Finding depth in short-term psychotherapy
“What is your job?”
This is one of the first questions I pose to clinical students under my supervision. Psychologists are often trained to be the expert in the room: the teacher (or psychoeducator), scholar, scientist, doctor.
But we are not these things.
Yes, we have expertise. But our expertise is in the understanding of human psychology, of patterns and emotions, and not in the arbitration of decisions made by our patients. We are not omniscient, and we do not possess an instruction manual for healthy living. We are experts in the psychology of human beings, but we are totally naïve to the complexities of our patients’ lives.
Until we meet them.
“What is your job?” My answer is straightforward: to be curious about my patient, and to work towards seeing and understanding the patterns of thought, emotion, desire, and personal and cultural values that have crafted them into the human being who sits across from me.
What kind of person is this?
But there is a second part to my answer. I am here to know and understand my patient; they are here to feel better. They are here to change something psychological about themself that has generated – directly or otherwise – an amount of suffering that they no longer wish to tolerate.
Together, these two pillars of my job are what my patients and I use to craft a case formulation. I say “my patients and I” because a formulation cannot exist only in the mind of the therapist. A case formulation is collaborative: a dynamic, ever-changing understanding of the patient’s psychology and what they wish to change in themselves that could lead to something desired, something meaningful, and a life lived with less emotional suffering.
In private therapy, there is no imposed limitation on how long it takes for our formulation to take shape, take hold, and produce lasting and meaningful change. Clinical factors aside, time and money are our only external limitations.
But in healthcare settings – hospitals, publicly funded programs, or structures imposed by insurance companies – we do not have the luxury of time.
16 sessions. Maybe 20. Four or five months is what is typically offered.
16 sessions does not allow much time for navel gazing, and that bellybutton-focused metaphor is precisely what insurers or public health officials are trying to avoid. We should get to work. We should fix those pesky problems.
And get to work we do: short-term psychotherapy is often organized around identifying and reducing symptoms: those easily observed, checklistable behaviours that cause suffering and pain and get in the way of our patients living better lives.
The problem here is that identifying symptoms is not the same as identifying suffering, and the removal of symptoms does not necessarily produce psychological health. Most psychologists know this, but either believe that 16 sessions is all you need to produce long-lasting change or, more commonly, have come to believe that 16 sessions is only enough to address the low-hanging fruit, the most overt symptoms picked up by a Beck Depression Inventory or GAD-7.
Somewhere along the way, many psychologists came to believe that deep psychotherapy equals long-term psychotherapy, and that short therapy must be shallow. This fallacy has produced two opposing camps among psychologists: those who believe that the imposed structure of 16-20 session programs forces a practice of subpar, shallow therapy – that the only way to achieve depth in our work is to make room for that pesky and self-indulgent navel gazing – and those who are convinced that 16-20 sessions are all a person needs to reap the benefits of psychotherapy.
Both conclusions are wrong, but for different reasons.
Good psychotherapy requires depth, but it does not require breadth. Depth is about the level of psychological understanding of the patient (or treatment target); breadth concerns the number of different treatment targets.
The distinction between short- and long-term therapy should not be one of depth, but one of purpose (McWilliams, 1999, 2004). What are you trying to achieve in this course of therapy? If the answer is a fundamental restructuring of a patient’s personality, then 16 sessions will be woefully inadequate (Shedler & Gnaulati, 2020). But if the goal of psychotherapy is to help our patients identify, understand, and modify a psychological pattern that has led to some specific subjective suffering, then a brief course of treatment might just be enough (Abbass et al., 2006). Psychological depth is about what the therapist attends to and how the patient is understood; psychotherapy is “deep” when it is interested in the processes underlying or generating the patient’s suffering (Shedler, 2010). It is not about how much of the patient’s story or experience – his or her content – you attempt to cover.
Good psychotherapy – regardless of its timeframe – does not state “we have 16 sessions to cure your depression.” Instead, it asks: “what kind of person is this, what kinds of patterns have led to this person’s suffering, and what specific changes could we work towards in 16 sessions that could have an impact in your life?” Forget the artificial dichotomy of symptom-focused vs. insight-oriented therapy. Instead, we must ask ourselves: what psychological process is producing or maintaining the symptom, and what can we do to change this process? The goal of brief therapy might then be to identify and interrupt a particular psychological (or interpersonal) cycle. As Paul Wachtel has outlined in his theory of cyclical psychodynamics, therapists and patients can work deeply on specific patterns without attempting a full and complete reconstruction of the patient’s entire personality (Wachtel, 2014).
Good, short-term psychotherapy is focused, but not shallow. Brevity requires selectivity.
Depth, not breadth.
A final word
I make the case here that short-term psychotherapy can also be good psychotherapy, but there is a crucial caveat: 16-20 sessions is not sufficient for everyone. Psychotherapy is not a one-size-fits-all discipline, and we must not accept that one unit of treatment equals x number of sessions. Rather – when freed from the impositions of public health, outside interests, and financial limitations – treatment planning becomes a function of the patient’s psychological organization, his or her unique circumstances, and agreed upon purpose of the work. One unit of treatment should be defined by what we hope to accomplish, not by how many hours it contains.
References
Abbass, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. The Cochrane database of systematic reviews, (4), CD004687.
McWilliams, N. (1999). Psychoanalytic case formulation. Guilford Press.
McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. Guilford Press.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378
Shedler, J., & Gnaulati, E. (2020). The tyranny of time: How long does effective therapy really take? Psychotherapy Networker. https://www.psychotherapynetworker.org/article/tyranny-time/
Wachtel, P. L. (2014). An integrative relational point of view. Psychotherapy, 51(3), 342–349. https://doi.org/10.1037/a0037219