U‘
| Irwt'wr‘s m3.“
1.4.;Vw his:
an»:
I

_ -. FWJ”M5

This is to certify that the

thesis entitled

Planned Short Term Treatment in a
Mental Health Clinic

presented by

Roger Cutting Smith

has been accepted towards fulfillment
of the requirements for

Ph. D. (mgeeni Social Science

 

 

 

M flan/41711)

Major professor
Date WU 36/777

0-7639

 

W at

 

 

 

 

PLANNED SHORT-TERM TREATMENT
IN A MENTAL HEALTH CLINIC

By

Reger C. Smith

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Interdisciplinary Social Science

1977

ABSTRACT

PLANNED SHORT-TERM TREATMENT
IN A MENTAL HEALTH CLINIC

By

Reger C. Smith

Planned Short—term Therapy has resulted from, and been
supported by a number of trends and crises in the broader field
of therapy in the past fifty years. The reaction to Freudian
therapy placed emphasis on more objective and more environmentally-
oriented treatment. The emergencies and shortages of World War II
necessitated briefer and more goal-limited forms. The Community
Mental Health Movement of the sixties reflected a long-term trend
to make treatment services available to unserved and disadvantaged
groups.

Unplanned termination makes most traditional therapy treat-
ment cases short-term. A review of PSTT process in a number of
studies revealed that time is a pivotal factor that affects the
role of the therapist, the role of the client, and the content of
the therapy.

The model of PSTT used in this study was developed by
Frank Reid and Laura Epstein in the early 19703. It contains
seven categories of client problems which the authors found
amenable to PSTT (Interpersonal Conflict, Dissatisfaction in
Social Relations, Problems with Formal Organizations, Difficulties

in Role Performance, Problems of Social Transition, Reactive

Emotional Distress, and Inadequate Resources). It also specifies
four categories of client problems which were determined unsuit-
able for PSTT. The model includes a client-therapist contract

of limited treatment objectives and no more than eight to twelve
interviews.

The therapists in a small, urban-rural mental health clinic
applied the Reid and Epstein model of PSTT to the clientele coming
for treatment during a six-month period. During the preceding
six months, the clinic's clientele was treated conventionally.

The scaled outcomes of the two forms of treatment showed no
significant difference. The second major finding of the study
was that PSTT averaged 4.7 interviews per case and conventional
therapy averaged 10.6 interviews.

Other significant findings of the study were:

When treating with PSTT:

1. there is no relationship between the time a client's
problem took to develop and the length of time it took to treat it.

2. the therapists agreed with Reid and Epstein in deter-
mining that some problems could not be treated with PSTT.

3. clients, therapists, and the independent rater agreed
in their assessments of therapy outcomes. They also agreed as
groups in their outcome assessment of PSTT and conventional therapy.

The study focused on 66 cases classified under five of the
model's seven problem categories and treated with an average of
4.7273 interviews. These 66 research cases were rated 2.9798 by

clients, therapists, and the researcher on a five-position outcome

scale. (The positions were: (1) aggravated, (2) unchanged,

(3) slightly alleviated, (4) considerably alleviated, (5) target
problem no longer exists.) A rating of 3 actually represents

67 percent success since "aggravated" is a negative outcome and
"unchanged" is neutral or zero.

The control group consisted of 86 cases treated conven-
tionally with an average of 10.5843 interviews. The clients,
therapists, and the researcher in combination rated the outcome
of this therapy as 3.0899 on the same scale used for the experi-
mental group. The difference in the average number of interviews
for the experimental and the control group was highly significant.
The difference in the treatment outcome ratings of the two groups
was not significant. (The test of significance yielded a t of
.5809 with 153 degrees of freedom and a probability of .568.)

The general hypothesis that PSTT is as effective as
traditional treatment and requires fewer interviews was supported
in this mental health clinic study. However, the sample was white
and therefore the results were not generalizable to a number of
minority and other special interest groups. Additional studies
can increase the empirical support base for PSTT and demonstrate

its client-centered characteristics.

PREFACE

Industrialization and technology are ongoing developments
that support increasing production and services. The result of
this burgeoning combination of science and economics has been an
increasingly complicated and stressful life for individuals and
families in Western society. During the last one hundred years,
several professions have develOped which specialized in alleviating
trauma and stress. However, the rapid increase in personnel to
treat emotional problems has not kept pace with the increasing
demand for treatment services.

American society has gradually broadened (albeit reluctantly),
the range of age, socio-economic, and ethnic groups that it attempts
to provide for. These groups need mental health services in a variety
of forms, locations and schedules. It has become increasingly
apparent that traditional, leisurely modes of treatment were too
inflexible and inadequate to provide the volume and variety of
needed services.

This study developed because of the combination of the need
to reduce a mental health clinic's waiting list and the limited time
available to a temporary therapist to work on the waiting list. The
writer is grateful to Mrs. Alice McKinnon, Director of the Blue
Water Mental Health Clinic, for her gracious and enthusiastic sup-

port, to the late Dr. Margaret Blenkner who helped with research

ii

design before she passed away, and to Dr. Lucille Barber who has
been guide, critic, and mentor as chairman of the author's

doctoral committee.

iii

PREFACE
LIST OF

LIST OF

Chapter

TABLE OF CONTENTS

Q 0 O O O O O O Q O O O O O O O O O O O O

TABLES O O O O O O O O O O O O O O O O O

FIGURES O O O O O O O O O O O O O O O O O

I. INTRODUCTION . . . . . . . . . . . . . . .

Purpose of the Study . . . . . . . . . .
General Hypothesis . . . . . . . . . . .
Agency Setting . . . . . . . . . . . . .
Rationale for the Study . . . . . . . . .
General Considerations . . . . . . . . .
Definition of Terms . . . . . . . . . . .

II. SHORT-TERM THERAPY: REVIEW

OF THE LITERATURE . . . . . . . . . . . .

Psychotherapy Research . . . . . . . . .
Doubts Concerning Traditional
Long-term Therapy . . . . . . . . . . .
Therapy Needs Versus Available Resources
A Short History of Brief Therapy . . . .
The DeveIOpment of Some Theories
Supportive of Brief Therapy . . . . . .
The Goals and Focus of Brief Therapy . .
Time Limits for Brief Therapy . . . .
The Types of Problems that Can be
Treated with Brief Therapy . . . . .
Characteristics of Clients Considered
Suitable for Short- -term Therapy . . .
The Process and Content of Brief Therapy

III. METHODOLOGY . . . . . . . . . . . . . . . .

Hypotheses . . . . . . . . . . . . . . .
Major Hypothesis . . . . . . . . . . .
Research Hypotheses . . . . . . . . . .
Statistical Hypotheses . . . . . . .
Rationale for the Hypotheses . . . . .

iv

ii

vi

vii

|-‘

\DGWNl-‘H

11
ll

15
19
21

27
29
36

43

44
48

58

58
58
58
59
6O

TABLE OF CONTENTS (Continued)

Chapter
III. (Continued)

Sampling of the Population . . . . . . . . . . . . . 61
Mechanical Procedures . . . . . . . . . . . . . . . . 64

Experimental Period . . . . . . . . . . . . . . . . 64

Control Period . . . . . . . . . . . . . . . . . . 65
Guidelines for Excluding Cases from

Experimental Group I and Control

Group I . . . . . . . . . . . . . . . . . . . . . . 66
Guidelines for Selecting PSTT Cases . . . . . . . . . 68
Rating of Outcome . . . . . . . . . . . . . . . . . . 69
Statistical Procedures . . . . . . . . . . . . . . . 70

IV. RESULTS OF THE RESEARCH . . . . . . . . . . . . . . . . 76

Comparability of Groups . . . . . . . . . . . . . . . 76
Testing the Hypotheses . . . . . . . . . . . . . . . 80
HO-l . . . . . . . . . . . . . . . . . . . . . . . 80
HO-2 . . . . . . . . . . . . . . . . . . . . . . . 82
HO-3a . . . . . . . . . . . . . . . . . . . . . . . 83
HO-3b . . . . . . . . . . . . . . . . . . . . . . . 85
HO-3c . . . . . . . . . . . . . . . . . . . . . . . 85
HO-4 . . . . . . . . . . . . . . . . . . . . . . . 86
HO-5a . . . . . . . . . . . . . . . . . . . . . . . 87
HO-5b . . . . . . . . . . . . . . . . . . . . . . . 90

V. INTERPRETATION OF THE RESULTS . . . . . . . . . . . . . 91

Comparability of Groups . . . . . . . . . . . . . . . 91
Discussion of Results . . . . . . . . . . . . . . . . 95
Hypothesis 1 . . . . . . . . . . . . . . . . . . . 95
Hypothesis 2 . . . . . . . . . . . . . . . . . . . 97
Hypothesis 3 . . . . . . . . . . . . . . . . . . . 99
Hypothesis 4 . . . . . . . . . . . . . . . . . . . 101
Hypothesis Sa . . . . . . . . . . . . . . . . . . . 103
Hypothesis 5b . . . . . . . . . . . . . . . . . . . 105

VI. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . 106
APPENDICES

A. Research Forms . . . . . . . . . . . . . . . . . . . . 109
B. Raw Data . . . . . . . . . . . . . . . . . . . . . . . 115

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . 122

10.

11.

12.

LIST OF TABLES

Income of Primary Clients of Experimental
Group I and Control Group I . . . . . . .

Income of Primary Clients of Experimental
Group II and Control Group II . . . . . . . .

Ages of Primary Clients in Experimental
Group I and Control Group I . . . . . . . . . .

Ages of Primary Clients in Experimental
Group II and Control Group II . . . . . . . . .

Race of Primary Clients of Experimental
Group I and Control Group I . . . . . . . . . .

Contracted Treatment Problems in
Experimental Group I and Control Group I . .

Contracted Treatment Problems in
Experimental Group II and Control Group II .

Means of Experimental and Control Groups

Compared According to the Three Types of Raters .

Treatment Outcome Means of Experimental
and Control Groups Compared According
to the Three Types of Raters . . . . . . . . .

Six PSTT Problem Categories and Mean Number
of Interviews Experimental Group I and
Control Group I . . . . . . . . . . . .

Analysis of Variance Summary Table Four PSTT
Problem Categories and Mean Number of
Interviews for Experimental Group I . .

Analysis of Variance Summary Table Four PSTT

Problem Categories and Mean Number of
Interviews for Control Group I . .

vi

76

77

77

78

78

79

79

80

86

88

89

89

LIST OF FIGURES

Figure
1. Experimental and Control Groups . . . . . . . . . . . 67

2. The Distribution of Experimental and
Control Cases according to number of interviews . . 84

Vii

CHAPTER I

INTRODUCTION

Purpose of the Study

 

The purpose of this study was to compare the effective-
ness of planned, short-term treatment with traditional open-
ended treatment in a mental health clinic. Some of the relevant
issues were:

1. Is brief therapy as effective as long-term therapy?

2. Can the same techniques be used in both kinds of
treatment?

3. Can the same problems and symptoms be treated in both
lengths of service?

4. Can general mental health clinic staff effectively
utilize long and short term treatment approaches?

5. Does PSTT increase the ability of treatment agencies
to serve a greater number of clients?

6. Do contracted time limits influence the quality of
treatment given in a mental health clinic?

7. Are there variations in goals for PSTT and long-term

treatment?

General Hypothesis
Planned, short-term treatment is as effective as long-

term, open-ended treatment.

2

The Reid and Epsteinl model of planned short-term treat-
ment was utilized in serving applicants who applied to the Blue
Water Mental Health Clinic during a six month period. The clinic
staff was trained briefly in this method just prior to the test
period. The clients who applied for treatment during the test
period and whose cases did not fit the Reid and Epstein model
were rated also to support internal validity.

Prior to the test period, there was another six month
period during which all of the incoming cases were fitted into
the PSTT model or rejected for it. These two groups were treated
according to the individual therapist's regular, traditional
treatment approach.

The study, therefore, encompassed Experimental Group I
and its corresponding Control Group I, and Experimental Group II
and its corresponding Control Group II. These four groups were
compared statistically using clients', therapists', and inde-

pendent ratings of outcome.

Agency Setting

 

In 1959, the newly-formed Adult Mental Health Clinic of
Saint Clair and Sanilac counties was united with the nine year
old Child Guidance Clinic in those counties to form the Mental
Health and Child Guidance Clinic of Port Huron. Since 1962,
this clinic has occupied a building constructed for the purpose

on the outskirts of Port Huron, Michigan.

 

1William J. Reid and Laura Epstein, Task Centered Casework
(New York: Columbia University Press, 1972.

3

The Clinic offers diagnostic and treatment services to the
residents of Saint Clair and Sanilac counties. It offers con-
sultation services to the schools, juvenile courts, agencies,
welfare service organizations and clubs in its service area.
Funding is from Act 54 Board funds, local United Funds, local
governmental units, and client fees based on a sliding scale.
Permanent clinic staff consists of a one-fourth time psychia-
trist, three clinical psychologists, and five psychiatric social
workers. The two-county population of approximately 150,000
has steadily increased its demands for clinic services. As the
ratio of requests for service to clinic staff increased, it be-
came more and more apparent that the population could not be
served expeditiously by traditional types and terms of therapy.
One of the treatment designs suggested to meet the need was

planned, short-term therapy.

Rationale for the Study

 

A number of recent writers have described the plight of
treatment agencies whose staffs and facilities cannot keep pace
with demands for service. Wolberg cited the psychiatrist-
population ratio of 1/16,000 as an index of the trained personnel
needs in all of the clinic disciplines.l Mental health clinics
tend to have fewer professionals than this population-at-large
ratio indicates. The rapid expansion of community mental health

services in the last two decades has popularized treatment and

 

1Lewis R. Wolberg, M.D., (ed.), Short-term Psychotherapy
(New York: Grune and Stratton Inc., 1965), p. l.

 

4

made therapy more acceptable; the training and employment of
personnel has not kept pace. Phillips and Johnson1 and Harold
Korner2 reminded us that one of the negative results of the
disparity between therapy needs and resources are long waiting
lists in many clinics throughout the country. Although this
report is several years old, and many waiting lists have been
reduced through more efficient case administration, this
problem has continued to plague a number of clinics from time
to time.

Since planned, short—term therapy represents a departure
from traditional methods, it was viewed initially with suspicion
by many workers. Shaw, Blumenfeld, and Senf's3 report of a
staff's reaction to the introduction of a short-term treatment
approach is typical of the attitudes reported by many researchers.
When their study was presented to the therapists at a New York
child guidance clinic, the skepticism was so pronounced that the
authors feared that the results of the research would be skewed.
(It apparently was not.) Clinicians more attuned to traditional
psychotherapy tend to dismiss approaches such as PSTT on the

basis of their bringing about only superficial attitude changes.

 

1E. Lakin Phillips and Margaret Johnson, M.H., "Theoretical

and Clinical Aspects of Parent-Child Psychotherapy," Psychiatry
37 (1954):267.

 

2Harold Korner, M.D., "Abolishing the Waiting List in a
Mental Health Clinic," Social Casework 13 (l964):1097.

 

3Robert Shaw, Harry Blumenfeld, and Rita Senf, "A Short-
term Treatment Program in a Child Guidance Clinic," Social Work
13 (l968):84.

 

5

Rosenbauml lists some therapists' attitudes which may
work against an early, mutual consideration between client and
therapist-—an integral part of PSTT. Since the therapist usually
sees himself as an accepting person (and has few concrete vali-
dations of his effectiveness), he may see early termination as
his own rejection of, or lack of interest in the client. In his
uncertainty and insecurity, he continues to offer his two main
commodities——time and attention.

A staff that successfully develops a PSTT approach must
consider more than differences in treatment time. The more
structured approach makes new technical and emotional demands
on its practitioners. Each worker must feel emotionally secure
and must be sufficiently flexible to examine his therapeutic
process and then be prepared to deal with the problems he may
discover in his examination.2

Elizabeth Kerns sums up the average therapist's readiness
to accept PSTT in the following statement:

The ease of assimilation seemed especially related to the
following factors: the worker's casework philosophy, his
willingness to assume a directive role, his view of the

meaning of time, his ability to work well under pressure,
and his general adaptability.3

 

1Peter Rosenbaum, "The Events of Early Therapy and Brief
Therapy," in Harvey Barten, M.D., Ed., Brief Therapies (New York:
Behavioral Publications, 1971), pp. 73-74.

2Phillips and Johnson, p. 269.

 

3Elizabeth Kerns, "Planned, Short—Term Treatment: A
New Service to Adolescents," Social Casework 51 (1970):345.

 

6

General Considerations

 

This study was undertaken to determine whether or not a
certain model of time-limited therapy could be as effective in
outcome as rated by client, therapist and researcher, as therapy
that is not time limited, and could thereby save time and serve
a larger population.

For the purposes of this study, psychotherapy is broadly
defined. The definition cited by Meltzoff et a1 seems apropos:

Psychotherapy is the intentional, causal, predictable modi-
fication of pathological behavior; the informed and planful
application of techniques derived from established psycho—
logical principles by persons qualified through training and
experience to understand these principles and to apply

these techniques with the intention of assisting individuals
to modify such personality characteristics as feelings,
values, attitudes and behaviors which are judged by the
therapist to be maladaptive or maladjustive.

Psychotherapy is no longer the exclusive province of
psychiatrists and clinical psychologists. It has been extended to
include social workers, counseling psychologists, the clerical
and legal professions, corrections workers, elementary and secondary
guidance counselors, etc. At the same time, psychotherapy has
developed laterally to include wider and wider heterogeneous
categories and larger and more encompassing definitions of what
needs changing. Therefore, today the "field" of psychotherapy is
a multi-faceted, heterogeneous aggregate of conflicting, competing,

segmented and unarticulated versions of theories, practices,

practitioners, and researchers.

 

1Julian Meltzoff and Melvin Kornreich, Research in Psycho-
Therapy (New York: Atherton Press, 1970), p. 3.

 

7

The aim of psychotherapy as one of the healing arts is to
help the patient feel better and function better. Psychotherapy
attempts to improve social behavior and functioning in its
braodest sense—~that is, the patient's ability to establish
mutually satisfying relationships with others. Some of the
response variables which indicate this movement are: changes in
the patient's behavior in the interview situation including
certain autonomic responses, and content of his verbalizations,
and verbal and non—verbal communication. Since the evaluation
of his social functioning cannot be done naturally, estimates
of his social effectiveness must be inferred from reports of
patients or other informants, and supplemented, confirmed or
called into question by observation of the patient in the in—
terview situation. While these comments apparently refer to
the evaluation of therapy in an in-patient situation, they do
illustrate some of the general questions around self-reports and
other subjective assessments of outcome.1

If psychotherapy is perceived as problem—solving, its pro-
cess can be delineated by the following steps: (1) The initial
recognition of a difficulty, (2) The identification (specifi-
cation) of the problem, (3) Analysis of the problem, (4) A summary
restatement of the problem, (5) The selection of objectives
which are to be effected, (6) Depiction of the criteria (values)

by which the solution will be judged, (7) The consideration of

 

1Gary E. Stollak, Bernard G. Guerney, and Meyer Rothberg,

eds., Psychotherapy Research (Chicago: Rand McNally, 1966), p. 87.

8
possible solutions, (8) The final solution, (9) The Operations
planning (how it is to be done and who is to do it), (10) The
implementation (actuation of the solution), (11) The subsequent
evaluation.1 This paper is more concerned with the outcome of
psychotherapy than with its process, but neither facet can be
adequately studied independently. Therefore, some process
considerations will be mentioned.

Psychotherapy research should not be exempt from the
qualities of reproducibility, generalizability and experimental
rigor. Dependent and independent variables should be made ex-
plicit and all relevant variables that might affect outcome
should be controlled or at least recognized and accounted for.
Criterion measures should be objective, reliable and valid. The
design should demonstrate systematic and not chance effects and
should permit generalization. Hypotheses are logical derivatives
of the question that prompted the research; they can be specific
or broad but they must be clear. They can be made about highly
Specific symptoms or behaviors.

Change implies a deviation from some baseline consistently
outside the normal limits of fluctuation of an act, action sequence,
or feeling state. The response, or set of responses to a given
stimulus or complex of stimuli can be expected to vary on suc-
cessive occasions and distribute themselves normally about a

mean for each individual. Behavioral change for that individual

 

1Allen E. Bergin and Sol L. Garfield, Handbook of Psycho-
therapy and Behavior Change (New York: John Wiley and Sons, 1971),
p. 8.

 

9
would consist of responses that fall outside of this distribution

and cluster about a new mean.

Definition of Terms

 

Perhaps definition of some of the terms used in this dis-
cussion and as background for the study would be helpful at this
juncture.

(Analogue Studies are usually described in contradistinc-

 

tion to naturalistic research. In this type of study the vari-
ables are manipulated to stimulate certain relationships.

Naturalistic Studies identify variables in terms of

 

measurements of already existing subject characteristics.
Change, defined above.

Placebo Effects of Therapy, the natural effect of the

 

interpersonal contact between client and therapist that would
take place without therapy.

Uniformity Assumption. This is the premise frequently

 

used as a basis for research that therapists, or clients, or
some other complex variable has a uniform effect.

Temporal Variables:

 

Total duration refers to the elapsed time between the

 

onset and the termination of therapy.

Unit duration is the length of a single "session."

 

Amount concerns the total contact time between patient

and therapist measured in units of time or sessions.

 

lBergin and Garfield, p. 354.

10
Frequency is the number of treatment contacts in a

given unit of time.

CHAPTER II

SHORT-TERM THERAPY: REVIEW

OF THE LITERATURE

This chapter is a survey of selected aspects of brief
therapy as portrayed in the social sciences literature of the
present and recent past. An effort will be made to explicate
theoretical antecedants and assumptions supporting some of the
significant and differential characteristics of short-term

therapy.

Psychotherapy Research

 

Bergin and Strupp1 have outlined the current status of
psychotherapy research. They feel that, until about two years
ago, it had failed to make a deep impact on practice and tech-
nique. The results of most investigations had not been of
practical significance; follow-up studies had been difficult to
carry out, and the crucial requirement of enlisting the full
cooperation of therapists, patients and institutions had been a
continual stumbling block. Vigorous design had been difficult to

impose on the therapeutic phenomena themselves since the phenomena

 

lAllen Bergin and Hans H. Strupp, Changinngrontiers in
the Science of Psychotherapy (Chicago: Aldine-Atherton Co., 1968),
pp. 2-99.

 

 

11

12

under study are extremely complex. There has been a lack of
communication and cooperation among researchers and thus a lack
of comparability of their research.

Psychotherapy is not a unitary process and is not ap—
plied to a unitary problem. Keisler1 feels that psychotherapy
can be defined ultimately as behavior modification; but it is
traditionally related to personality modification. Cronbach2
dichotomizes psychotherapy research into (1), personality re-
search which seeks to determine high average or uniform per—
formance and to manipulate variables toward that end, and (2),
clinical research which seeks variations from the norms and wants
natural rather than manipulated conditions. There is a need to
synthesize these two sides by research designs that incorporate
treatment manipulations apg_organismic factors so that the focus
can shift the interaction effects.

Adequate research in psychotherapy should answer the
following question: What specific therapeutic interventions pro-
duce specific changes in specific patients under what specific
conditions? Such research should include the following consider—
ations: (l) Therapists cannot be regarded as interchangeable

units, therefore different therapists, depending on variables in

 

1Donald J. Kiesler, "Experimental Designs in Psychotherapy
Research," Handbook of Psychotherapy and Behavior Changa, ed.
Allen E. Bergin and S01 L. Garfield (New York: Wiley and Sons,
Inc., 1971), pp. 37-38.

2L. J. Cronbach, cited by Donald J. Kiesler, "Experi-
mental Designs in Psychotherapy Research," Handbook of Psycho-
therapy and Behavior Changa, ed. Allen E. Bergin and Sol L. Gar-
field (New York: Wiley and Sons, Inc., 1971), p. 37.

 

 

13
their personality, training, experience, etc., exert different
conditions, (2) Patients, depending on variables in their per-
sonality, education, intelligence, the nature of their emotional
problems, motivation,and other factors, are diffentially re-
ceptive to different forms of therapeutic influence, (3) Tech-
nique variables cannot be dealt with in isolation but must be
viewed in the context of the patient and therapist variables
enumerated above. (4) Outcome measures are frequently restricted
to dimensions derived from specific theoretical positions and thus
evidence based upon such measures is difficult to generalize.1
The inherent uniqueness of the particular dyadic relationship
between patient and therapist limits exactitude and the weight
of evidence suggests that change is multi-dimensional rather than
unitary.

There are many other complexities to be considered in de-
signing psychotherapy research. There are problems of conceptual-
ization--the specification and uniformity of terms and parameters
of precise behaviors is sorely needed. Another problem is brought
about by the multitudinous and diverse theories extant that attempt
to explain human behavior and causation. An additional serious
problem relates to failures to formulate specific therapy objectives
that are capable of implementation and empirical testing and the
lack of a specification of desired outcome to which techniques are

directed. The therapist permits changes to occur without foresight

 

1Bergin and Strupp, p. 8.

l4
and planning, and he reconciles himself to whatever changes emerge.
There has been difficulty in rendering the goals of therapy and
behavior change specific and sufficiently explicit to permit the
utilization of effective criterion measures. Should the goal be
symptom removal or a fully functioning person? Again, problems
with respect to the specification of therapeutic objectives are
inherently conceptual problems.

The psychotherapy "artisan" practices, using vague methods
with little structure, definition or predictive ability. However,
some practicing psychotherapists have attempted to order, formu—
late,and measure what they do-—these therapists are scientists.
Truax and Carkhuff go so far as to say that until society specifies
criteria for "effectiveness" in an explicit manner, the effective-I
ness of the practice of psychotherapy cannot be empirically evalu-
ated.1 David Malan2 has done two careful and complicated brief
therapy research studies using precise methodology and rigorously
controlled influencing variables. His orientation and case
materials are decidedly clinical. He quotes from Barten to
emphasize the tie between brief therapy and traditional, more ex—
tended methods: "The brief therapies are a distillation based
upon the understanding of personality dynamics and patterns of

illness which the traditional techniques delineated."

 

1Truax and Carkhuff cited in Bergin and Garfield, p. 44.

2David H. Malan, The Frontier of Brief Psychotherapy
(New York: Plenum Medical Book Co., 1976), p. 6.

 

15

Again on the more positive side, Arnold et all feel that
many of the greatest advances in therapeutic theory came through
clinical experimentation rather than through laboratory research
or controlled field trials. They go on to suggest that different
kinds of data and levels of information come from the laboratory
and the clinic. Innovation is the outcome of experimentation
and most clinical advances are preceeded by what might be termed
a frustration—observation sequence. Clinicians should not be
limited to trying only the methods suggested by their theories.
Some techniques may prove effective for reasons that do not
remotely relate to the theoretical ideas that gave birth to them.
However, in utilizing this approach, the authors advocate caution,
tentativeness, and empirical testing when adopting any theoretical
position.2

Doubts Concerning Traditional
LongeTerm Therapy

 

 

The effectiveness of long-term therapy from the standpoint

 

of patient benefits and therapist efficiency, and the cost in time
and therapy resources of the traditional treatment approach, have
both been questioned for a number of decades.

Harvey Barten3 is typical in describing traditional therapy

as tending to be more passive, reflective, open-ended,and

 

lArnold, cited in Bergin and Garfield, p. 196.

2Ibid., pp. 197-99.

3Harvey Barten, ed., Brief Therapies (New York: Behavioral
Publications Inc., 1971), p. 9.

 

l6
patient—steered; he saw it as oriented toward feelings, self-
understanding as a prerequisite to action, and as reflecting the
past in the present. He adds that traditional techniques are
cautious, non-directive, comprehensive, and indirect.

Bellak, et a11 see the traditional approach to therapy
as long-term (which results in less emphasis on the immediate);
and as placing more emphasis on transference and resistance,
dreams, free association, and fantasies. It is also concerned
with uncovering infantile wishes and conflicts. These emphases
lead to a passive role for the therapist who spends much time in
reflection and interpretation. What can also prolong therapy is
the therapist's involvement in countertransference reactions.

As early as 1938, Franz Alexander3 led a Chicago group
which questioned some assumptions concerning traditional treat-
ment. One traditional belief that they questioned was that the
depth of therapy is necessarily proportionate to the length of
treatment and the frequency of the interviews. Another was that
the therapeutic results achieved by a relatively small number of

interviews are necessarily superficial and temporary, while

 

lLeopold N. Bellak, et a1, "Factors Related to Improve-
ment in Brief Psychotherapy," An Evaluation of the Results of the
Psychotherapies, ed. Stanley Lesse, M.D. (Springfield, Illinois:
Charles Thomas, Publisher, 1968), p. 102.

 

 

2Franz Alexander, "Psychoanalytic Contributions to Short—
term Therapy," Short-Term Psychotherapy, ed., Lewis Wolberg (New
York: Grune and Stratton, Inc., 1954), p. 84.

3Franz Alexander cited in Libbie G. Parad, "Short-term
Treatment: An Overview of Historical Trends, Issues and Poten-
tials," Smith College Studies in Social Work (Vol. 41, No. 2,
1971). p. 130.

17
results achieved by prolonged treatment are necessarily more stable
and more profound. The third assumption questioned was that the
prolongation of an analysis is justified on the grounds that the
patient's resistance will eventually be overcome and the desired
therapeutic results achieved. /

Parad1 went on to compare long-term therapy by social
workers with consultation: "This leisurely and long-time kind of
assistance stands in contrast to most consultation practice, which
may be described as short-time treatment and which certainly
implies that the service given must itself be the basis of
continued contacts." Her implication is that long-term therapy
may not sell itself so well or justify itself in terms of patient
satisfaction.

Alexander2 notes a general trend toward over-treatment in
traditional therapy. Functionally, this trend caters to a pro-
gressive dependency. This dependency, of course, tends to lengthen
therapy.

Szasz,3 Orlansky,4 Stevenson,5 King,6 and Alexander,7 all
criticize traditional diagnosis as a part of traditional therapy
which emphasizes past history. Others stress that, in an

efficient approach to therapy, details of the patient's background

 

1Ibid., p. 126. 2Alexander, p. 84.

3T. S. Szasz, cited in Short-term Psychotherapy and
Structured Behavior Changa, E. Lakin Phillips and Daniel N.
Wiener (New York: McGraw-Hill Book Co., 1966), p. 48.

 

4Orlansky, cited in ibid. 5Stevenson, cited in ibid.

6King, cited in ibid. 7Alexander, p. 84.

18

cannot be explored and historical analysis must be minimized.
Glasser tersely admonishes patients to "forget the past," and he
focuses the therapy on the individual rather than the family.1

A significant part of the traditional therapy system is
a lengthy delay between application for treatment and the treat-
ment itself. This is exacerbated by the increasing demands for
therapy and the shortage of personnel. One study indicated that
clients who wait for treatment may make pathological adaptations
to their symptoms. If the wait is prolonged, the pathology may
deepen so that symptoms become superimposed on symptoms.2

Ratibor-Ray Jurevich3 summarized findings from a number
of writers who criticized traditional therapy. He found the
following eight criticisms to be valid and strongly supported:

1. The gathering of insights about past traumas is not
essential in treatment.4

2. The emphasis on the past and the unconscious is

deleterious to treatment.5

 

lWilliam Glasser, Reality Therapy (New York: Harper and
Row, 1965), pp. 37-38.

 

2Samuel Rosenberg, et a1, "Factors Related to Improvement
in Brief Psychotherapy," An Evaluation of the Results of the
Psychotherapies, Stanley Lesse (Springfield, Illinois: Charles
Thomas, Publishers, 1968), p. 83.

 

 

3Ratibor-Ray Jurevich, ed., Direct Psychotherapy: 28
American Originals (Coral Gables, Florida: University of Miami
Press, 1973), pp. 20-21.

 

 

4Grinker, cited in ibid., p. 20.

5Glasser, cited in ibid., p. 21; Salter, cited in ibid.,
p. 21.

19

3. Healthy, rather than sick, aspects should be stressed
in therapy.1

4. Symptom substitution is a canard.2

5. The medical model needs to be discarded.3

6. For many patients, their value structure is inter-
woven with their mental health.4

7. There is now a wide applicability of direct psycho-
therapy methods.5

8. Theoretical complexity is not equal to therapeutic

effectiveness.

Therapy Needs Versus Available Resources

 

As early as 1919, Sigmund Freud foresaw that psychoanalytic
techniques would not be adequate for the demands placed upon the
mental health community. From Freud's time until World War II,
the recognized need for psychotherapy increased, while the length
of psychoanalysis and other traditional forms of therapy became
longer and longer.

Child Guidance clinics face an increasing discrepancy be-

tween demands for treatment services and available therapy hours.

 

lWeiss, cited in ibid., p. 22.
2Eysenck, cited in ibid., p. 23.
3Mainord, cited in ibid., p. 23.

4Mlowrer, cited in ibid., p. 22.

5Tweedie, cited in ibid., p. 23; Heine, cited in ibid., p. 24.

6Gottesman, cited in ibid., p. 25.

ll

20
In 1970, Karl Lewin wrote that in one year in the United States
1,000 psychiatrists are added to the psychotherapy resources and
3,000,000 pe0ple are added to the general pOpulation.1 A further
indication of inadequate service delivery is Jacobsen's comment
on the gap between the intention to serve the entire population
and the relative lack of service to patients from the lower
socio-economic classes.

The rapid expansion of community mental health services
in the 19503 and the 19603 was paralleled by increasing personnel
shortages. This discrepancy led to the growth of long waiting
lists. There is evidence that the decade of the seventies has
seen the dimunition of the waiting lists as a result of crisis
intervention and other more flexible services, and more efficient
treatment in general. Shaw et al3 posited that the concept of
the waiting list is incompatible with the concept of the painful-
ness of emotional illness. They added that long waiting lists
develop into a triad that includes delayed treatment services
and little, if any preventive and consultation time.

Koegler and Koegler4 believe that psychotherapy is unavail-

able to most people because of time-consuming procedures and that

 

lKarl Lewin, Brief Psychotherapy: Brief Encounters (St.
Lous, Missouri: Warren H. Green, Inc., 1970), p. 3.

 

2G. Jacobsen, cited in Leonard Small, The Briefer Psycho-
therapies (New York: Brunner/Mazel Publishers, 1971), p. 9.

 

3Robert Shaw, cited in Harold Korner, "Abolishing the
Waiting List in a Mental Health Clinic," Social Work 13:3, p. 1097.

 

4Koegler and Koegler cited in Small, p. 8.

21
unless procedures are abbreviated, most people will go unaided.
Bellak and Small1 argue that adequate brief psychotherapy based on
psychoanalytic principles is necessary to prevent extensive drug-
based treatment.

From a functional as well as a pragmatic standpoint, tradi-
tional, long-term therapy has been questioned for some time. The
increasing need for therapy, the limited supply of trained personnel,
and, more recently, shrinking funding have supported the necessity
for the more efficient treatment of selected emotional problems.

Short-term therapy is viewed increasingly as fulfilling this need.

A Short Historyyof Brief Therapy

 

Nearly everyone who has thought seriously about psycho—
therapy has entertained notions of how to shorten it. The Jewish
Board of Guardians has a long history of exploring the suitability of
varied psychotherapeutic techniques for large patient populations
through the medium of a multidisciplinary team.2 The development of
crisis theory as well as an interest in prevention suggested that one
promising avenue for possible solution to the problem of better
utilizing the time of professionals is in the area of short-term
therapy. The Community Mental Health Movement has encouraged change
and a new perspective such as utilizing modest interventions before

complex therapy.3

 

lBellak and Small, cited in Ibid., p. 10.

2Libbie Parad, pp. 137-38.

3Harvey Barten and Sybil Barten, Children and Their Parents
in Brief Therapy (New York: Behavioral Publications, 1973), p. 3.

 

 

22

Private insurance plans are increasingly oriented toward
short-term therapy and many proposals for federally-supported
national health insurance visualize brief therapy. Thus treat-
ment organizations are being pushed by considerations of expediency
to be more innovative about ways and means of serving larger
numbers of people more quickly and more effectively.

Libbie and Howard Parad, in three different articles, list
some factors contributing to the relevance of short-term treatment.
They mention:

1. The current interest among the mental health disciplines
in models of crisis intervention which theorize that a state of
psychosocial disequilibrium is by its very nature time-limited.

2. The emphasis in ego psychology on the mobilization of
the individual's or family's strengths to improve social functioning
with respect to specific and limited treatment goals.

3. The interest in time-limited behavior modification
techniques.

4. The existential thrust which demands solutions in the
here and now.

5. The limited financial and personnel resources that

necessitate the efficient use of time.1

 

1Howard J. Parad and Libbie Parad, "A Study of Crisis-
oriented Planned Short-term Treatment," Social Casework 49:6 (1968):
344; Howard Parad, "The Use of Time—Limited Crisis Intervention
in Community Mental Health Programming," Social Service Review
40:3 (l966):275; Libbie Parad, p. 119.

 

 

23
Barten lists some additional historical developments which
were supportive of emerging brief therapy:
1. The growing professional commitment to provide
immediate, relevant treatment to all segments of the

community.

2. The increasing shift from psychoanalytic techniques
to ego-oriented psychotherapy.

3. The new emphasis on preventive and emergency measures.

4. An acceptance of limited therapeutic goals.

5. The broadening and redefining of professional roles to
include professionals in other disciplines and parapro-

fessionals.

6. The recognition of the non—standard therapy needs of
different cultural and socio-cultural groups.

7. The growth of prepaid, limited, outpatient psychiatric
insurance coverage.

Brief therapy, as it is generally practiced today, has its
roots in psychoanalytic theory. Malan,2 who extensively reviewed
Freud's works, wrote in 1963 that Freudian psychoanalysis began as
brief treatment. Many of Freud's early patients were not ex-
tensively treated timewise. He started out by trying quick
cures and active interpretation. He used brief treatment to cure
the impotence of the composer, Gustav Mahler. He also treated

Bruno Walter in six sessions.3 His Studies in Hysteria describe

 

his brief treatment of an hysterical woman and examine the problems

of brief treatment in general.

 

1Barten, p. 3.

2Malan, cited in Small, p. 3.

3Ibid.

24
However, Freud's theoretical formulations became more and
more sophisticated and therapy as practiced by him and his
successors grew longer and longer. As time progressed, therapy
was forced to relate to some environmental factors and to some
shifts in focus, especially within the realm of social work. Dr.
Parad sums up the years between early Freud and World War II:

The factors stimulating the study of the short-term case
included the shift in emphasis from social diagnosis to social
treatment, the interest in differential diagnosis and treat-
ment, the newly—formulated concept of relationship, and the
press of increasing numbers of cases (during the depression
years) for which the limited resources of the agencies could
offer only minimal help.1

The emergencies and crises of World War II increased the pressure
to change. According to Grinker and Spiegel,2 brief therapy was
used during the War for relief of tensions, strengthening of the
ego, and decreasing the severity of the super-ego. It did not
attempt personality reconstruction. Under wartime conditions
Guthiel3 found eighteen kinds of emotional disorders which he felt
would respond to brief therapy.

After the War, Baker4 recommended short-term psychotherapy

as "first aid when long-term therapy was impractical." He cited
six steps in such a procedure: intellectual clarification of the

problem, advice giving, catharsis, interpretation of the trans-

ference and resistance, the use of prolonged supportive therapy

 

1Libbie Parad, p. 23.

2Grinker, cited in Small, p. 17.
3Guthie1,.cited in Phillips and Weiner, p. 28.

4Baker, cited in ibid., p. 28.

25
devoid of personality change efforts, and the favorable attitude
of the therapist.1 Also immediately after the War, Alexander and

2
French produced their Psychoanalytic Principles and Application.

 

The section on brief therapy was a landmark in the development of
the mode. They emphasized that the patient's emotional experience
must be focused on present life problems and the therapist must

try to prevent regression and dependency. He must work at probleme
solving and teach the patient to handle his new experiences.

In the late forties, Malumud, Koye, and Deutsch described
brief therapy in medical and community settings, and examined the
theoretical basis of brief therapy procedures.3

During the decade of the fifties, Wolpe was an effective
and persistent voice in the formulation of the theoretical basis
of brief therapy. Morton experimented with short-term therapy
using learning theory and comparing his test groups to matched
control groups. The number of psychoanalysts who showed an interest
in brief therapy grew, but few fully accepted it on theoretical
grounds. Pumpian-Mindlin became involved in brief therapy by
necessity. He was fairly explicit concerning short-term treatment
goals, the techniques to be used, and how to choose cases
according to given criteria. During this period, Phillips and

Johnston did a study comparing conventional methods with

 

lBaker, cited in ibid.

2Franz Alexander and Thomas French, Psychoanalytic
Principles and Application (New York: Ronald Press, 1946),
p. 145.

3Malmud, cited in Phillips and Wiener, p. 29; Koye,
cited in ibid.; Deutsh, cited in ibid.

 

 

26

short-term parent-child psychotherapy. The short-term group showed
fewer dropouts before termination, fewer interviews, and greater
parental satisfaction. In 1955, Ellis reviewed over 400 articles
concerning newer approaches to psychoanalytic orthodoxy and a more
active patient-therapist role. In addition to the above, Phillips
and Weiner cited fifteen authors as examples of the many who did
brief therapy between 1955 and 1960 and reported it as successful.
The trends during this period included increasing use of controls
and independent outcome measurements in therapy experiments.
There was also increasing interest in the impact of spontaneous
remission and the placebo effect. Variations in the short-term
therapy experiments included the settings for treatment, client
and therapist attitudes, structured versus permissive approaches,
and, of course, the amount and scheduling of time spent in therapy.
The rates of attrition also received increasing attention. In
the fifties, the number of brief therapy practitioners who empha-
sized behavior change through learning theory continued to in-
crease. They included Bandura, Paschal, Eysenck, Wolpe, Frankl,
and Saul.1

As therapists accepted treatment of patients in all classes
and with all kinds of problems, traditional, slow-paced tech-
niques became increasingly insufficient. They were found un-

wieldly, impractical, and often excessive in treating emergencies

 

lWolpe, cited in ibid., p. 36; Morton, cited in ibid., p. 29;
Pumpian—Mindlin, cited in ibid., p. 30; Phillips and Johnson,
cited in ibid; Ellis, cited in ibid., p. 31; Phillips and Wiener,
cited in ibid., pp. 31-39.

27

and crises, adjustment problems of recent origin, and uncompli-
cated anxiety and depressive reactions. They were equally un-
suited for long-term disease processes such as alcoholism,
chronic schiZOphrenia, or organic brain disorder.1 Brief
techniques have now expanded to include short-term group and
family therapies, behavior therapies, drug therapies, etc.

Libbie Parad briefly traced the development of short-
term treatment within social work. She pointed out that the
bulk of casework practice has always been short term. In a
variety of settings such as schools, courts, medical settings,
Travelers Aid Societies, Red Cross Home Service, and public
welfare, the function of the service or agency has determined
that the case would usually be short-term. Even in the family
service agencies and the child guidance clinics which tend to
view themselves as therapeutic agencies devoted to insight-
oriented treatment, examination of service statistics from three
studies cited by Parad reveals that the majority of case contacts
are of limited duration.2

The Development of Some Theories Sppportive of
Brief Therapy

 

 

Phillips and Weiner3 see aims to shorten psychotherapy

as following two broad trends: (1) The development of shortened

 

1Barten, p. 3.

2Libbie Parad, p. 120; Leonard Kogan, "The Short-term Case
in a Family Agency, Part I," Social Casework 38:5 (1957):232.

3Phillips and Wiener, p. 27.

 

28

approaches to therapy without regard to specific orientation, and
(2) the application of learning theory to psychotherapy. However,
the developing trend that they see as without a theoretical basis
is probably broadly psychoanalytic. Menninger,l Alexander and
French,2 and Bellak and Small3 all owe their brief therapy theories
to psychoanalytic theory; but a number of therapists have developed
their own brief therapy modifications of the psychoanalytic theory
base. Fenichel,4 in supporting his development of a brief therapy,
stresses that psychoneurosis is the result of conflicts between
impulses that are warded off, and anxieties and feelings of guilt
which are warding off in nature; he posits that only a change in
the dynamic balance and relationship between these two components
can change the neurosis. Other brief therapists argue that re—
pression (as above) can be avoided, and conflict resolved without
increasing resistance.5

Lydia Rapaport,6 in a journal article, discusses in detail
some of the theories that tend to discount traditional therapy and
support brief treatment. One of the fallacies concerning traditional

treatment that she mentions is that "depth," as referring to the

 

lMenninger, cited in Small, p. 27.

2Alexander and French, cited in ibid.

3Bellak and Small, cited in ibid.

4Fenichel, cited in ibid., pp. 28-30.

5Harris, Kalis, and Freeman, cited in ibid., p. 33.

6Lydia Rapaport, "Crisis Oriented Short-term Casework,"
Social Service Review 41:1 (1966):32-34.

 

29

strata of personality to be tapped, can only be reached by
psychoanalytic treatment, which is therefore the preferred mode.

The opposite of "depth" is given as superficial; a more
functional term conceptualizing that continuum might be "come
plexity." This refined understanding of ego-organization and
emotional functioning requires a knowledge of the complex
organization of the personality which is unrelated to the question
of depth or superficiality. Another erroneous assumption is
that, if change is to be lasting, it can be achieved only by a
long process. One additional misunderstanding is the substitution
of the concept of cure for the concept of restoration of function.

Another myth that Dr. Rapaport mentions is that in order
to bring about a cure one must at least know and get at the causative
factors. This concept of a specific etiology also tends to en-
courage a search for a single cause. Some structural realities
can become confused with methodological considerations. An example
is the process of intake which may include multiple workers,
waiting periods, labelling, and other side effects which tend to
be dysfunctional. The waiting for treatment may foster a re
gressive transference which militates against the goals of therapy.
More of the theoretical bases of brief therapy will be explicated

in the section on the process and content of brief therapy.

The Goals and Focus of Brief Therapy

 

One early 19303 definition of short-term was "the single

interview case." Its proponents advised "focusing on the problem

30
of most concern at the moment," dealing with the presenting
situation rather than history-taking, and on leaving responsi-
bility for the solution of his problems to the client. They
claimed positive treatment value for this procedure.1

The nature of Travelers Aid Society's contact with
transients was always dictated by very limited treatment contacts.
The passage of the Social Security Act caused the Travelers Aid
agency to take a broad look at its program which was published in
a two-volume work.2 This work showed some advanced thinking on
the treatment possibilities of short-contact services and stressed
the need for delineating tangible, reachable, limited goals and
offering immediate treatment.

Fern Lowry,3 who wrote on short-contact casework during
that same early period, summed up her view of brief treatment in
these words: "Just as time may be limited without being limiting,
so in short-contact casework the limit of time need not limit our
services."

A number of therapists have developed definitions which
cover the goals and focus of brief therapy. Harvey Barten's
follows:

Brief therapy is characteristically a technique which is

active, focused, goal—oriented, circumscribed, warmly-supportive,

 

1Libbie Parad, p. 123.

2Robert S. Wilson, The Short Contact in Social Casework,
Volumes I & II (New York: National Association for Travelers Aid
and Transient Service, 1937), pp. 193-201.

 

3Lowry, cited in Libbie Parad, p. 124.

31
action-oriented and concerned with present adaptation. Initially,
the treatment approach need not be comprehensive and definitive
if periodic reevaluations are available. It deals with a specific
problem constellation; it may aim for the resolution of a present
conflict or discomfort and it may be of an emergency or stopgap
nature. Basic brief therapy principles include early formulation
of the problem, focussing, bypassing areas of resistance, and
accepting and sometimes strengthening defenses rather than
challenging them.1

Wolberg's2 paradigm includes: (1) The relief of symptoms;
(2) The restoration to the level of functioning existing prior to
the illness; (3) Some understanding of the forces that precipitated
the current upset; (4) The recognition of some interfering per—
sonality problems; (5) A partial understanding of the origin of
problems in past experiences; (6) Some awareness of relationships
between personality problems and the current illness; and (7) A
comprehension of measures to remedy environmental difficulties.
Others cite the resolution of current crises as a viable goal of
short-term therapy.

Barten's and Wolberg's paradigms condensed above cover the
goals and focus of brief therapy as formulated by a number of
writers. Maquire's and Gillman's briefer definitions are congruent.

Maguire writes of tightly-structured brief therapy that

selects the emotional conflict to be treated and emphasizes active

 

lBarten, pp. 8—9.

2Wolberg, cited in Small, p. 18.

32

therapy, instruction on techniques, a sequential ordering of per-
ceptions, and the use of partial interpretations. Gillman focuses
on current reality, face-to-face interviews of less frequency, a
"healthy" employment of free association, an avoidance of re-
gressive dependency and ambivalent transference, and an active
therapist.1

Most authors who describe the focus of contemporary short-
term therapy find some way of saying that this mode of treatment
should be concerned with current problems of living. Many further
narrow the immediate focus to the relief of symptoms. Rosenbaum
warns that the symptoms may persist but change in importance. They
also may disappear but return later in a different perspective.
Norman and his colleagues cite similar goals for short-term clinic
service to lower socio-economic populations--immediate intervention
to ameliorate symptoms. Lester adds equivalent brief psychotherapy
goals for children. They are to eliminate or relieve symptoms
which he sees as exaggerations of otherwise adequate behavior
patterns.2

Several therapists see the primary goals of brief therapy
as prevention and/or restoration. Normand et a1 posit that its

goals are not to cure, but to reestablish a prior, more effective

 

1McGuire, cited in ibid., p. 20; Gillman, cited in ibid.,
p. 25.

2Rosenbaum, cited in Small, p. 17; Normand et a1, cited
in ibid; Lester, cited in ibid.

33

state of equilibrium. Coleman and Zwerling add to this the
restoration of previously effective defensive structures.
Bellak tersely emphasizes a preventive goal: "To still pain, make
functioning possible, and save life." Rado sess brief therapy as
palliative; instead of reforming from within, its supports from
without. Lewin posits a two-part goal for children: the reverse
of the process of infantile expectations and gratifications,
and the turning of complex anger from its inward direction against
the self. His goals sound more complex but are still quite
limited in focus.1

Some therapists stress the limited "depth" of brief
therapy Malan stresses a limited aim, a limited number of sessions,
and a "focal" technique. Malumud sets as a goal some degree of
operational relationship with the environment. Sifneos somewhat
disagrees. He states that the aims of such therapy involve the
choice of and concentration on one of the predicted areas of
emotional conflict and the avoidance of conflict involving
character problems.2

Other therapists discuss the potential that brief therapy
has for working on more submerged factors or extensions of
problems. Lydia Rapaport explains how this can happen in social

work treatment.

 

1Coleman and Zwerling, cited in ibid., p. 17; Bellak,
cited in ibid., p. 19; Rado, cited in ibid.; Lewin, cited in ibid.,
p. 18.

2Malan, cited in ibid., p. 19; Malmud, cited in ibid.,
p. 18; Sifneos, cited in Barten, p. 12.

34

Treatment should be highly focused and segmental. The
focus is on the present and the segment to be dealt with is
the precipitating stress and its consequences for the in-
dividual or family . . . when possible and necessary, there
should be a clarification of the linkage of the current
stress and upset with a previous, old, preconscious or un—
conscious conflict that was not entirely successfully
resolved.1

Peter Sifneos sees confrontation as the key tool in short-
term therapy. He feels that anxiety should be generated rather
than suppressed and that the therapist should work as quickly as
possible to prevent limiting complications.

Although many brief therapists confine their discussions
with clients to the present problem, some will probe the past,
examine characterological problems,or interpret transference
distortions. Sowis, Dewees, and Johnson posit that the therapist
should deal with whatever will facilitate adaptation but should
begin with the presenting difficulty and use it as a point of
reference.

This paper describes short-term therapy in terms usually
associated with better-known traditional therapy. However, it
would be helpful to look at a few writings that compare the two
modes more directly. Barten and Barten3 describe short—term

treatment as rapidly delineating problem areas and as being

active, focused, and incisive. They emphasize that it is an

 

1Rapaport, p. 39.

2Sifneos, cited in Small, p. 157; Sowis, et a1, cited in
Barten, p. 9.

3Harvey Barten and Sybil Barten, Children and Their
Parents in Brief Therapy (New York: Behavioral Publications,
1973), p. 5.

 

 

35

eapansion of a therapist's repertoire rather than a substitute for

it. Bellak and Small1 differentiate brief therapy from psycho-

 

analysis by discussing goals, time factors, and methods. The goal

is to focus on the symptoms or maladjustments that demand the

quickest possible relief; it is limited to the removal or amelioration

of specific symptoms and is not concerned with personality recon—

stitution. It seeks to improve the individual's psychodynamic situ—

ation sufficiently to allow nature to continue the healing process.
Brief psychotherapy is freed from the investigative goals

of psychoanalysis. Its limited and well—defined aims make it

distinct and not just abbreviated therapy. It differs from tra—

ditional psychoanalysis in that it uses limited free association,

modified interpretation, constraints on transference neurosis,

an emphasis on positive transference, and the coupling of modified

interpretation with environmental change.2 Hoch3 finds the most

important methodological difference between the two therapies to

be the degree of activity of the therapist. Krick4 asks and

answers the same question: "How active should the counselor be?

As active as the sophistication of his techniques permits, to get

the clients to take charge of their own lives right then and there."

 

lBellak and Small, cited in Small, p. 16.

21bid., p. 22.

3Paul Hock, "Short-term Versus Long-term Therapy," Lewis
WOlberg, ed., Short-term Psychotherapy (New York: Grune and
Stratton, Inc., 1955), p. 55.

 

4Aaron Krick, "Active Strategies in Marriage Counseling,"
Active Psychotherapy, Harold Greenwald, ed. (New York: Atherton
Press, 1967), p. 166.

 

36

An active, rather than a passive stance, is certainly a
part of brief therapy according to the literature reviewed here.

In summary, it can be seen that most writers adopt limited
goals, stress symptom removal or amelioration, reversal of current
distress, or prevention of more serious problems. Barten1 sees
a consensus on the focus, on health rather than a sickness
orientation, and on time limits as summarizing characteristics.
Dr. Edwin Stainbrook once stated: "The geneticist figures you're
done for when you're born, the psychoanalyst figures you're done
for when you're six, but the crisis interviewer says you're not

done for 'till you're dead."2

Time Limits for Brief Therapy

 

There are a number of factors which affect the availability
of treatment services and provide a setting which permits the
optimum utilization of therapy time.

Structure in the organization of short—term therapy refers
to the purposeful selection by therapist and client of variables
related to behavior change. The structuring process can be pro-
moted by selecting specific variables for manipulation such as
Specific tasks or time schedules, or arranging behaviors to
achieve a specific goal. The limits must not be the goal but must

only be set in relation to goals.

 

1Barten, pp. 25-27.

2Stainbrook, cited in Small, p. 180.

37

Several studies have shown that patient and therapist
work more quickly when time is limited (Frank,1 Shlien,2 and
Gottschalk3). In fact, if we closely examine the matter of time,
we note that almost everything that happens or is thought about
in brief therapy may be related to it.

Phillips and Weiner,4 broaden the application of the
concept of structure to brief therapy. They feel that it can
include the therapist's use of external controls and manipulations
that will lead to self-control and direction. It can also include
observing the relationship between given antecedent and resultant
e1ements—-interfering in pathology to realign variables so as to
produce a different outcome or effect, using environmental manipu-
lations, introducing and assuring as much certainty and depend-
ability and control as possible in heretofore uncontrolled and
uncertain situations. What structure does pg£_mean here is
permissiveness with nebulous purpose; reliance on creative,
sporadic, or unpredictable bursts to solve problems that have
been chronically unsolved; it does not include the belief that
nonenvironmental or internal conditions and motivations will
solve problems through unfocused or indirect methods.

In order to help people who are in a state of crisis, we

need to have rapid access to them and they need to have
easy access to us--a little help, rationally directed and

 

lFrank, cited in Barten, p. 10.
2Shlien, cited in ibid.
3Gottschalk, cited in ibid.

4Phillips and Weiner, p. 25.

38
purposefully focused at a strategic time, is more effective
than more extensive help given at a period of less emotional
accessibility--there needs to be a continuity of contact,
and within such limits, flexibility arranged.l

Louis Gottschalk2 emphasizes that the schedule of inter-
views should be individualized. He feels that highly disturbed
patients may need interviews as frequent as five to seven days
a week. When the acute state has receded somewhat, two or three
interviews a week may suffice. When the patient has reached a
fairly stable emotional state, weekly, bimonthly or monthly
interview periods may be satisfactory. As long as changes in the
frequency of interviews are made in a consistent way, according
to some definite plan that the patient can appreciate and has some
part in determining, there is less danger of confusing the patient
or jeopardizing the patient-therapist relationship.

Gottschalk explained how therapy can be related to the
variable of time, Lakin and Wiener3 contend that time is not a
true variable but a concept that carries other variables. There-
fore, when time limited therapy is practiced, all other variables
and considerations are brought into bold relief; "when the pivotal
consideration is time, changes in goals result."

The consideration of the time factor must include the in-

terval between sessions as illustrated by Gottschalk above. Once

weekly is an average schedule but therapy can be daily. Another

 

1Rapaport, p. 38.

2Louis Gottschalk, "An Introductory Outline of a Short

Method of Psychotherapy," Journal of Nervous and Mental Disease
110:3 (1933):321.

3Phillips and Weiner, p. 4.

39
aspect of the time factor is the range of time required by the
entire course of brief therapy (usually from one month on up).
Another factor is the length of the individual session. These
can be as brief as fifteen to twenty minutes but they average
forty-five to sixty minutes. Then there are the intensive,
marathon sessions of several hours per day for a brief number
of days.

Jessie Taft'sl delineation of the function of time in
brief therapy still has relevance after four decades. She felt
that if one interview provided no therapeutic understanding, many
interviews would not help. She viewed time as a tool in casework
within a broad philosophical conception of time. "Time repre-
sents more vividly than any other category the necessity of
accepting limitation as well as the inability to do so, and sym-
bolizes therefore the whole problem of living." She did not see
the therapeutic relationship as the reworking of the earlier
oedipal and other conflicts through the transference, but rather
as a reworking of the client's problems through his reactions to
the reality limitation of the therapeutic relationship shared by
worker and client—-that is, the reality of time. Unfortunately,
Miss Taft's influence on brief therapy was lost to social work in
the general rejection of functionalism.

A number of authors explicitly mention some time limits

for brief therapy and provide some rationale for their limits.

 

1Taft, cited in Libbie Parad, p. 125.

40
McGuire1 specifies ten to twenty interviews as a format that
evolved from his clinical experience and as roughly adequate to
achieve certain therapeutic goals. He states that the acknowledge—
ment of limits determines the therapist's objectives and tech-
niques; thus the emphasis is on active therapist participation
and therapy is tightly structured.

How short is short-term therapy? Because the broad field
of short—term therapy practice includes such a variety of models,
an exact number of hours cannot be set. Various figures are used
in different studies so that any set number is arbitrary. Phillip
and Wiener's2 survey found the number of session contacts defined
as brief therapy ranging from one to 217. However, they do
summarize five general time categories from the literature:

(1) from one to six sessions, (2) around ten sessions, (3) between
twelve and twenty-five sessions, (4) includes several formats, i.e.
one to twenty, three to thirty, eight to fifty sessions, (5) W61pe's
wide range of four to 217 sessions for behavior therapy.

Barten3 advises that brief therapy time limits should fall
somewhere between six and twenty session; but he feels that this
mode can also be defined in terms of its limited objectives. How—
ever the limits are established, it is essential that both therapist

and patient know that they exist. The duration of treatment often

 

lMichael McGuire, "The Process of Short-term Insight
Psychotherapy," Journal of Nervous and Mental Disease 141:1
(l965):219.

2Phillips and Wiener, cited in Small, p. 21.

 

3Barten, p. 10.

41
expands to fill the available time; dependent patients are inclined
to drag out the process.

Normand, et al1 are more restrictive. They see brief
therapy limited to six interviews followed by a possible re-
ferral.

Sol Garfield2 surveyed traditional therapy research and
concluded that the median number of treatment interviews is five
or six and the majority of patients are seen for five interviews
or less. He quoted other studies that show a majority of patients
leaving treatment before the eighth interview. This pattern of
treatment service utilziation is viewed as a problem and is 335
the result of deliberately planned brief therapy. In most
instances, the patient failed to return for a scheduled appoint-
ment; therefore unplanned and premature termination is common for
a large number of clients. According to Garfield, brief treatment
is distinguished from regular therapy by planning and focus rather
than by time limits. Leonard Kogan's3 comprehensive study of short-
term Family Service Agency contacts revealed that over 80 percent
of the clients were treated in less than five interviews and two-

thirds of the brief contacts ended by planned terminations.

 

lWilliam Normand, et al, "A Systematic Approach to Brief
Therapy for Patients from Low Socio-Economic Community,"
Communipy Mental Health Journal 3:4 (1967):349.

 

2Sol Garfield, "Research on Client Variables in Psycho-
therapy," Handbook of Paychotherapy and Behavior Change, Allen
Bergin and $01 Garfield (New York: John Wiley and Sons, Inc.,
1971), p. 275.

 

3Leonard Kogan, "Short-term Case in a Family Agency, Part
11," Social Casework 38:6 (l957):296-99.

 

42

Other research that relates time limits to therapy out-
come indicates that the frequency of one interview a week is
optimum. Barten1 reports from his review of brief therapy studies
some evidence that time limits may facilitate and accelerate the
therapeutic process. The research evidence also indicates that
thirty and fifty minute interviews are equally productive.

The time element alone does not characterize and dis—
tinguish brief treatment from other treatment modalities. However,
even the operationalization of time factors within brief therapy
is not simple. The temporal variables can be defined as (1) total
duration and (2) unit duration, (3) amount, (4) frequency and
(5) regularity. Decisions concerning these five variables are
based to some extent on custom, dogma, personal predilection,
availability of the patient and therapist, and economic con-
siderations. Stieper and Wiener2 remind us of the natural
tendency to overtreat; the amount of help most pe0ple need to
get moving satisfactorily is surprisingly modest.

The time limit in brief therapy is the independent
variable that operates a number of other variables. The limited
amount of time, set in advance by patient and therapist, activates

the therapist and makes the fewer therapy sessions more productive.

 

1Barten, p. 358.

2Steper and Weiner, cited in Phillips and Weiner,
p. 22.

43

The Types of Problems that Can be
Treated with Brief Therapy

 

 

Bellakl suggests that we utilize trial brief therapy as an
intake procedure for the gamut of problems that are presented. After
intake, more therapy could be offered if necessary. Short—term ther-
apy can play a preventive role. It can be helpful in the treatment
of grief reactions and it can prevent the chronicity of many other
difficulties by treatment during the onset of the condition or early
childhood. It can also prevent hospitalization or rehospitaliza-
tion.2 Paul Hoch,3 writing in Wolberg's anthology, sees planned,
short-term treatment useful for acute conflictual problems and for
neurotic responses that are immediately reactive to the environment.

Phillips and Weiner4 posit that any problem that troubles
the individual or any behavior that creates a problem for others
is worth treating. However, Wolberg5 considers short-term therapy
second-best and he believes that there are long-term problems that
do not yield to short-term therapy.

When it comes to selection criteria, there are a number
of opinions and classifications, some focusing on the type of
client and others on the type of problem. Some therapists feel

that the response of the patient to test interpretations is

 

1Bellak, cited in Barten, p. 10.

2Kris, cited in Small, p. 10; Lindemann and Dawes, cited
in ibid.; Jacobsen, et a1, cited in ibid.

3Hoch, cited in Wolberg, p. 51.
4Phillips and Weiner, p. 19.

5Wolberg, cited in ibid., p. 17.

44
prognostically significant. However, the more commonly-mentioned
factors are acuteness of onset, adequacy of previous adjustment,
circumscribed complaint, environmental stability, favorable
diagnosis, and degree of precipitating stress. Some of the patient
variables deemed significant in the selection of clients for short-
term therapy will be discussed in the next section.

Perhaps Rosenbaum's1 discussion of situations that bring
people into brief therapy can be used as a summary for this section.
Certain recent events must have upset the patient's inner and
outer equilibrium sufficiently for him to seek help. Some examples
would be a recent disruption of object relationships, a bind with
a previous source of help, identification with another person
followed by disequilibrium, a surge of unmanageable and possibly
unfamiliar impulses, or a threat to current adjustment because of
changes in the environment.

Characteristics of Clients Considered Suitable
For Short-term Therapy

 

A number of authors suggest personal and environmental
factors which make some clients better prospects for brief therapy
than others. However, these criteria, and proper time limits
are less certain and agreed-upon than amenable problems and
relevant techniques. Rosenberg2 et a1, lists some client criteria

for good therapy prognosis for both long and short therapy. They

 

lC. Rosenbaum, "The Events of Early Therapy and Brief
Therapy," in Brief Therapies, ed. Harvey Barten (New York: Be-
havioral publications, 1971), p. 6.

 

2Rosenburg, et al, in Lesse, p. 99.

45

feel that the best risks have youth, lack of chronicity, are
neurotic but not psychotic, have a positive relationship with the
therapist, have a nonpathological work history and can utilize
medication as an adjunct to therapy. Sifneos1 gives a longer
list which is predictive of successful short-term therapy and
somewhat overlaps the one above. His criteria include:

1. Above average intelligence.

2. At least one meaningful relationship with another
person during the lifetime.

3. Patient must be able to interact with the therapist
by expressing feelings and showing flexibility.

4. Patient must be able to voice a specific chief
complaint.

5. Patient must be motivated to change more than his
symptoms; he must be able to recognize symptoms as psy-
chological, be able to be introspective and to give an
honest and truthful account of his emotional difficulties.

6. He must be curious, and be willing to understand
himself and participate actively in treatment.

7. He must be willing to explore, experiment, and make
reasonable sacrifices.

8. He must have realistic expectations of outcome.
Phillips and Johnson2 describe the children suitable for
short-term therapy who come to their clinic as out-patients with

no problems of a deep nature. Typically, they suffer from a

 

1Peter Sifneos, Short-term Psychotherapy_and Emotional
Crisis (Cambridge, Mass.: Harvard University Press, 1972),
pp 0 78-85 0

2E. Lakin Phillips and Margaret Johnson, "Theoretical
and Clinical Aspects of Short-term Parent-Child Psychotherapy,"
Psychiatgy 17:8 (l954):269.

 

 

46
too-loose structure of interpersonal relationships; the parent-
child problems tend to be management difficulties.

Greenwald1 warns us that the patient's psychological
strengths also must be carefully evaluated. The brief therapy
patient should be one who can form a therapeutic alliance and who
can sustain some degree of independent functioning. Gottschalk2
adds the absence of paranoid trends and the inclusion of varifiable
emotional stress and conflict that can accompany physiological
and anatomical alterations. He sees this mode as applicable to
patients classified clinically as having a psychoneurosis, a
psychosomatic disorder, or even a character disorder. He even
suggests it for some psychotic patients who have undergone a
partial or complete remission of symptoms. This is certainly in
contradistinction to the majority who see brief treatment as
limited to the relief of symptoms and short-term emotional
problems. Pumpian-Mindlin3 would also try brief therapy on some
depth problems. He says that it can have more than supportive
objectives. In fact, it can be useful for those who manifest severe
pathology provided that there is sufficient ego strength, some
adequate coping techniques, some capacity to obtain gratification,

some degree of frustration tolerance, and some flexibility in

 

1Harold Greenwald, ed., Active Psychotherapy (New York:
Atherton Press, 1971), p. 273.

 

2Louis Gottschalk, "An Introductory Outline of a Short
Method of Psychotherapy," Journal of Nervous and Mental Disease
110:3 (l933):316.

 

3Pumpian-Mindlin, cited in Barten, p. 96.

47
interpersonal relationships. McGuirel also discusses some poor
risks who nevertheless benefit from short—term therapy. He
argues that those whose egos are less organized, whose impulses are
less well controlled, who have a larger variety of symptoms and
whose symptoms are more debilitating, can benefit noticeably from
therapy of the same length as that planned for the better risks.

In summary, the literature indicates that there can be
successful short-term therapy with poor prognostic risks if peOple
seek help at a time when they want to change and are sufficiently
motivated. There is less hope for stubbornly resistive patients
or those who deny the existence of any problem. The literature
also indicates that clients and therapists can form limited
transference relationships to reach the limited goals of PSTT.

Some therapists emphasize the adaptibility and potential
resources of the patient rather than the nature and severity of the
illness. Peter Sifneos2 divides brief therapy techniques into
anxiety suppressive and anxiety expressive modes. The type of
patient who can use anxiety suppressive (or supportive) therapy
is someone who is genetically, biologically, developmentally or
environmentally inadequately developed with a precarious level of
emotional functioning which leads to poor interpersonal relationships,

limited ability to cope, and lifelong emotional difficulties.

 

lMichael McGuire, "The Process of Short-term Psychotherapy,"
Journal of Nervous and Mental Disease 141:1 (1965):83-94.

 

2Sifneos, p. 34.

48

But another class of patients who can use anxiety-
suppressive brief treatment are those who have adequate
character, who deal with reality and function well but who under-
go stress which temporarily incapacitates. Their developed
emotional problems are limited, their complaints are clearcut
and do not interfere with their overall emotional functioning.

It can readily be seen that in spite of some concensus,
there is no clear-cut agreement among therapists as to whom should
be treated with brief therapy. The majority of writers would
select the better adjusted and more environmentally sound as

candidates.

The Process and Content of Brief Therapy

 

This division is somewhat arbitrary since some process
and content has been included in each of the above sections.
However, this section may help by explicating some of the typical
methodology and subject matter of short-term treatment.

Peter Sifneosl helps us begin this discussion by defining
some of the terms that may occur. Many of the relevant concepts
also belong to crisis intervention and show a relationship between
that mode and brief therapy.

An emotional crisis is a focal point in the lifelong,

 

ever-changing continuum of psychological processes; it is an
intensification or aggravation of a painful state of being. The

understanding of an emotional crisis throws light on the steps

 

1Ibid., pp. 29—33.

49
involved in the production of psychiatric symptoms before such
symptoms become crystallized into a neurosis.

A stressful situation is one which elicits painful

 

emotions in an individual.

A hazardous situation is a difficult or dangerous sit-

 

uation that becomes stressful to some individuals but not to
others. Hazardous situations may arise from the environment (the
threat of nuclear war), or from.within the individual (the
adolescent stage of development).

A painful state is an unpleasant emotional state in which

 

anxiety, sorrow, anger, and fear predominate and which usually
arises as a result of stressful or hazardous situations.

Dr. Franz Alexander1 sees no methodological differences
between long and short-term therapy. In his view, whether therapy
will be long or short depends in the ultimate analysis of the
ego's integrative capacity. However, defining for patients that
treatment must be as short as possible discourages their pro-
crastination in the face of important issues (and thus also
affects the length of therapy).

The role of the therapist in brief treatment can gen-
erally be described as active. His initial assessment of the

treatment situation should include dynamic and action

 

1Alexander in Wolberg, pp. 84-126.

50

formulations and an action-oriented working hypothesis, according
to Normand, et a1.1 His treatment must be more active and
aggressive, not traditionally passive. He should be more
directive, and focus on the target symptoms and the patient's
difficulties. Hardened resistance is rare in this mode but it
should be handled immediately if it arises. Counseling, supportive,
and reconstructive techniques can be used in PSTT treatment.

McGuire2 further defines the therapist's active role in

treatment. He organizes the patient's already conscious per-

 

ceptions and emotions in response to both internal and external
stimuli. Out of the vast number of seemingly unrelated ex-
periences, organizing concepts and ideas--"reference points"--are
introduced to tie together similar experiences and to establish
that certain repetitious kinds of feeling and behavior stand out.
The therapist's ordering and activity are required initial steps
in getting therapy under way and defining its limits.

There are a number of ways that definitions of time and
other structures affect the process and content of brief therapy.
Patients respond to the knowledge of "briefness" both by
assigning a number of meanings to it and anticipating a number of
happenings. Certain patients imagine their "cure" will require
only a few visits--the patient expects to be "cured" magically
rather than by his own participation. Some may assume that the
clinic does not really care and others will conclude that "very

little must be troubling me."

 

lNormand, p. 349. 2McGuire, p. 87.

51

The patient's expectancy response to short-term therapy is
that the therapist will "direct" tasks. If the patient's ego is
receptive and flexible, the guiding may be helpful. But if he
feels subjected to his environment, he may imagine that the
therapist may manipulate him and he thus becomes ambivalent to
treatment. Ego support is provided through the therapist's
active participation in conflict ordering and solution. Ex-
pectations are supported in that the therapist's ordering suggests
that there is a problem and that it may be solved by therapy.

Another effect of briefness is the timing of therapy to
coincide with the patient's beginning of his mental ordering and
analysis of conflicts. (This usually occurs in the period be-
tween the evaluation and the beginning of therapy.) Although the
ordering may not be accurate, it is time saved in the first phase.

Part of the therapist's "task" of therapy is to keep it
a "task" for the patient but to change the aim of the task when it
is to avoid discussion of conflicts and symptoms. The response
of the patient to the "task" can have the effect of "filtering
out" some useful information that might surface if the patient
talked in a more random fashion.

Turning to a different aspect of time, patient fantasies
concerning the relationship of their life to time are affected
by their comprehension of "briefness." McGuirel mentions six

types of time-related fantasies that may surface in brief therapy:

 

1Ibid.

52
the return of the past (patients ordering their experiences in
this way believe that previous unpleasant occurrences are
"imminent" in the immediate future), the present is alone (these
patients believe that the present is isolated from both past and
future), expected moment of realization (these patients feel that
the immediate future holds the potential of becoming the time for
fulfillment), the present is door to the future (these patients
believe that both the immediate and the distant future will be
determined by moves made now), the present is the inevitable result
of the past (these patients think that the present is the result
but not the cyclical reoccurrence of previous trends).

The present—directedness of therapy focuses on the immediate
or pending future and only allows discussion of a few important past
experiences that are related to the immediate conflict. Patients
tend to expect more specific answers to their questions and these
direct exchanges do facilitate ordering of the patient's exper-
iences and concentrating on the present. This present-directedness
also delays the development of the transference neurosis.

The type of transference interpretations called for in
short-term therapy, again according to McGuire, are more than
"support" but less than interpretations in traditional analysis.
The interpretations should stress the patient's positive feelings
and his fears about them, and perhaps hint at his ambivalence.

They should be aimed at consolidating what has already been per-
ceptually ordered, learned, and uncovered in therapy and should not

attempt to "uncover." These consolidating or "partial" W

53
interpretations are focused on the dissection of a single emotional
conflict; this focus means that some information must be withheld
from therapy in order to limit it. The content, the construction,
and the timing of the interpretation are crucial.

An eaperience bias may be defined as the repetitious way

 

patients order their experiences in life. Experience biases may
be useful in short-term therapy since patients are uniformly aware
of both the extent and depth of this determined ordering, and
these biases are generally outside the range of therapeutic
intervention. The biases usually influence the patient's pre-
sentation of his conflict, and therefore determine in large part
both the content of statements and the way the early phases of
therapy will be conducted. The more subtle manifestations are
found when clarifications, and/or interpretations, at first
apparently understood and accepted by patients, are reformulated

to fit the bias view in between therapy sessions. Then, at a

 

following session, this reformulation can be analyzed and rein-
terpretations made to utilize the bias in achieving the aims of
therapy.

McGuire goes on to discuss some of the problems in using
short-term therapy with sick patients. A major difficulty is the
determination of the optimal time for interventions. Several
variables which appear to be related to the optimal time are the
positive transference, the transference neurosis, the experience
bias, and the symptom generated in therapy. It is interesting to

note that McGuire considers a transference neurosis not a "dirty

54
word" or an experience to be avoided in brief therapy, but a
useful stage in the therapeutic process.

Normand et a1 believe that transference can occur in brief
therapy and evolve rapidly and traumatically. Sifneos speculates
that there is an optimal time in which the aims may be achieved;
they are achieveable as long as the positive transference exists
but must be achieved prior to the full development of the trans—
ference neurosis. This avoidance of a transference neurosis is an
important point emphasized by many proponents of short-term
therapy. Alexander differs from many of his colleagues in under-
standing that a transference neurosis always develops in both
therapy modes. Rosenbaum warns that the therapist may become
over-concerned with the client's use of him as a transference
object. He may worry about hurting the client by having become
a part of his magical thinking. He would therefore spend a dis-
portionate amount of time in attempting to resolve the trans—
ference.1

Lydia Rapaport reflects the broader field of therapy as
she suggests process and content appropriate to short-term case-
work:

Communication should be addressed to certain aspects of
the ego, such as the defensive system which needs to be
strengthened; the cognitive system, which needs to help with
intellectual mastery through explanation and clarification,
the affective system, in order to lower tension, anxiety,

or guilt, and the adaptive and coping parts of the ego, which
need strengthening and enlargement.2

 

1Normand et a1; Sifneos,, cited in Small; Alexander in
Wolberg; and Rosenbaum in Barten.

2Rapaport, p. 38.

55

In general, the approach needs to be more active and
directive than in traditional work. This includes advice-giving
and a greater use of authority. Time management is an important
consideration. It can be used to provide structure and limits
and as pressure to get on with the problem-solving task. Time
limits also serve to relieve the client of anxiety concerning
development of dependency or a regressive transference. Time can
also be an important variable in relation to the goal of enlarging
the client's sense of autonomy and mastery as far and as fast as
possible. Dr. Rapaport would permit the client to set his own
treatment schedule within limits but on a self-demand basis.

She echoes Dr. McGuire in stressing the importance of the
client describing, defining, and reordering recent experiences.
She sees this process as helping to lower anxiety, reduce confusion,
and enhance cognitive mastery as first steps in problem solving.
In addition to the restoration of previously useful and adequate
defenses, attention is given to finding new adaptive patterns as
ways of handling conflict or finding solutions. Other techniques
include anticipatory guidance, rehearsal for future reality,
learning new social and interpersonal skills, and enlarging the
capacity for anticipatory thinking and predicting.

In short-term therapy with children, Phillips and Johnson
emphasize the need to perceive a child's testing of an unstable
parent-child relationship as clumsy, inarticulate ways of seeking
a dependable relationship with an adult rather than indicating

deep, underlying problems.

56

The treatment experience must be structured so that the
load is carried by the total milieu rather than by the time limits
alone. Since the child can be regarded as a shifting point in an
interaction matrix, changing his interpersonal system of family,
neighborhood, school, etc., should change the child. Emphasis
is placed on his own forward direction in treatment. Since in
therapy he is placed in a situation of "concurrent stimulation"
from all sides, he can change as he will and when he will, without
any prescribed order of "getting at this before tackling that,"
"seeing their hostility before they can relax" etc. Changes can
occur concurrently and in nondiscernable ways.1

This section on the process and content of brief therapy
will be concluded with a summary of Gottschalk's2 paradigm of a

brief therapy procedure.

I. Ascertaining the Personality Problem

 

A. First or early interviews should cover the determining
of the patient's problem; strong rapport should be
established.

B. Goals of First Interview
1. Allow patient to reconstruct present illness.

2. Relate symptoms to life experience. Look for common
factors in life events that symptom complexes are

related to.

 

1Phillips and Johnson, pp. 269-272.

2Gottschalk, pp. 315-334.

57

3. Construct an initial mental status survey.
4. Formulate initial diagnostic and prognostic

impressions.
Use significant others and key persons as sources of
information.
Evaluate the patient's apprOpriateness for therapy and
prepare him for it.
Individualize the schedule of interviews.
In beginning therapy, deal with the many forms of
resistance.
Make interpretations of what has been verbalized or
acted out.
Try to understand unsatisfactory psychological

mechanisms.

11. Modifying Behavior Patterns and Psychological Mechanisms

 

A.

Explain and foster therapeutic behavioristic techniques.

1. Avoid situations which have induced motivational
conflict by changing environment, rest, physio-
therapy, medication, reassurance, practicing desired
responses, etc.

Select out those who do not respond and refer them to

other modes of therapy.

III. Termination

 

This outline in its original form was quite detailed and

written for students. It illustrates some of the sophistication

that now makes brief therapy an accepted mode for the treatment

of a broad spectrum of emotional problems.

CHAPTER III

METHODOLOGY

The purpose of this chapter is to present the research
hypotheses, the sampling procedure, the methods of gathering
the data, and the statistical techniques used in analyzing the

findings of the study.

Hypotheses

 

On the basis of the assumptions and issues from the
review of the literature that were deemed relevant to this

study, the following research hypotheses were developed:

Major Hypothesis

 

Planned, Short-term Treatment in a mental health clinic
is as effective as traditional, open-ended treatment, and is more

economical of patient-therapist time.

Research Hypptheses

 

H-l. Planned, Short-term Treatment is as effective as
traditional, open-ended treatment.

H-2. Planned, Short-term Treatment achieves its objectives
in fewer interviews than does traditional, open-ended treatment.

H-3. Clients assessing their own treatment, therapists

assessing their treatment of clients, and independent raters

58

59
assessing the same treatment as the clients and therapists will
derive consistency in scores on outcome evaluations.

H-4. The seven client problem categories in Reid and
Epstein'sl model of PSTT will require varying numbers of inter—
views to reach their treatment objectives.

H—5a. In PSTT therapy, the number of interviews required
for treatment will vary according to the length of time the
problem being treated has been developing.

H-5b. In conventional therapy, the number of interviews
required for treatment will vary according to the length of

time the problem being treated has been developing.

Statistical Hypotheses

 

HO-l. There is no difference between the treatment out—
come of PSTT and the treatment outcome of conventional therapy.

HO-Z. PSTT requires an equal or greater number of inter-
views than does conventional therapy to reach its treatment goals.

HO-3a. There is no consistency among the assessments of
outcome of clients, therapists, and independent raters.

HO-3b. There is no difference between the outcome ratings
of clients in Treatment Group I and Control Group I.

HO-3c. There is no difference between the outcome ratings
of therapists in treatment Group I and Control Group I.

HO-4. There is no difference in the number of treatment

interviews for each of the seven categories of client problems.

 

1William J. Reid and Laura Epstein, Task-Centered Case-
work (New York: Columbia University Press, 1972).

 

6O
HO-Sa. In PSTT, there is no difference in the number of
interviews for the three time periods that client problems took
to develop.
HO-5b. In conventional therapy, there is no difference
in the number of therapy interviews for the three time periods

that client problems took to develop.

Rationale for the Hypotheses

 

H-l. If PSTT was found as effective as traditional therapy
in meeting manifest treatment goals and (H-2) it met these goals
in fewer interviews, it would have been proven more economical in
time and money.

H-3. If the clients, the therapists, and the independent
rater agreed in their assessment of an individual case and if the
clients, therapists, and raters as groups derived equivalent mean
scores in their ratings of all the cases, their agreement would
have supported the validity of the outcome ratings, and the
reliability of the individual and group scores.

H—4. There was a question as to whether or not cases which
were assigned to some category of the Reid and Epstein PSTT para-
digm took so long to treat that they were not handled as PSTT
problems. There was also a need to know which category of problems
in the paradigm or deliberately excluded from it took longer than
others to treat.

H—5a. Crisis theory seemed to support the assumption that

problems which were a long time developing would take a long time

61
to treat. Conversely, problems with a short developmental history
should have been treatable in a short period of time.
H-5b. This relationship of the length of developmental
history of a problem and the length of treatment required to
correct it was also tested on the control group to provide further

support for the assumption mentioned in Sa.

Sampling of the Population

 

The subjects of this study were divided into Experimental
and Control groups which were further divided into Experimental
Groups I and II and Control Groups I and II. All of the groups
were selected from the population which applied for treatment to
the Blue Water Mental Health Clinic during a twelve-month period.
The manner of selection was as follows:

1. Experimental Group I consisted of all the cases that
fit the Reid and Epstein model (according to the treating therapist)
in which the first treatment interview occurred between June 15, and
December 15, 1973. N)lOO.

2. Experimental Group II consisted of all of the cases in
which the first treatment interview occurred between June 15, and
December 15, 1973, but which were rejected by the individual
therapists for the PSTT model and treated traditionally by the
individual therapist. N)70.

3. Control Group I consisted of all of the cases that
were closed between January 15, and June 15, 1973, that fit the
Reid and Epstein model of PSTT according to the Researcher.

N)lOO.

62

4. Control Group II consisted of all of the cases that
were closed between January 15 and June 15, 1973, and that did
not fit the Reid and Epstein model according to the researcher.
N)50.

One of the characteristics of a classic research design is
the random assignment of subjects to experimental and control
groups. Two of these groups are usually selected simultaneously
from a single population. However, this study does not follow
that "pure" research design for the following reason.

One of the purposes of well-designed research is to "keep
all conditions the same for both groups, except for exposing only
the experimental group to the experimental treatment for a specified
period of time.1 The study was done in a small clinic where the
staff of seven had to be trained in the PSTT method which differs
in several important characteristics from traditional therapy
process. If the staff had attempted to treat every other case with
PSTT and the other cases with traditional therapy, the PSTT training
WOuld have contaminated the traditional treatment. If the staff
had been divided.with one half (three or four therapists) being
trained in, and using PSTT.and the other half using conventional
therapy, it would have been difficult to prove that therapists'
characteristics did not account for the major variance in the

dependent variable.

 

1Ibid.

63

Experimental Group I and Control Group I were assumed to
have simdlar characteristics. The two groups were compared accord-
ing to four client characteristics. The results of these four
comparisons supported the assumption of comparability.

As a test of internal validity, the two major groups
(Experimental and Control), were compared according to the income
category, age, race, and presenting problem of the primary client.

Possible sample bias could have been caused by seasonal
differences in clinic clientele. However, the two major groupings
included in the study did encompass the universe of intake for a
limited period of time. Some variables which may have accounted
for some seasonal differences in intake were: referrals from
schools were heavier during school months; summer vacations de-
creased middle-class referrals; hot weather and decreased parental
supervision may have increased court referrals. However, the major
effect of seasonal differences was to decrease the number rather
than to significantly vary the types of cases that came to the
clinic during those comparative halves of a calendar year. The
fact that school based problems are not clinically different than
other family problems minimizes the variations between the samples.

Bias could also have resulted from staff changes during
the study year. However, it was assumed that most, if not all of
the therapists were treating during both experimental and control
phases of the study year.

The two samples in the study were all of the cases taken

in during the two time periods. They therefore are representative

64
of the Blue Water Clinic's population and the resultant statistics
should be generalizable to similar clinic populations. However,
to test the comparability of the two sets of samples and the
internal validity of the study, tables were prepared comparing
percentages of the various factors found in comparable groups.
Experimental Group 1, Control Group 1, Experimental Group II,
and Control Group II were all compared on two levels of family
income. The four groups were also compared on four age categories
of the primary client. They were compared next on race categories,
"White," "Black," or "other," and they were finally compared by
comparing the seven problem categories of Experimental Group I
and Control Group I and separately comparing Experimental Group II
and Control Group II in their four problem categories. Chi—square
was used to test for significant differences between the tabulated
results of paired groupings. The data of age and income were
collected as categories. Therefore, age, income, race, and problem

category were all analyzed as nominal data.

Mechanical Procedures

 

Experimental Period (June 15 to December 15, 1973)

 

The Research Clerk assigned all of the incoming cases to
the seven therapists according to the following guidelines:

1. A uniform pattern of rotation

2. The current workload of the individual therapist

During the first, or first and second treatment interviews,

the client and therapist determined what the target problem(s)

65
were and the therapist determined whether or not the case was
included in Experimental Group I. (If it fit into one of the seven
problem categories in Reid and Epstein's typology and into the other
guidelines listed below, it was included in Experimental Group 1.)
Client and therapist made a contract during the first or second
interview which included:

1. the agreed-upon target task or tasks

2. the planned number of interviews for working on the
specific task or tasks.

The contract was recorded on form number 2a (see
appendix A) by the therapist on the day the contract was agreed
upon.

The therapist used the guidelines delineated below to
determine which cases fell into Experimental Group I and which
became Experimental Group II.

For Experimental Group 11 cases, the therapist did not
make a contract with the client, but treated according to his
customary manner.

In both Experimental Group I and Experimental Group II,
the number of treatment interviews that had actually taken place

were recorded on the rating sheet by the therapist.

Control Period

 

During this phase, the therapist treated according to his
customary manner, made no contract, and recorded the number of

interviews after the termination of treatment for each case. The

66
researcher later reviewed these cases and assigned them to one of
the seven problem categories and determined whether they fit the
PSTT criteria (the same guidelines and problem categories used for
Experimental Group I). The cases that fit these guidelines became
Control Group I. The cases which did not fit the above guidelines
but did correspond to the categories of Experimental Group II, be-
came Control Group II.
Guidelines for Excluding Cases

From Experimental Group I
and Control Group I

 

 

 

The therapist in the experimental phase, and the researcher
in the control phase, assigned to Experimental Group II and Control
Group II, respectively, all of the cases which fell into at least
one of the following categories: (see Figure l)

h. Neuroses

i. Well-established behavior and personality disorders
(over twenty—four months in development and/or at least twelve
months in development and firmly entrenched).

j. Alcoholism or drug addiction

k. Character disorders

1. Client problems which the therapists excluded from
Experimental Group I and which could not be subsumed under cate-
gories h to k. (Experimental phase, June 15 - December 15.)

Control phase: All of the cases which were not placed in

Control Group I and which could not be subsumed under h to k.

67

manouw Houuaou mam HmuamEHuoaxm .H ouanm

xlm aH vmvnHoaH uoz H
muovuomHv Houomumnu x//
GOHuoHvum wont .EmHHo:OOH< h .. Anonoummmou
.Aumsoomuuao amok H um>o no mono» N Ho>ov znv hvoum aoum
muovuomHv H0H>mson new huHHmoomumo Emma waOH H . vownHoxm HH macaw
mmmouooz n .mH\oImH\H
pompouoo 3oH>umucH
w uaoaummuu HmHuHaH
m :oan 3H momma HH<
Amommo hvsum HmuooaHuoaxo cu m
consume mHaammv moHuowoumo amHnoum v momma mwsum H anouo
o
o
m

 

macaw Houuaou

xlm 3H wmvsHoaH uoz H
muowuomHm pmuomumno. x
GOHuoHuvm mane .EmHHonooH4 m mHnmuonu any
mumvuomHu u0H>mnoo mom muons Scum
muHHmaowumm .08 NH monocouuam Emma woOH H vmvoHoxm HH maouw
monounoz : .mH\~HImH\o
mmuuoooo 3mH>umuaH
w unoaummnu HmHuHoH
m///// noHos :H momma HH<
o
moHoowoumo aoHooum _vmwwmmwv momma husum H macaw
UHHHHVH
o
m

 

macho HmuomEHummmm

68

Guidelines for Selecting_PSTT Cases

 

1. The client must be able to see the problem clearly and
must express a willingness to work on it.

2. The problem must fall within the scope of the resources
of the client and the therapist--the client must be in a position
to act to relieve the problem with the worker's help.

3. The problem must be relatively limited and specific.

4. The targeted problem must fall within one of the seven
following categories:1

a. Inteppersonal Conflict: Problems of conflict between

 

two specific individuals which involves their interaction. The
behavior of one or both is objectionable to the other; but the two
antagonists are bound together in a relationship from which neither
can readily withdraw.

b. Dissatisfaction in Social Relations: This problem is

 

centered in the individual client rather than between two clients.
The client usually perceives deficiencies or excesses in his inter-
action with others. He may lack assertiveness, be isolated,
lonely, or too shy, dependent or aggressive. He may be dissatisfied
with his relations with a particular group such as the opposite sex
or those in authority.

c. Problems with Formal Organizations: This occurs between
the client and a specified other--an organization. His interaction
with individuals may be troublesome but their troublesome behavior

is based on their role in the organization.

69

d. Difficulties in Role Performance: Difficulty in

 

carrying out a particular social role such as family role or
student, employee or patient. (Limited to achieved roles rather
than ascribed roles such as age or sex.)

3. Problems of Social Transition: This category includes

 

problems regarding potential changes and problems concerning
changes already decided upon. Problems can include discharge,
migration, divorce or becoming a parent.

f. Reactive Emotional Distress: Includes the anxiety,

 

depression or other affective disturbances which might accompany
problems in categories a to e. Client must be more concerned with
these feelings than with the situation that gave rise to them.

g. Inadequate Resources: The client lacks tangible and

 

Specific resources and the therapist can help him secure them

through systematic effort.

Rating of Outcome

 

In both Experimental and Control groups, the therapist
filled out a rating sheet (form no. 1, Appendix A) as soon as
possible after treatment. The client was mailed a rating sheet
with a covering letter (form 1-a, Appendix A), and the independent
rater filled out a rating sheet from case record information.

None of the raters saw another's results. The sheets were kept
folded in an envelope in the case folder. Each simply placed a
check mark in a bracket after one of the five ranked assessment-
of-outcome positions that had been defined in a few words on the

assessor's rating sheet.

70

The Research Clerk maintained a checklist (form 4, Appendix
A) and checked off each step in the research as it was completed.
These steps included: (1) assignment of the case to a therapist,
(2) assignment of the case to the research or the control group
phase, (3) the closing of each case, (4) the completion of the data
sheet and rating sheet by the therapist, (5) the mailing of the
rating sheet and covering letter to the client, (6) the mailing
of the follow-up letter to the client (if necessary), (7) the
receipt of the rating sheet from the client, (8) the completion of
the rating sheet by the Independent Rater, and (9) the recording
of the three ratings on the data sheet (form 3, Appendix A).
During the entire process, the cases involved in both phases of
the study were maintained in a separate file. It was assumed that
almost 100 percent of the cases would be rated by the therapists
and the independent rater. Since the clients' responses were
dependent on mail contact and followed termination by two weeks to
three months, their response rate was not expected to be over
50 percent. If it was significantly less than this, some of the
cases rated by therapist and independent rater but not by clients

would have been excluded from the study.

Statistical Procedures

 

HO-l. There is no difference between the treatment outcome
of PSTT and the treatment outcome of conventional therapy.
The five positions on the outcome rating scale (form 1,

Appendix A), were assigned numerical ranks as follows:

71

Aggravated ............................ .. #1
Unchanged .............. . ....... ......... #2
Slightly alleviated ... .................. #3
Considerably alleviated .. ............ ... #4

Target problem no longer exists ......... #5

It is assumed that these are scaled scores and of at least
ordinal level data. However, a number of authorities consider the
numerical equivalents assigned to ranked outcome values to be
interval level data. Presumably, this scale has an arbitrary zero
point and fixed intervals between designations.1

The treatment outcomes for Experimental Group I and Control
Group I were compared using the t test for independent sample means.
Because it was felt that the assumption of homogeneity of variance
might not be tenable, this assumption was first tested. If the
assumption had not been upheld,the Welch2 method would have been
used to correct for degrees of freedom.

HO-Z. PSTT requires an equal or greater number of inter-
views than does conventional therapy to reach its treatment ob-
jectives.

This variable number of interviews (the term, "interview"

was defined earlier in the paper) is assumed to be interval level

 

lSheldon G. Levy, Inferential Statistics in the Behavioral
Sciences (New York: Holt Rinehart, and Winston, 1968), p. 49;
William L. Hays, Statistics for the Social Sciences (New York:
Holt, Rinehart, and Winston, 1973), p. 89.

 

 

2George A. Ferguson, Statistical Analysis in Psychology and
Education (New York: McGraw-Hill, 1976), pp. 68-170.

 

72
data but could be considered ordinal. It ranged from two to one
hundred for an individual case or treatment sequence. The means
of the four groups in the study were compared for significant
differences using two methods.

1. The t test for independent means was applied along
with the same procedures with respect to homogeneity of variance
that were outlined under hypothesis 1.

2. Kendall's tau was used on the assumption that the data
were only on an ordinal scale.

The groups were arranged in the following order:

1. Experimental Group I

2. Control Group I

3. Experimental Group II

4. Control Group II

The sample sizes were large enough to assume normality.
One or the other of the two statistical procedures tried should
have fit according to the equalness or unequalness of the standard
deviations in the samples.

The inclusion of Experimental Group II and Control Group II
in the comparisons was to give internal validity to the study by
determining whether or not the same kinds and proportions of cases
were assigned to comparable groups.

HO-3a. There is no consistence among the assessments of

outcome by clients, therapists, and independent raters.

73

This operation helped determine the reliability of the
outcome scoring, and, hopefully, showed a high correlation among
the mean evaluation scores of the three types of evaluators.

Analysis of variance1 was used to Show reliability between
the ratings of the three evaluators. The three observations for
each case were assumed to remain constant as repeated measures,
while the agggg in measurement for each of the three was assumed
to vary. With the assumption that repeated measures of the same
person remain constant, then the variance between the measures for
that person (within the person) was due to error of measurement.
The pooled within-person variance therefore estimated the total
variance due to error of measurement. On the other hand, the
variance between the persons in the group was in part due to the
true magnitude of the characteristics possessed by the different
people in the group, and, in part due to differences in the
average error of measurement for each person.

The estimated reliability for the mean of K persons is:

(l/k) (MS between people - MS within people)

 

rk=
(l/k) (MS between people - MS within peOple) + (l/k) MS
w. peOple
The reliability of a single measure was estimated thus:
MS between people - MS within people
r1=

 

MS between people + (K-l) MS within people3

 

13. J. Winer, Statistical Principles in Experimental

Design (New York: McGraw-Hill Book Co., 1971), p. 278.

2Ibid. 3Ibid.

74
I3 = the estimate of the reliability of the average of the three
ratings.

MS within people
r3=1_ =

 

MS between people

This analysis of variance process was run using the data
from Experimental Group I. A coefficient of unity would indicate
perfect consistence between raters. A coefficient of zero would
indicate no consistence and would support the HO.

HO-3b. There is no difference between the outcome ratings
of clients in Treatment Group I and Control Group I.

The means of the two samples were compared using the pooled
variance t-test since the assumption of homogeneity of variance was
upheld by an F-test.

HO-3c. There is no difference between the outcome ratings
of therapists in Treatment Group I and Control Group I.

The means of the two samples were compared using the pooled
variance t-test and the same procedures with respect to homogeneity
of variance outlined under HO-l.

HO-4. There is no difference in the number of treatment
interviews for each of the seven categories of client problems.

The mean number of interviews for each problem category
of Experimental Group I was determined and the seven means com—
pared with each other. The same process was carried out for Control
Group I. Since these are considered interval level data, and the

numbers in each category are presumed unequal, analysis of

75
variance was used for each group. The independent variable was the
seven problem categories and the dependent variable was the number
of interviews.

HO-Sa. In PSTT, there is no difference in the number of
interviews for the three time periods that the various client
problems took to develop.

Questions to the client such as, "When did this difficulty
begin?," or, "When did you first notice a change?," identified
a date for the therapist that began the time period in which the
problem surfaced. The period ended with the date of the first
treatment interview. Zero to three months fell into category 1,
three months to nine months into category 2, and more than nine
months into category 3. The assumption was, the longer the problem
was in developing, the more interviews it took to alleviate it.
Therefore there should be a direct relationship between the number
of interviews and the problem categories. Since the length of
time divided into three categories is an ordinal variable, Kendall's
tau was used to compute the degree of association. This statistic
includes a method of correcting for tied ranks that was needed
since there are three time period ranks to relate to approximately
100 treatment interview ranks.

The above process for HO-Sa was repeated for HO-Sb using
the data for Control Group I.

Since the number of interviews might be considered interval
level data, HO-5a and HO-5b were tested also by a one-way analysis

of variance program.

CHAPTER IV

RESULTS OF THE RESEARCH

Comparabilityyof Groapa

 

As a test of internal validity and comparability of corre—
sponding groups, Experimental Group I was compared to Control
Group I, and Experimental Group II with Control Group II according
to the income category, age, race (Experimental Group I and Control
Group I), and contracted problem of the primary client. Chi-square
was used to determine whether or not the selected statistics of the

corresponding samples were significantly different.

TABLE 1

INCOME OF PRIMARY CLIENTS OF EXPERIMENTAL
GROUP I AND CONTROL GROUP I

 

 

 

Under Over
$8,000.00 $8,000.00 Totals
Experimental Group I 42 24 66
Control Group I 47 39 86
Totals 89 63 152

 

The number with incomes above and below $8,000.00 in each
group were comparable. Chi-square was 1.24 with one degree of free-
dom; the difference in income between Experimental Group I and

Control Group I was not significant.

76

77

TABLE 2

INCOME OF PRIMARY CLIENTS OF EXPERIMENTAL
GROUP II AND CONTROL GROUP II

 

 

 

 

Income
Under Over
$8,000.00 $8,000.00 Totals
Experimental Group II 34 31 65
Control Group II 33 15 48
Totals 67 46 113

 

The number with incomes above and below $8,000.00 in each
group were comparable. Chi-square was 3.09 with one degree of free—
dom; the differences in income between Experimental Group II and

Control Group II were not significant.

TABLE 3

AGES OF PRIMARY CLIENTS IN EXPERIMENTAL
GROUP I AND CONTROL GROUP I

 

 

 

 

Ages
0-5 6-12 13-19 20+ Totals
Experimental Group I 5 24 14 20 63
Control Group I 5 24 18 36 83
Totals 10 48 32 56 146

 

The number of primary clients in the four age categories were
comparable in the two groups. Chi-square was 1.66 with three degrees
of freedom; the differences in age distribution between Experimental

Group I and Control Group I were not significant.

78

TABLE 4

AGES OF PRIMARY CLIENTS IN EXPERIMENTAL
GROUP II AND CONTROL GROUP II

 

 

 

 

Ages
0-5 6-12 13—19 20+ Totals
Experimental Group II 4 28 24 7 63
Control Group II 7 10 29 47 93
Totals 11 38 53 54 156

 

The number of primary clients in the four age categories
were 395 comparable in the two groups. Chi square was 32.24 with
three degrees of freedom; the differences in age distribution be-
tween Experimental Group II and Control Group II were highly sig-
nificant at the .001 level of probability. Although statistically
significant, the actual differences in the numbers of clients
served in each age group were not as great as they appear. (See

discussion, Chapter V, p. 92.)

TABLE 5

RAGE OF PRIMARY CLIENTS OF EXPERIMENTAL
GROUP I AND CONTROL GROUP I

 

 

 

Race
White Black Other Totals
Experimental Group I 64 O l 65
Control Group I 86 1 1 88

 

Totals 150 l 2 153

 

79
The numbers of clients in the three categories of races were
almost equal in the two groups. By inspection it became obvious
that the differences in the racial composition of Experimental Group I

and Control Group I were slight and not significant.

TABLE 6

CONTRACTED TREATMENT PROBLEMS IN EXPERIMENTAL
GROUP I AND CONTROL GROUP I

 

Problem Catagories
a b c d e f g h i j k Totals

 

 

 

Experimental Group I 21 13 2 16 0 13 65
Control Group I 27 13 l 22 O 24 87
Total 48 26 3 38 O 37 152

 

The number of clients assigned to each of the seven problem
categories used in these two groups was comparable. Chi square was
.97 with four degrees of freedom; the differences in problem cate-
gory distribution between Experimental Group I and Control Group I

were not significant.

TABLE 7

CONTRACTED TREATMENT PROBLEMS IN EXPERIMENTAL
GROUP II AND CONTROL GROUP II

 

Problem Cataggries
a b c d e f g h i j k Totals

 

 

Experimental Group II 6 4 O 14 5 22 0 1 9 3 2 66

Control Group II 0 O 0 O O 0 O 9 22 5 8 44

 

Totals 6 4 O 14 5 22 9 10 31 8 10 110

 

80
The number of clients assigned to each of the eleven problem
categories used in these two groups were not comparable. Chi-square
was 51.98 with eight degrees of freedom; the difference in the num-
bers of problems in the categories of Experimental Group II and Con—

trol Group II are highly significant at the .001 level of probability.

Testing the Hypotheses

 

HO-l

There is no difference between the treatment outcome of PSTT
and the treatment outcome of conventional therapy.

An N of 66 represents the cases which the therapists chose to
treat with Reid and Epstein's PSTT model during the Experimental
phase of the study. The client's, therapist's, and researcher's out-
come ratings for this group were compared with the ratings of the
eighty-nine cases during the Control, or conventional treatment phase,
that were fitted into the seven categories of the PSTT model by the

researcher. The resultant means are compared in the following table.

TABLE 8

MEANS OF EXPERIMENTAL AND CONTROL GROUPS COMPARED
ACCORDING TO THE THREE TYPES OF RATERS

 

 

 

Means
Exp. Control Deg. of
Group I Group I Diff. t Freedom Prob.
Clients 2.6061 2.7191 .1130 .3776 153 .706
WOrkers 3.1970 3.3146 .1176 .7868 153 .433

Researcher 3.1364 3.2360 .0996 .5785 153 .564

 

81

The assumption of homogeneity of variance was upheld in all
three cases. The results of the t tests are shown in the last
three columns of Table 8.

The comparison of the means of the client ratings in the
PSTT sample and the corresponding control group yielded a t of
.3776 with 153 degrees of freedom. At a probability of .706 on a
2-tailed test the difference is not significant.

The means of the therapists' ratings in Experimental and
Control Group I were not significantly different. Mean of
Experimental Group I - Mean of Control Group I = 3.1970 - 3.3146 =
.1176. This data was also found to be homogeneous. A t of .7868
with 153 degrees of freedom has a probability of .433; and there-
fore the means are not significantly different.

The researcher's mean ratings of Experimental Group I and
Control Group I were only .0996 apart. A t of .5785 with 153
degrees of freedom showed a probability of .564 (two-tailed test).
Again the means were not significantly different.

The mean of the three ratings of Experimental Group I
compare favorably with the mean of the three ratings of Control

Group I-—2.9798:3.0899.

H0-2
PSTT requires an equal or greater number of interviews than
does conventional therapy to reach its treatment objectives.

The mean number of interviews was 4.7273 for the 66 cases

in Experimental Group I and 10.5843 for the 89 cases in Control

82
Group I. These means were compared in two ways: Method 1:
t—test for independent means. The test of homogeneity of variance
yielded F=33.00 with p(.001. Hence the assumption could not be
upheld, and the method of Welch was used for adjusting degrees of
freedom. The test yielded t = -3.3235 with 93 df and p< .001.
This difference was highly significant. Method 2: Considering
the measures to be an ordinal rather than an interval scale,
Kendall's tau was used for two groups (Experimental Group I and
Control Group I). This test gave r = .273 which was highly sig-
nificant (Z = 5.043, p<:.001).

The two procedures gave closely similar results. The
difference between the mean number of interviews for the two groups
is highly significant.

Method 1 above was repeated with two extreme scores (over
100 interviews) deleted. The mean of Experimental Group I re-
mained the same but the mean of Control Group I was decreased to
8.4138. The assumption of homogeneity of variance was not upheld
and the Welch procedure was used to adjust for degrees of freedom.
t was -4.ll90 with 108 degrees of freedom and p<;.0001. Again the
difference in the number of interviews for the two groups is highly
significant.

The mean number of interviews for Experimental Group II
(65 cases) and Control Group II (47 cases) were compared also. The
means were 6.7692 and 20.4893 respectively. The F test yielded
12.9492 with a probability‘(.0001. Since the homogeneity of var-

iance was not upheld, the Welch procedure was used to adjust the

83
degrees of freedom. t was -2.9592 with 53 degrees of freedom and
a probabilityW(1005. The difference in the number of interviews
for the two groups was significant.

The number of interviews and frequencies of cases during
the experimental phase (Experimental Groups I and II), and during
the control phase (Control Groups I and II), were compared in a
line graph. It demonstrates that the PSTT phase took fewer inter-

views consistently. (See Figure 2.)

£929.

There is no difference among the assessments of outcome of
clients, workers, and the researcher.

Seventy percent of the clients contacted after the Experi-
mental phase returned their rating sheets. The rating sheets sent
to them offered a choice of five positions to be marked: Number 1
was labelled "aggravated," number 2 was labelled "unchanged,"
number 3 was "slightly alleviated," number 4 was "considerably
alleviated," and number 5 was "target problem no longer exists."
The clients' ratings on this scale averaged 2.6061 for the Experi-
mental Group I PSTT cases (N=66). An F-test upheld the assumption
that the variances within the group were homogeneous. The same
cases were rated on the same scale by the workers who treated the
clients. The workers who treated with PSTT during the experimental
phase had a mean rating of 3.1970. The F-test upheld homogeneity
of variance for this set of data. The researcher rated therapy
outcome by reading all of the cases in both groups. His ratings

averaged 3.1364 for the PSTT group (Experimental Group 1). Again

84

.m3oH>uwucH mo Mommas cu wchuoouo
momma Houuoou can HousmSHHoaxm mo SOHuooHuumHo one .N mustm

mameumuaH mo umoaoz

 

68£9SV€
IIIIITI
I..._.._
0I68£9SV TIT.
WOOOOOOO ZI068£9SV€ZI
wIA \/
s/

\ l‘x /
x z

/
k c

I

/

 

mommo oOHuom Houuooo

mommo vOHuom HmucoaHumaxm II I...

ONQNQMQ‘MNHO

CO®N©W¢MNHO
NHHHHHHHHHH

saseg go JaqmnN

85
the F-test upheld homogeneity of variance, therefore analysis of
variance was used. The reliability of the mean was:

1.333

1 ’ 3.333

 

= 1 - .40 = .60

The reliability of a single measure was:

1.989
5.988

 

= .33 1 - .33 = .67

Both coefficients were relatively high. The H0 is rejected. There
is a reasonable degree of consistency between the ratings of clients,
therapists, and independent researcher when the ratings are taken as
groups, and also a high correlation between the three ratings on a

given case.

HO-3b

 

There is no difference between the outcome ratings of
clients in Treatment Group I and Control Group I. The difference
between the ratings of outcome for PSTT and traditional treatment
was measured by comparing the client ratings in Experimental Group I
with client ratings in Control Group I (see Table 9). The F test
yielded F - 1.1240 with p = .6049 which upheld the assumption of
homogeneity of variance. The difference was not significant so
the null hypothesis was upheld; there is no significant difference

between the client ratings of the two types of treatment.

HO-3c
There is no difference between the outcome ratings of
therapists in Treatment Group I and Control Group I. The dif-

ference between the ratings of outcome for PSTT and traditional

86

treatment were measured by comparing the therapists' ratings in
Control Group I (see Table 9). The F-test yielded F = 1.4234
with P = .1226 which upheld the assumption of homogeneity of
variance. The difference was not significant so the null
hypothesis was upheld; there is no difference between the
therapists' ratings of Experimental Group I and Control Group I.

If the t values from these three comparisons are taken
together, it can readily be seen that, from the ratings of clients,
workers, and the researcher, the outcome of both kinds of therapy

is essentially the same (see Table 9).

TABLE 9

TREATMENT OUTCOME MEANS OF EXPERIMENTAL AND CONTROL
GROUPS COMPARED ACCORDING TO THE THREE
TYPES OF RATERS

 

Exp. Control

 

 

Raters Group I Group I Diff. t d.f. Prob.
Clients 2.6061 2.7191 .1130 .3776 153 .706
Workers 3.1970 3.3146 .1176 .7868 153 .433
Researcher 3.1364 3.2360 .0996 .5785 153 .564
Totals 8.9395 9.2697 .3305 1.8429 459 1.703
Average 2.9798 3.0899 .1101 .6143 153 .5677
HO-4

There is no difference in the number of treatment interviews
for each of the seven categories of client problems (in the Reid and

Epstein model).

87
Number seven of Reid and Epstein's seven problem categories,

' was not chosen by the workers as fitting any

"Inadequate Resources,’
of the cases in any part of the study. Therefore, only six problems
were included in the PSTT phase analysis of the number of inter-
views it took to treat each problem. Category 5, "problems of
social transition" was not chosen either but it was included in the
study and is shown as blank cells in the Anova tables (see Table 10).
The clinical orientation of the therapists led them to perceive
client problems as intrapersonal or interpersonal between two in—
dividuals.

With the exception of "Problems With Formal Organizations,"
the cell frequencies were large and uniform enough to use analysis
of variance. "Problems With Formal Organizations" had a frequency
of 2 in Experimental Group I and 1 in Control Group I. This data
was analyzed by inspection.

The variation in the number of interviews for each of the
six problem categories included in Experimental Group I (only five
of these were utilized), was not significant. The same problem
categories treated as Control Group I did not vary significantly

in the number of interviews they required. The F ratios for both

Experimental Group I and Control Group I were non-significant.

HO-Sa
In PSTT therapy, there is no difference in the number of
interviews for the three time periods that client problems took

to develop.

88

 

 

 

o o mwm.mH «N o o Hwo.m Nu o.m H mqo.m SH mmw.n mm H 0 S00
0 o Hno.o MH 0 o om~.e 0H on.N N Hm~.¢ MH one.q HN H 0 Sam
OuaH
.uSH e mommo .uSH * wommo .uSH * mommu .uSH H mommu .uSH * mommo .uSH * mouse * Swmz wommo
mmmuumHn SOHuHmSmuH moSnahomuom SOHSSNHSmwSo mSOHumHom com
moousomom HmSOHuoam HmHoom SH mHom SH Hmauom nqu SH SOHuumH uoHHmSoo
oumavoomSH opHuomom maoHooum moHuHSoHHHHn maoHnoum ImHummmHn HmSomumSuouSH

 

H mbomo HOMHZOU nz< H macaw H<HZNZHMmmxm
m3MH>mmHZH mo mMMZDz z<mz Qz< mmHmowma<U ZMHmomm HHmm NHm

OH mHm<H

89
TABLE 11
ANALYSIS OF VARIANCE SUMMARY TABLE

FOUR PSTT PROBLEM CATEGORIES AND MEAN NUMBER OF
INTERVIEWS FOR EXPERIMENTAL GROUP I

 

Source D.F. Sum of Sq. Mean S. F Proba- Signifi-
Ratio bility cance

 

 

 

Between Groups 3 27.6105 9.2035 1.1278 65 N.S.
Within Groups 59 481.468 8.1605
Total 62 509.0786

TABLE 12

ANALYSIS OF VARIANCE SUMMARY TABLE
FOUR PSTT PROBLEM CATEGORIES AND MEAN NUMBER OF
INTERVIEWS FOR CONTROL GROUP I

 

Source D.F. Sum of Sq. Mean S. F Proba- Signifi-
Ratio bility Cance

 

 

Between Groups 3 857.3867 285.7954 1.0561 .6 N.S.
Within Groups 83 22,461.4687 270.6199
Total 86 23,318.8555

 

The three time periods that problems took to develop in Ex-
perimental Group I were correlated with the number of interviews for
each case. The Kendall's Tau of .135 produced a Z of 1.602 which
was not significant. There was no meaningful relationship between
the number of interviews it took to treat a case and the length of

time the problem treated was in development. N = 66 cases.

90

39:22

In conventional therapy, there is no difference in the
number of therapy interviews for the three time periods that client
problems took to develop.

The three time periods that problems took to develop in
Control Group I were correlated with the number of interviews for
each case. The Kendall's Tau of .208 produced a Z score of 2.888
which meant that there was a significant relationship between the
number of interviews it took to treat a case and the length of

time that the problem treated had been developing. N = 89 cases.

CHAPTER V

INTERPRETATION OF THE RESULTS

Comparability_of Groups

 

As a test of internal validity of the study and comparability
of corresponding groups, Experimental Group I was compared to Control
Group I on the income, age, race and problem category of the primary
client. Experimental Group II was compared to Control Group II on
the income, age, and problem category of the primary client.

Experimental Group I and Control Group I were not signifi-
cantly different when family income was compared. Control Group I
contained a few more clients with middle class incomes; this could
reflect slight seasonal or cyclic variations in economic conditions.
However, the fact that the differences were slight indicated that
the two samples were drawn from the same populations.

Clients' incomes in Experimental Group II and Control
Group II were also comparable. Control Group II had a slightly
greater preponderance of lower class clients. This would not in-
dicate that a seasonal or economic variation was Operating since
this skew is the opposite of the skew of the income distribution
for corresponding groups Experimental I and Control I. Perhaps
clients whose problems could be categorized into the Reid and

Epstein categories were more expressive verbally and tended to be

91

92
middle class. However, the differences were not significant so that
income did not seem to be a variable affecting therapy outcome.

The ages of primary clients were grouped and compared to see
whether or not clients were picked for the two kinds of treatment
according to their ages. Experimental Group I and Control Group I
were comparable according to client ages and the differences were
not significant. However, when comparing Experimental Group II and
Control Group II--those cases excluded from the PSTT categories
during the PSTT treatment and the conventional treatment phases—-it
was found that the two groups were not comparable and the differences
were highly significant. Experimental Group 11 cases were taken in
and treated during a six-month period afgag the Control Group II
cases were treated. Experimental Group II had many more elementary
age children and far fewer adults than did its corresponding Control
Group II. This reflects a change in Clinic intake policy; the par-
ent planning organization began at that time to limit the Blue Water
Clinic to children's cases. The age statistics were tabulations of
primary clients, or the family members for whom help was sought.
Child primary clients were seen with their parents. The younger
the primary client, the more likely it was that the child was
treated through the parent. Therefore, the shift to a greater
proportion of child primary clients did not mean a pro-rata re-
duction in the number of adults served.

Presumably, teen-age clients in their middle to late teens
were seen sometimes without the involvement of a parent. Therefore,

there may have been less involvement of adults in Experimental

93
Group II when compared to Control Group II. However, the major
focus and concern of the study is Experimental Group I and its
counterpart, Control Group I. In these groups the percentages of
child primary clients presumably treated with their parents or
through their parents are 52 percent and 42 percent respectively.
The Chi-square comparison of the two groups found the differences
not significant. The change in clinic policy during the study did
not vary the population served enough to threaten the validity of
the research.

Table 5 shows that the number of minority group clients
seen by the Clinic is very limited. Since non-whites were only
about 2 percent in both Experimental Group I and Control Group 1,
they were readily seen as comprising about the same proportion of
either group. The lack of significant numbers of minority clients
in the study means that the results cannot be generalized to
minority or racially mixed populations.

In Table 6 the Experimental and corresponding Control
groups were compared on the basis of the assignment of client
problems to the problem categories designated by Reid and Epstein.
Experimental Group I and Control Group I were not significantly
different in the proportions of cases assigned to each category.

The therapists who made these decisions during the experi—
mental phase saw some of the cases assigned to them as not treatable
through the Reid and Epstein seven-category model. The rejected
cases became Experimental Group II. However, the problem category

distribution of cases selected for the model during the control

94

phase of the study when conventional treatment was used, was not
significantly different from the distribution into problem cate-
gories during the treatment phase where PSTT was used.

The client problems rejected for the PSTT paradigm of the
Reid and Epstein model during the treatment and control phases of
the study became Experimental Group II and Control Group II. The
cases in these groups were fitted into the four categories that
Reid and Epstein said were not suitable for PSTT treatment.
(Neurosis, well-established behavior and personality disorders,
alcoholism or drug addiction and character disorders.) The
problem category distribution of cases in Experimental Group II
and Control Group II was significantly different. Information on
which to base a decision for problem categories in these two
groups differed somewhat. In Experimental Group II, the therapists
gathered information for a decision from the first, or first and
second, interview with the client. In Control Group II, the re-
searcher used the case records as the basis for his decisions
concerning problem categories. During the experimental phase, the
emphasis was on treating as many cases as possible with PSTT; many
therapists treated almost all of their cases with PSTT during this
period. Experimental Group II, therefore, represents rejects from
the normative program for that six months.

A basic assumption of Reid and Epstein's PSTT model is that
PSTT is 225 appropriate for all client problems. Conventional
therapy is not limited specifically to certain types of problems.

This research supported the limited characteristic of the PSTT

95
model when the problem paradigm was applied by the individual
therapist during the experimental phase apd_when it was applied
by the researcher during the control phase. PSTT was found not

suitable for all client problems.

Discussion of Results

 

Hypgthesis 1

 

Planned, short—term treatment is as effective as traditional,
open-ended treatment.

One of the two major concerns of this study is whether or
not PSTT is as effective as more traditional therapy. The two
types of treatment were found to be equally effective. However,
the goals of the two types and potential lengths of therapy
differ. In fact, the goal of any individual series of treatment
interviews in either treatment category should be idiosyncratic.

A number of studies have established the premise that a
variety of types and lengths of treatment under a number of con-
ditions are 60 to 75 percent successful when evaluated by a
variety of raters and devices.1 It was felt that, if the results
of PSTT in this study (Experimental Group I) were comparable to the
results of traditional treatment in the test group (Control Group I),
and if both sets of results fell within the broad range established
for the outcome of "successful" therapy, then the therapy outcome
could be considered held constant while the average length of

treatment for the two groups was compared for significant variation.

 

1Denker cited in Bergin and Garfield, p. 239; Eysenck,
cited in Ibid.

96

A number of researchers and clinicians believe that the
effect of therapy cannot be measured adequately without some
follow-up feed-back at periodic intervals after the initial
therapy is completed. They state that it is important to know
whether or not progress claimed at the close of therapy has held
up over time. Other research-oriented therapists believe that time
distorts a client's or worker's perception of what happened during
treatment and that various post-treatment influences also may bias
a follow-up evaluation. The clients in both phases of this re-
search rated their treatment from two weeks to three months after
treatment termination. This time lapse provided some perspective
without the danger of distortion posed by a longer delay.

The sixty-six clients who responded to the request for a
rating of their treatment represent a 79 percent return, which is
a high percentage of response to a mailed questionnaire. Some
clients had moved or could not be reached for other reasons. This
left a small percent who refused to cooperate. The clients who
did respond to the request for rating provided an opinion or view-
point of their therapy which may have been more subjective than a
before-and-after symptom's checklist or psychological profile. How-
ever, it could be argued that the client's opinion of his or her
treatment is more real than someone else's categorization of what
the client needed and an outside assessment of whether or not he
or she received what was needed in treatment.

The researcher who rated all of the cases for outcome had

had no direct contact with the client. He was dependent on

97

whatever information was written in the case record, especially
the contract between client and worker. However, his ratings
were consistent with the ratings of the clients and therapists.

A number of mechanical procedures were used to prevent
contamination between raters, especially between clients and
therapists. A research clerk provided an enve10pe in the case
folder in which the therapist could deposit his folded rating
sheet. The clerk mailed rating sheets to the clients and folded
and deposited them when they were returned. The researcher then
added his folded sheet to the envelope. The research clerk re-

corded the ratings on the data sheet.

Hypothesis 2

 

Planned, short-term treatment achieves its objectives in
fewer interviews than does traditional, open-ended treatment.

The major advantage of PSTT over traditional therapy is its
economy of time and more expeditious use of expensive therapy
resources. The focused use of time in this type of therapy does
reach the limited goals contracted for in fewer interviews than
does the less focused traditional therapy which is directed
toward less explicit goals.

A number of research studies show that most movement in any
type of therapy takes place in the first few interviews, and because
of early, unplanned termination by clients, most conventional treat-
ment sequences do not go beyond the six to eight interview limit set

for most PSTT. Therefore, the mean number of interviews for

98
Control Group I is skewed by a small number of high scores.
(Seventeen cases of between twenty and one hundred interviews.)
When the data was run a second time omitting the two most extreme
scores (over one hundred), the mean score for Control Group I was
reduced from 10.5843 to 8.4138. However, the difference between
the means of Experimental Group I and Control Group I with the two
extreme scores omitted from the latter group, is still significant.

PSTT takes less time to reach more limited goals, but its
goals should be closer to the expressed needs of the client because
of the explicit statements recorded as part of the contracting
process.

The non-PSTT cases treated during the two major phases of
the study (Experimental Group II and Control Group II) were compared
according to the average number of treatment interviews. The fact
that the ratio of Experimental Group II to Control Group 11 mean
number of interviews was comparable to the ratio of mean interviews
for Experimental Group I to Control Group 1 represents a validation
of Reid and Epstein's client category model. The therapists (during
the experimental phase), and the researcher (during the control
phase), independently decided that proportionate numbers of cases
did not fit the Reid and Epstein model. The therapists selected
cases for Experimental Group II by deciding that certain cases
were not treatable by PSTT and fit the non-PSTT categories of the
model. The therapists handled those cases in far fewer interviews
than they did comparable cases during the Control phase before they

were trained in PSTT. However, the comparison of the mean number

99
of interviews for Experimental Group I and Control Group I is the

most relevant to this study.

Hypothesis 3

 

Clients assessing their own treatment, therapists asses-
sing their treatment of clients, and independent raters assessing
the same treatment as the clients and therapists will all derive
equivalent scores on outcome evaluations.

The five-position rating instrument used in assessing the
three group's evaluations of outcome was suggested by Dr. Laura
Epstein, one of the developers of the PSTT model. It was used in
the Reid and Epstein studies of the early 19703. Its primary use
in this research was the comparison of treatment effectiveness by
different groups in the study rather than comparing results to a
baseline or standardized result from other studies. There were a
limited number of positions on the rating scale, but the numbers
in the groups being rated were large enough to smooth out the
modal effect of the data.

There are many possible sources of bias that may have
affected the clients, the therapists and the independent researcher's
assessment of outcome. The client could be influenced by his like
or dislike for the clinic itself, or any person connected to the
clinic or for any part of the clinic process. The independent
rater could have been influenced by his desire for a certain out-
come for his research. The therapists could be influenced by a

preference for a method of treatment, a desire for "successful"

100
research, a like or dislike for a client, and a host of other
factors. But the similarity of evaluations among the three groups
suggests a balancing of the potentially positive and negative
biasing factors.

There were no significant differences in outcome ratings.
The clients, therapists, and independent researcher all indicated
that the outcome of PSTT and conventional therapy was about the
same. However, all three groups rated conventional therapy as
slightly more successful than PSTT. (The clients' mean for
Experimental Group I was 2.6 and for Control Group I was 2.7. The
therapists' ratings were 3.2 and 3.3 and the researcher's ratings
were 3.1 and 3.2, respectively.)

Of the three types of raters, the therapists were most
positive in rating the outcome of their own therapy. The inde-
pendent researcher was slightly less positive and the clients the
least positive. However, these differences were not significant.
Perhaps the most comprehensive knowledge of the problem and its
setting provided the most critical look at its resolution.

The clients treated conventionally (Control Group I), and
the clients treated with PSTT (Experimental Group 1), evaluated
their treatment results almost equally. The therapists in both
groups also assessed their treatment as equally successful. The
therapy outcome variable remained constant during both types of

treatment while the time variable fluctuated.

101

Hypgphesis 4

 

The seven client problem categories in Reid and Epstein's
model of PSTT will require varying numbers of interviews to reach
their treatment objectives.

The seven-category model used in this study was developed
and used by Reid and Epstein at an earlier stage in their research.
Its range of coverage was sufficient for most problems encountered
by a mental health clinic, but it specifically eliminated some
broad and some narrow categories of other client problems (see
Figure 1, h-l).

The decisions to define problems in certain ways and place
them in certain categories varied somewhat among the different
therapists. They were trained briefly in making such decisions,
but their idiosyncratic backgrounds were a bias. None of the
group used the category "inadequate resources," perhaps because
the provision of resources was not a clinic function according to
their traditional perspective of clinic services. They therefore
tended to classify a problem handled primarily by referral not as
a part of clinic services nor within the bounds of the PSTT phase
of this study.

The category "problems in social transition" relates to a
developmental model of problem definition that apparently was not
congruent with the problem paradigms the therapists were familiar
with. There were problems in social transition that were treated
during the study but otherwise defined. Because of this and perhaps

other factors, this category was not used by any therapist. Better

102
problem differentiation would have resulted in some client problems
being categorized as problems in social transition. Problems with
formal organization was used only twice in Experimental Group I
and once in Control Group I.

"Interpersonal conflict" was the category most frequently
chosen for client problems. This large number probably included
many client situations that would have been labeled "problems in
social transition" if the therapists had used a theoretical frame-
work congruent with that concept. Again, this relates to the
therapists' way of perceiving problems as well as to the number of
clients who presented that problem for treatment. Most of the
therapists were closer to a psychological view of human behavior
than they were to a sociological or anthropological viewpoint. In
spite of differential labeling, the study covered the gamut of
common clinic problems. There were zero frequencies in some cells,
but problems were shifted rather than lost.

The uniformity in the number of interviews that each type
of problem took to treat in Experimental Group 11 may have been
influenced by the structural limits of the prescribed number of
interviews in PSTT. The Experimental Group 1 problems compared to
Control Group I problems did take a significantly different number
of interviews in this traditional mental health clinic setting.
This result agrees with the major findings of Hypothesis II--that
PSTT and conventional therapy does require a significantly different
number of interviews. The traditional mode of therapy usually

accomplishes most of its movement and terminates in a few interviews.

103
It is the few cases that require many interviews that make the
average treatment longer for conventional therapy. The statistics
do support the premise that PSTT type problems can be treated with
either type of therapy in most cases, with a small variation in
the number of interviews.

The fact that the therapists and researcher decided to
classify proportionate numbers of cases into each category during
both Treatment and Control phases indicates that they did not
generally exclude cases from PSTT that they thought were too
difficult or complicated. They used both treatment methods on the
same types of problems and excluded similar types of problems from
the Reid and Epstein paradigm during both phases of the study.

Experimental Group II and Control Group II included some-
what different types of cases that were selected differently. The
therapists decided that some cases fell into one of the seven cate-
gories of Experimental Group I, but could not be treated by PSTT.
Since the cases were rejected for PSTT, they became part of
Experimental Group II. Control Group 11 cases were selected by
problem category alone, therefore none of those types of cases

were assigned to a-g (Experimental Group 1) categories.

Hypothesis 5a

 

In PSTT the number of interviews required for treatment
will vary according to the length of time the problem being

treated has been developing.

104

This assumption seemed logical and seemed to be supported
by crisis theory, but it did not hold true for PSTT cases in this
study. The term "problem" as used in the experimental phase of
therapy, was defined by what was contracted,in contradistiction
to the broader definition of problem that is more generally used
in therapy. Many of the client problems that arose within a few
weeks of treatment took as long as problems that had been developing
for over a year.

There was a possibility that the difficulty the client
contracted to treat was the current manifestation of a deeper,
more long-term problem. In PSTT, it is acceptable to work on the
alleviation of symptoms; the problems that these symptoms illustrated
may never be fully explicated.

There are a number of factors which operate together to help
a client decide to seek help with a certain problem at a certain
time. The painfulness of a certain problem or the discomfort of
an acute phase of a long-term problem are only two of them.

Related to the assumption that short-termed problems would
take less time is the assumption that clients would tend to con-
tract more short-term problems for PSTT treatment. It was assumed
that clients faced with a time limit would focus on and contract
something immediate and limited rather than to attempt to treat a
chronic condition with PSTT. This unwritten assumption was not

supported by the study.

105

Hypothesis 5b

 

In conventional therapy, the number of interviews required
for treatment will vary according to the length of time the problem
being treated has been developing.

In the regular treatment cases in Control Group I, the
relationship between the length of treatment and the length of
time the problem being treated was developing was significant at a
low level. This low level of significance called into question the
unwritten assumption that clients and therapists would decide that
long-term problems could not be treated in PSTT.

Although the term "problem" was not as specifically defined
in conventional therapy, it was more concisely defined in the PSTT
phase of this study. Therefore, the assumption that something
different was defined and contracted for in each of the two groups,
and that the term "problem'I as used in the conventional therapy
phase was more generally defined, may be valid.

The average problem in Control Group I took longer; there
was more freedom for the range of the number of interviews to
assume a wider spread than would interviews for the PSTT group

which were constrained by the arbitrary limit of eight interviews.

CHAPTER VI
SUMMARY AND CONCLUSIONS

"Reid and Epstein have formulated a theory for short-term
casework based on the assumption that effectiveness and efficiency
of treatment can be greatly increased."1

"While we think that the problem typology comprises most of
the problems caseworkers can be expected to deal with successfully,
it is not meant to be exhaustive. It certainly does not Span the
range of human problems that caseworkers generally deal with."2
The authors addressed these remarks to caseworkers. However, this
study applying PSTT in a clinic setting included three clinical
psychologists and four caseworkers.

These two statements from the authors of the book in which
the research model is defined, epitomize the two foci of the study.
Does this experiment using the Reid and Epstein model of PSTT
demonstrate that treatment can be effective and efficient? Does
the research support the model in showing that some client problems
are suitable for PSTT and some are not?

The study did demonstrate that therapy outcome can remain

constant when using PSTT g£_conventional, open-ended therapy as a

treatment method. Since the PSTT treatment was accomplished in

 

1Reid and Epstein, jacket. 2Ibid., p. 54.

106

107
less time, that method represents efficiency and effectiveness for
certain settings and types of client problems.

The individual therapists during one treatment phase, and
the researcher during one other phase, distributed client problems
into various categories within and outside of Reid and Epstein's
PSTT typology. This operationalized the structural characteristic
of the model's suitability for some client problems and unsuitability
for others.

Therapy outcome research is complicated, expensive and
usually ambiguous because of the difficulty of keeping variables
constant. However, the increasing emphasis on accountability,
the need to extend treatment services to more and more unserved or
poorly served groups, and the escalating cost of treatment make
PSTT programs desirable and necessary; but their value must be
demonstrated by objective studies and hard data.

There is a need to test forms of PSTT with minority groups,
the aged, and other distinctive groups. If control groups are used
in such studies (and many researchers believe that studies have
limited validity without them), care should be taken to keep the
PSTT and the contrasting method as "pure" and free from cross-
contamination as possible. Some form of specific contrast is
needed in both phases to provide baselines for measuring the
accomplishment of goals. The debate over the efficacy of treating
symptoms versus treating the whole person goes on and may never
be settled. However, the utility of treating symptoms must be

more thoroughly tested by well-designed studies. Staffs which

108
attempt a differential approach to treatment such as PSTT need
careful training which includes open discussion to help them
overcome prejudice against a different methodology. Related to
this is the question of whether the client or the therapist is the
best definer of what the problem is and what successful treatment
is. There is also continuing disagreement on the role of the
therapist--how active he or she should be, whether or not any
advice should be given, etc. These and other questions make the
worth of studies such as this one depend to a large extent on
value judgments related to the theoretical orientation of the judge.

This author's initial interest in PSTT developed out of
necessity-~a limited work assignment in a treatment center which
forced the setting of time limits and limited goals for individual
cases. That experience and this study, which was prompted by that
experience and the ratio of the Clinic's therapy needs to its
resources, have been truly rewarding and have permanently shaped
the basic counseling style of the writer.

PSTT offers the busy therapist an efficient mode of treat-
ment that perhaps can be applied even beyond the limits of the
Reid and Epstein model. To the counselor who does not want a new
mode, PSTT offers many objective and client-centered components
and characteristics that can enrich an eclectic approach. Examples
of these are the use of the treatment contract and more active
and focused goal-setting and direction for treatment dictated by

time limits.

APPENDICES

APPENDIX A

RESEARCH FORMS

FORM 1

RATING SHEET

Pre-Study [ ]

Study [ ]

Coordinator [ ]

Worker [ ]

Client [ ]

Number of Case Date

 

 

I now see the problem we agreed to work on as:

(l) Aggravated (worse) [ ]
(2) Unchanged [ ]
(3) Slightly Alleviated [ ]

(a little better)

(4) Considerably allevi-
ated (much better) [ ]

(5) Target problem no longer
exists [ 1

Please mark the box in front of the words that come closest to
expressing your opinion.

109

FORM la

COVER LETTER FOR RATING SHEET

BLUE WATER MENTAL HEALTH AND CHILD GUIDANCE CLINIC
1501 Krafft Road
Port Huron, Michigan 48060
Telephone: 985-5125

Mrs. Alice McKinnon Charles N. Hoyt, M.D.
Director Psychiatric Consultant

Dear

Within the last few months, you came to this clinic for
counseling. We are now trying to find out from those who have
been to the clinic whether or not they found the service helpful.

Would you please mark an X in one of the boxes on the
enclosed rating sheet and return it in the stamped, addressed
envelope? Your prompt cooperation will be greatly appreciated
and will help us evaluate our service in order to improve it.

Your response will be kept confidential. The information
will be reviewed by Reger C. Smith, Study Coordinator.

Sincerely yours,

Worker

110

FORM 2

CASE SUMMARY SHEET

SUMMARY SHEET FOR DIRECT SERVICES

 

DEFINITION OF PROBLEM:

 

TREATMENT DESIGN: (Planned Short Term or Open-ended treatment:
patient and family members involved; individual,
group, family, conjoint or Workshop, Specify:
Consultation with other Community Agencies.)

 

111

FORM 2a

GOALS: (Specify)

CLOSING ASSESSMENT (include length of treatment, no. of interviews
improved, etc.)

 

112

FORM 3

DATA SHEET

Name Case Number

Age

0-5
5-1
13-
19-

Ref

Pro

a.

b.

 

Name of Worker

 

 

 

 

Category Dates
( ) First Interview
2 ( ) Recontract
l8 ( ) Final Interview
( )

erral Source

 

blem Category

Interpersonal conflict (
Dissatisfaction in social relations (
Relations with formal organizations (
Role Performance (
Social transition (
Reactive emotional distress (

Family Income

Und

Rac

Whi

er $8,000 ( )

e

te ( ) Black ( ) Other

Number of treatment interviews

Rat

Cli

$8,000 and over

 

History of Problem

Less than 3 months (
3 months to 1 year (

more than 1 year (

h. Neuroses

Personality
disorders

j. Drug addiction

V v V V V V
p.
O

k. Character disorders

1. All not in a-k

( )

)

 

 

Core . . . . . . . . »
Collateral , , , , , , , ,
ings
ent Worker Independent Rater

 

 

113

)

 

g. Inadequate resources (

(

AAAA

V

VVVV

FORM 4

MASTER CONTROL SHEET

CHECK

CHECK

WORKER

 

JBBHS
Surusg IBMJOM

 

panaIdmog
naaqs eneq

 

axenuj

 

nuerto
imoz; pauznaau

Jeans Surnea

 

IIPO auoqg
Klonsiedaig

 

panatdmoo
:aaqs Kismmns

 

naaqs
9390 ternrul

 

(Kpnns-ala)
NOIIVHTVAH

 

LflfllS

 

 

filer

 

OIQDDOJL

 

xaqsrg

 

anrum

 

sSSag

 

senor

 

uosxapuv

 

uouurxon

 

 

 

Case Number

 

 

 

 

 

 

114

 

 

 

 

 

 

 

 

 

APPENDIX B

RAW DATA

RAW DATA

 

oaooSH
Hmuuomom
moSJ
uSovSmmovSH

Soxuozi

Ratings

namaHo

mBmH>umuSH
Ho nooaSzl

huowmumu
amHnoum

amHnoua
Ho huoumHm

mw<

HHmm Soz\HHmL

 

16 17 18 19 20 21

10 11 12 13 14 15

8 9

7

Column 123456

 

1-11 1-120 1-5 1-5 1-5 1-3 1-4 1,2

1,2 1,2 1-4 1-3

Desig.

 

227.21112121212211221221111121..

11442222 2

1111111111

3351432214444

3333333543

3 [43/422443

2440222287

0001000100

0000000000

22663141611

0000000000

3333333223

44222332 2

1111111111

1.1.1.1.
22222231222212122231 211
1.111.111.11111.111111111111111111111. 11111.1.
.513,4nznz.4n3.3x3,4.4.4n2.3n2.3n2.4n3n3q3n2
1.7.6.7.230202.332.J.J,5,4.4nznznz.4.1.4nz.4.3n2
9.1.1.13 5.1.4. .5

3 42 555

216331159744447435662242

000001000000000000000000

000000000000000000000000

64/... 16464411222261242422

000 00000000000000000000

233332333322332233333323

332231242321444322243343

llllllllllllllllllllllll

111111111111111111111111

583387121219557341085996
219334081568857851116457
798332328227022222222422
424555534554233555555333
111111151111555111111155
000000000000000000000000
123456789012345678901234
111111111222222222233333

115

116

 

maoocH
Hmuummmm
mama
unwvcmamvaH
S
m. um no
.1 x 3
a
R uamflnu

m3mfi>umuaH
mo umnasz

%uow0umu
amanoum

amanoum
mo huoumam

mm<

98mm coz\HHmm

unoo\axm

Case
Number
Column 123456

 

16 17 18 19 20 21

10 11 12 13 14 15

8 9

7

 

1-11 1-120 1-5 1-5 1-5 1-3 1-4 1,2

1,2 1,2 1-4 1-3

Desig.

 

111122112121112111121211122221221112221

13113222422134 2 7.2222214224131221 2111/...

11.1111131111111...1111111111111111111111111

6.444336342243224 4334343 4.544323432544145

4445/4433 2I...32452424434334.414433354344444

4445 13 [.../445 55 I44]... I44 444/435 5 245

7221626011473432277554654525044632 55802

000000010000000000000000000101000 00013

000000000000000000000000000000000 00010

611611244114166114141214641426136111166

000000000000000000000000000000000000000

2221333332333 123 322233222323313 32332

412423341143431223 223/44 22434224 24 I42

111.111.111.111.1.11111.1.1.1.1.1.1.111.111.111.1.11111.1.1.1.1.1.1.11111.1.1.

117

 

waoua
Hmuummm
mom
uamvammmva

umxuo

Ratings

uamfial

m3mw>umuc
mo Hugs:

huowmum
amanou

amanou
mo huoumfi

mm

88mm coz\HHm

uaoo\mx

r
.m
m
n"

Case

 

 

16 17 18 10 20 21

10 11 12 13 14 15

8 9

7

Column 123456

 

1-5 1-5 1-5 1-3 1-4 1,2

1-120

1-11

1,2 1,2 1-4 1-3

Desig.

 

222111211122111222211222112222111111le2

2 1121323121223222121222222323222111111

1111111111111111111111111.111111111111131

44543222324242224343 34332 323345345433

5544/4332224342332445355232333234323323]...

45433 24 43 2 443/4534 4233444454 [.../4

009092539258934845855246021352255202170

420100000000000000010000102000011021002

000000000000000000000000000000000000000

I422211212626lbw/4266146464666[466413464212

000000000000000000000000000000000000000

33233333332333322133322322333333333 233

I44 42432343424432244423223222233 [4444/44

111111111113111111111111111111111111111

542507747625835598465983258400130497409
08979624058134.7822362654980935356351610
70678788917980089911111199889378880011].
1200404443414334443135554.444444440933333
555515111515155111555111111111111555555
000000000000000000000000000000000000000
567890123456789012345678901234567890123
77777888888888899999999990000000000111...l

11111111111111.—

118

 

maouaH
Hmuummmm
mama
ucmvammmuaH

uwxuoz

Ratings

uamfiao

mBmH>umucH
mo umnanz

muowmumo
amanoum

amanoum
mo huoumfim

ow<

HHmm aoz\HHmm

uaoo\mxm

A

Column 123456

Case
Nugget

 

16 17 18 19 20 21

10 11 12 13 14 15

8 9

7

 

1-11 1-120 1-5 1-5 1-5 1-3 1-4 1,2

1,2 1,2 1-4 1-3

Desig.

 

122111121121122222111221211111121122112
ll 2 7.311342222211131233242222221211111
11111111111111111111lllllllllllllllllll
34433324142443334414444432143444433342 244
34./43333342I4333334144444424.443433333424244
[43/4423 I4 34 3 53 [.../4144414424033]... 1454353

471128335005578633703016172299051925 68
01000000011001000001001000110040210O 00

000000000000000000000.100000000000000 00
246664411161644411161644624422141211141
000000000000000000000000000000000000000
333 23333333232333223323122 [43333333 33
4432324/4442322224444433332121123433 I44

lllllllllllllllllllllllllllllllllllllll

5282961685305752 4127451074732276082491
3278114986608158572835732023155352814.1071
114011007072181311101399189999510491200
334355330245545433333244444444453443333
551111555511111155555111111111115115555
000000000000000000000000000000000000000

119

 

maoocH
kuummmm
mama
“WmvamawvcH

umxuoz

Rating

unmaao

m3ma>umuaH
mo Hwnasz

muowmumo
amanoum

awanoum
mo huoumfim

mw<
98mm aoz\HHmm

uaoo\axm

Case
Number

Column 123456

16 17 18 19 20 21
1-5 1-5 1-5 1-3 1-4 1,2

1-120

10 11 12 13 14 15
1-11

8 9

7
1,2 1,2 1-4 1-3

 

 

 

Desig.

1.1222111222221le121

12211

11111111111111111113

23442

23542

255

3246541751

1101000002

0000000000

11661154691946460646

00000000000000001000

3313 33

43244211133222323322

11111222222222222222

2332232

11122121 2121221122

1111111111111111111

l3 70723141962627.1109

00 07.300000000010011.

00 0000000000000000

1566904469906465246

0000010000010000000

313 32332 3333 23 3

2222 32232333323231

120

 

maoonH
Hmuummmm
comm
ucmwamamvaH
8
mo “31.83
.1
t
a
R

uawwao

mBmH>umunH
mo umaasz

huommumo
amanoum

amanoum
mo muoumfim

mw<
99mm coz\HHmm

uaoo\axm

Case
Number
Column 123456

 

16 17 18 19 20 21

10 11 12 13 14 15

8 9

7

 

1-11 1-120 1-5 1-5 1-5 1-3 1-4 1,2

1,2 1,2 1—4 1-3

Desig.

2112212221122211221112121121111121221111

121111111111111111211

495636

000000

000000

15636951

00000000

00000000

9.7.1.1.A.1.A.1.11

111111111111111311

3514343453

344343333

35 5

345386141222132440858793

110304100100010021000000

000000000000000000000000

 

0166814.46641456652411092651256969198889981

1100000000000000000000000000000100000001

3 2221132323333333333233313332 23423
3 7.23242333323642233223234244444334444444

2222222222222222222222222222222222222222

1111111111111111111111111111111222222222

9958002783748933453510264944786237496819
6315486850228180615014838977873878487039
3333373229333313382332322222222970110011
5555545534455555535555555533333443333333
1111011111111111111111111.155555115555555
0000000000000000000000000000000000000000
2345678901234567890123456789012345678901
9999999900000000001111111111222222222233
1111111122222222222222222222222222222222

121

 

maooaH
Hmuummmm
mama
uwmvcmamvcH

umxuoz

Rating

unoHHo

m3ma>umudH
mo umnaaz

knowmumo
amanoum

amapoum
mo mucumfim

mwd

HHmm GOZ\HHmm

udoo\axm

Case
Number
Column 123456

 

16 17 18 19 20 21

10 11 12 13 14 15

8 9

7

 

1-11 1-120 1-5 1-5 1-5 1-3 1-4 1,2

1,2 1,2 1-4 1-3

Desig.

 

121212211111212221111121112111111111221

11331123111111132214311 23333221 111313

111111111111111111111111111111111111111

[.../44.322432354342344]... 3342342224343544433

334332442344232433443342333224334434324

4 535 I4 4 3]... 5344444335 I... 5 3414/4/43 l4

451213950474102057055486224229253073533

000000001050050003447000010007031102100

000000000000000100000000000000110000000

909099091009998999999981881111899998089

010100101110000000000001001111000000100

33123 32 333233 233333 3232333343333332

44334432444444.4222 2443423233444444 343

212222222222222222222222222222222222222

BIBLIOGRAPHY

BIBLIOGRAPHY

Adler, Gerald, M.D., and Myerson, Paul G., M.D., eds. Confrontation
in Psychotherapy. New York: Science House, 1973.

 

 

Alexander, Franz, and French, Thomas. Psychoanalytic Principles and
Application. New York: Ronald Press, 1946.

 

 

Alexander, Franz. "Psychoanalytic Contributions to Short-term
Therapy." Short-term Psychotherapy. Edited by Lewis Wolberg.
New York: Grune and Stratton, Inc., 1965.

 

Barten, Harvey, M.D., ed. Brief Therapies. New York: Behavioral
Publications, Inc., 1971.

 

Batten, Harvey and Barten, Sybil S. Children and Their Parents in
Brief Therapy. New York: Behavioral Publications, Inc.,
1973.

 

 

Ballard, Robert G., and Mudd, Emily H. "Some Sources of Difference
Between Client and Agency Evaluation of Effectiveness of
Counseling." Social Casework 39 (1958).

 

Bellak, Loepold, et a1. "Factors Related to Improvement in Brief
Psychotherapy." An Evaluation of the Results of the Psycho-
therapies. Edited by Lesse Stanley. Springfield, 111.:
Charles Thomas Publishers, 1968.

 

, et al. "An Experimental Study of Brief Psychotherapy."
Lesse, Stanley, M.D., ed. An Evaluation of the Results of
the Psychotherapies. Springfield, 111.: Charles C.
Thomas, 1968.

 

 

 

, and Small, Leonard. Emergsngngsychotherapy and
Brief Psychotherapy. New York: Grune and Stratton, 1965.

 

 

 

Berenson, Bernard G., and Carkhuff, Robert R., eds. Sources of
Gain in Counseling and Psychiatry Psychotherapy. New York:
Holt, Rinehart, and Winston, 1967.

 

 

Bergin, Allen, and Garfield, Sol. Handbook of Psychotherapy and
Behavior Change. New York: John Wiley and Sons, Inc.,
1971.

 

 

, and Strupp, Hans. ChanginggFrontiers in the Service
of Psychotherapy. Chicago: Aldine and Atherton Publishing
Co., 1972.

 

 

122

123

Bloom, Bernard. "Definitional Versions of the Crisis Concept."
Journal of Consulting Psychology 27:6 (1963).

 

Chasson, J. B. Research Design in Clinical Psychology and
Psychiatry. New York: Appleton-Century-Crofts, 1967.

 

 

Eysenck, Hans. "The Effects of Psychotherapy." Journal of
Consulting Psychology 16:1 (1952).

 

, ed. Handbook of Abnormal Psychology. New York:
Basic Books, Inc., 1961.

 

 

Ferguson, George A. Statistical Analysis in Psycholggy and Edu—
cation. New York: McGraw-Hill, 1976.

 

Garfield, Sol. "Research on Client Variables in Psychotherapy."
Handbook of Psychotherapy and Behavior Changs. Bergin,
Allen and Garfield, Sol. New York: John Wiley and Sons,
Inc., 1971.

 

Glasser, William. Reality Therapy. New York: Harper and Row,
1965.

 

Goodman, Nathaniel. "The Use of the Movement Scale with Brief
Recording." Social Casework 39:5 (1968).

 

Gottschalk, Lewis, M.D. "An Introductory Outline of a Short Method

of Psychotherapy." Journal of Nervous and Mental Disease
110:3 (1933).

 

; Mayerson, Peter, M.D., and Gottlieb, Anthony A., M.D.
"Prediction and Evaluation of Outcome in an Emergency
Brief Psychotherapy Clinic." Journal of Nervous and Mental

Disease 144:2 (1967).

 

 

, and Auerback, Arthur, M.D. Methods of Research in
Psychotherapy. New York: Appleton-Century-Crofts, 1966.

 

 

 

Greenwald, Harold, ed. Active Psychotherapy. New York: Atherton
Press, 1971.

 

Guthiel, E., M.D. "Psychoanalysis and Psychotherapy." Journal of
Clinical Psychopathology and Psychotherapy 6 (1944).

 

 

Hart, J. T., and Tomlinson, T. M. New Directions in Client-

Centered Therapy. Boston, Mass.: Houghton Mifflin Co.,
1970.

 

 

Haskell, David, M.D.; Pugatch, Donald, M.D.; McNair, Douglas M.,
M.D. "Time Limited Psychotherapy for Whom."

124

Hays, William L. Statistics for the Social Sciences. New York:
Holt, Rinehart and Winston, 1973.

 

Hock, Paul. "Short-term Versus Long-term Therapy." Short-term
Psychotherapy. Edited by Lewis WOlberg. New York:
Grune and Stratton, Inc. , 1955.

 

 

Isaac, Stephen and Michael, William. Handbook in Research and
Evaluation. San Diego, Calif.: Edits Publishing, 1971.

 

 

Jurevich, Ratibor-Ray, ed. Direct Psyshotherapy. Vol. I. Coral
Gables, F1a.: University of Miami Press, 1973.

 

, ed. Direct Psyshotherapy. Vol. II. Coral Gables,
F1a.: University of Miami Press, 1973.

 

 

Kaplan, David. "Observations on Crisis Theory and Practice."
Social Casework 49:3 (1968).

 

Keisler, Donald J. "Experimental Designs in Psychotherapy Research."
Handbook of Psychotherapy and Behavior Chasgs. Edited by
Allen E. Bergin and Sol L. Garfield. New York: Wiley and
Sons, Inc., 1971.

 

Kerns, Elizabeth. "Planned Short-term Treatment, a New Service to
Adolescents." Social Casework 51:6 (1970).

 

Kogan, Leonard. "The Short-term Case in a Family Agency, Part I."
Social Casework 38:5 (1957).

 

"The Short-term Case in a Family Agency, Part II."
Social Casework 38:6 (1957).

 

 

. "The Short-term Case in a Family Agency, Part 111."
Social Casework 38:7 (1957).

 

 

Korner, Harold, M.D. "Abolishing the Waiting List in a Mental
Health Clinic." Social Work 13:3 (1964).

 

Krause, Merton S., Ph.D. "Predicting Client Discontinuance at
Intake." Social Casework 43:6 (1962).

 

Krick, Aaron. "Active Strategies in Marriage Counseling." Active
Psychotherapy. Edited by Greenwald. New York: Atherton
Press, 1967.

 

Lesse, Stanley, M.D., ed. An Evaluation of the Results of the
Psychotherspies. Springfield, 111.: Charles Thomas
Publishers, 1968.

 

125

Lester, David, Ph.D., and Brockopp, Gene W., Ph.D., eds. Crisis
Intervention and Counseling_by Telephone. Springfield, 111.:
Charles C. Thomas Publisher, 1973.

 

Levy, Sheldon G. Inferential Statistics in the Behavioral Sciences.
New York: Holt, Rinehart and Winston, 1968.

 

Lewin, Karl, M.D. Brief Encounters: Brief Psychotherapy. St.
Louis, Mo.: Warren H. Green, Inc., 1970.

 

Long, Judith, "Planned, Short-term Treatment in a Family Agency."
Social Casework 55:6 (1974).

 

Malan, David. The Frontier of Brief Therapy. New York: Plenum
Publishing Corp., 1976.

 

Maliccio and Marlow. "The Case for the Contract." Social Work
19:1 (1974).

 

McGee, Richard K., Ph.D. Crisis Intervention in the Community.
Baltimore: University Park Press, 1974.

 

McGuire, Michael, M.D. "The Process of Short-term Insight Psycho-
therapy." The Journal of Nervous and Mental Disease 141:1
(1965).

 

. "The Process of Short—term Insight Psychotherapy,
Part 11, Content, Expectations and Structure." The Journal
of Nervous and Mental Disease 141:3 (1965).

 

 

 

Meltzoff, Julian, and Kornreich, Melvin. Research in Psychotherapy.
New York: Atherton Press, 1970.

 

Nebl, Nikolaus. "Essential Elements in Short-term Treatment."
Social Casework 47:197.

 

Normand, William, M.D.; Fensterheim, Herbert, Ph.D., and Schrenzel,
Susan, M.S.S.W. "A Systematic Approach to Brief Therapy
for Patients from a Low Socio-Economic Community."
Community Mental Health Journal 3:4 (1967).

 

Orley, Genevieve B. "Short-term Therapy with Student Couples."
Social Casework 5:4 (1973).

 

Parad, Howard. "The Use of Time-Limited Crisis Intervention in

Community Mental Health Programming." Social Service Review
42:3 (1966).

 

Parad, Libbie. "Short-term Treatment, an Overview of Historical
Trends, Issues, and Potentials." Smith Collsge Studies in
Social Work 41:2 (1971).

 

126

Parad, Howard and Parad, Libbie. "A Study of Crisis-Oriented
Planned, Short-term Treatment." Social Casework 49:6
(1968).

 

Parad, Libbie and Parad, Howard. "A Study of Crisis-Oriented
Planned, Short-term Treatment, Part II." Social Casework
49:7 (1968).

 

Pesso, Albert. Movement in Psychotherapy. New York: University
Press, 1969.

 

Phillips, E. Lakin and Johnson, Margaret. "Theoretical and
Clinical Aspects of Short-term Parent-Child Psycho-
therapy." Psychiatry 37:8 (1954).

 

and Wiener, Daniel. Short-term Psychotherapy and
Structured Behavior Changs. New York: McGraw-Hill Book
Co., 1966.

 

 

 

Rapaport, Lydia. "Crisis-Oriented Short-term Casework." Social
Service Review 41:1 (1966).

 

Raynes, A. E., M.D. and Warren, G., M.S. "Some Distinguishing
Features of Patients Failing to Attend a Psychiatric Clinic
After Referral." American Journal of Orthopsychiatry (1971).

 

Reid, William and Epstein, Laura. Task-Centered Casework. New
York: Columbia University Press, 1972.

 

and Shyne, Ann. Brief and Extended Casework. New York:
Columbia University Press, 1969.

 

 

Reznikoff, Marvin, and Tommey, Laura. Evaluation of Changes
Associated with Psychiatric Treatment. Springfield, Ill.:
Charles C. Thomas, Publisher, 1959.

 

 

Rosenbaum, Peter, M.S. "Events of Early Therapy and Brief Therapy.‘
Archives of General Psychiatpy 10 (1964).

 

Rosenburg, S. Prola; Meyer, M.; Zucherman, M.; Bellak, L. "Factors
Related to Improvement in Brief Psychotherapy." An Evalu-
ation of the Results of the Psychotherspies. Edited by
Stanley Lesse, M.D. Springfield, 111.: Charles Thomas,
Publishers, 1968.

 

Sargent, Helen W.; Horwitz, Leonard; Wallerstein, Robert S., and
Appelbaum, Ann. "Prediction in Psychotherapy Research."
In Psychological Issues 6:1 (Monograph 21, 1968).

Sellers, Lyn, et a1. "Pretesting Methods for Follow-up to Validate
Mbvement in Casework." Social Casework 35:7 (1954).

 

127

Shaw, Robert; Blumfield, Harry; and Senf, Rita. "A Short-term
Treatment Program in a Child Guidance Clinic." Social
Work 17:7 (1968).

Sifneos, Peter. Short-term Psychotherapy and Emotional Crisis.
Cambridge, Mass.: Harvard University Press, 1972.

Singer, Erwin. Key Concepts in Psychotherapy. New York: Random
House, 1965.

Small, Leonard. The Briefer Psychotherapies. New York: Brunner/
Mazel Publishers, 1971.

 

Sonquist, John A. Multivariate Model Buildipg. Ann Arbor,
Michigan: Brown and Brumfield, 1970.

 

Stein, Morris L. Contemporary Psychotherapies. New York: The
Free Press of Glencoe, 1961.

 

Stollak, Gary E.; Guerney, Bernard G., Jr., and Rothberg, Meyer, eds.
Psychotherapy Research. Chicago: Rand McNally and Co.,
1966.

 

Strupp, Hans. "The Outcome Problem in Psychotherapy Revisited."
Psychotherapy: Theosy, Research and Practice 1:1 (1963).

 

Wilson, Robert S. The Short Contact in Social Caseworky Volume I.
New York: National Association for Travelers Aid and
Transient Service, 1937.

 

. The Short Contact in Social Casework1 Volume II. New
York: National Association for Travelers Aid and Transient
Service, 1937.

 

 

Winer, B. J. Statistical Principles in Experimental Design. New
York: McGraw-Hill Book Co., 1971.

 

Wolberg, Lewis, ed. Short-term Therapy. New York: Grune and
Stratton, Inc., 1965.

 

The Technique of Psychotherapy, Part II. New York:
Grune and Stratton, 1967.