received throughout her life.

Constructs are, as mentioned previously, developed throughout the lifespan, and they can either turn toward a true reality or they can turn away from reality depending on what experiences the individual has. Because it is easy for a construct to become faulty, many people require some means of rearranging what they believe to come closer to reality. Sometimes this can be accomplished simply through maturity. The person has enough experiences that they come to understand where they were at fault in their thinking. Education is also a method that can be used as a means of gaining enough knowledge to overcome experiential deficits. However, sometimes that individual needs some unbiased coaching to help them determine a truer reality.

In the past when someone needed a counseling adjustment, it was possible for a therapist to delve deeply into the person's psyche and help them deal with a large scope of issues. This type of therapy was possible because either health insurance or the person could and would pay for it. Of course, there was always the possibility that the therapist would abuse the fact that a client could pay, but, usually, ethical considerations kept them from it. However, healthcare companies eventually started to decrease the amount of sessions that they were willing to pay for, and this created a need for new paradigms.

Therapists started looking at constructivist thinking closer because they realized that here was a new method of counseling that could work with the new time constraints that they were under. Since the constructs that people have are often very narrow, it is possible for the therapist to work with the individual to broaden those perspectives. Another reason for the switch to this new paradigm is that social constructivist thinking "may allow the profession a broad and encompassing framework for providing an array of services otherwise defined within the paradigms aligned with other professions. For example, social constructivism allows for the application of systemic-relational techniques or individual psychotherapy, depending on the consensus that emerges around a problem -- is it a relationship problem? Or is it primarily a concern best addressed individually? Because choice of approach is based on the "communities of understanding" around a problem, there is unlimited flexibility for the practitioner" (Levenson, Speed & Budman, 1995).

This is because these other professions have been studying the social constructivist approach for a long while, and what they have researched will have value for the counseling profession. No profession "operates in a vacuum" so it is important to understand where new theories can be effective for clients.

Since these facts were realized by psychotherapy researchers, they began to study the effects of this approach to counseling and found that it could be efficacious, especially when it came to new directives to decrease the number of sessions required for a client. The reason for this is that constructivism allows for brief therapy in a more complete way than other types of therapy than had been used in the past. Of course, the historical view of counseling is that it happens in a manner that fits with the development of the client through the problem. However, time constraints made this thinking untenable. An individual can talk about their problems forever and never actually make any progress, but this new type of therapy allowed counselors to set a timeline. Solutions are the mantra of brief therapy instead of a long-term therapeutic relationship. Also, studies revealed that these techniques were effective.

In an initial session the counselor may conduct themselves in much the same way as they always did. The client will give pertinent information about themselves, and help the therapist understand what the individual believes the problem is. The counselor will construct theories just like before, but will be quicker to act on them. Previous to brief therapy, the therapist may spend weeks or months allowing the consumer to talk about all of the issues that are likely present, while the counselor formulates a solid theory about what the real issue is. The therapist may require some conjoint sessions with other people involved, or they may do other research that takes time. Brief therapy does not allow the therapist the time to do all of this work. In the first counseling session the groundwork is laid, and the counselor asks open-ended questions that lead quickly to the heart of the issue.

After the initial session the therapist likely has just six to nine more sessions to assist the consumer in every way possible. This is where the social constructivist mindset lends itself to brief therapy. It will be apparent from the first interview what constructs are most troublesome for the client, and where the counselor can go as a result. The purpose of the counselor is to broaden the reality of the client. The reason that the person is having an issue is because they have a narrow perspective, and they need to understand that reality includes more than they may have thought of before. This type of therapy will work for a variety of ills.

Brief therapy, and especially solution-focused brief therapy, has been very successful with chemical dependency. The reason for this is that there is most likely an underlying cause to the reliance on a substance, and if the client can be helped to realize the broader perspective, then they can be relieved of that dependence. Solution-focused therapy establishes a goal for the sessions from the very beginning, and constantly works toward that goal. For example, a person is an alcoholic and is in therapy because of multiple DUIs. The court has ordered that the individual complete a ten therapy sessions. The focus of the therapy sessions is the cessation of alcohol dependence, but it is primarily to define the constructs the problem drinker has and arrest them. It is possible that depression is the main cause, that the alcoholic has abandonment issues, or any of a number of other problems. The therapist listens what the person says to determine how the views of that individual have caused to issue that presents itself. Knowing what the problem is, the therapist then seeks to give solutions that can work for this particular individual. This is an important step. Not every method of rearranging concepts will work for every client. In the remaining sessions the therapist must choose from a variety of solutions to determine which will work best for this particular individual.

This is the reason that constructivism is the bedrock of brief therapies. The counselor does not have the time to work with the client in the traditional manner, so they have to use this method to rapidly treat a construct. This may also mean that the person will require more therapy sessions in the future if other problems exist, but this single construct focus allows the therapist to work on a specific issue with great focus. It also allows the therapist to become a teacher of sorts. The therapist offers solutions instead of allowing the time to help the client reach these same conclusions on their own.