As a therapist I’ve never subscribed to the ‘you need to do X number of sessions with me’ school of thought. Over the course of the years I’ve noticed that there is no set pattern. Some people are helped with just one session, others come more regularly, and others fall into all the variations in between. I’ve always put this down to the way I work with people: I translate what their body and energy system is trying to tell them so that every session is tailor-made. So I was very interested to unearth some findings on ‘brief but intensive’ therapies for this month’s On the Border.
Psychotherapy is not what most people think of as a quick fix. From its early Freudian roots, it has taken the form of 50- to 60-minute sessions repeated weekly (or more often) over a period of months or even years. For modern cognitive-behavioural therapy (CBT), 10 to 20 weekly sessions is a typical trajectory. But must it be so?
For nearly 20 years Thomas Ollendick, director of the Child Study Center at Virginia Tech, has been testing briefer, more intensive forms of CBT for childhood anxiety disorders and getting results that closely match those of slower versions. His centre often has a waiting list for treatments that include a four-day therapy for obsessive-compulsive disorder (OCD) and a three-hour intervention for specific phobias (such as fear of flying, heights or dogs). Around the U.S. and Europe, short-course therapies for anxiety disorders have begun to catch on, creating a new movement in both adult and child psychology.
The idea originated with Swedish psychologist Lars-Göran Öst, now professor emeritus at Stockholm University. Some 40 years ago Öst got the impression that not all his phobia patients needed multiple weeks of therapy and decided to ask if they would like to try a single, three-hour session. His first taker was a 35-year-old spider-phobic woman. She lived five hours away and was happy to be able to be treated in one go. He later showed the efficacy of the approach in a clinical trial, although it took four years to recruit 20 participants. The reason it took so long was, he discovered, that people with a specific phobia rarely apply for treatment. It appeared that they just adjust their lives [say, avoiding spiders] or think they can’t be helped. Öst went on to work with a team in Bergen, Norway, to test an intensive therapy for OCD known as the Bergen four-day treatment. By the early 2000s Ollendick was adapting brief therapies for adolescents and kids.
The details vary, but the quick treatments have some common features. They generally begin with “psychoeducation,” in which patients learn about their condition and the catastrophic thoughts that keep it locked in place. In Bergen, this is done in a small group. With children, the lessons may be more hands-on and concrete. For instance, Ollendick might help a snake-phobic kid grasp why the creature moves in a creepy, slithering way by having the child lie on the floor and try to go forward without using any limbs.
A second part usually involves “exposure and response prevention,” in which patients confront in incremental steps whatever triggers their anxiety: perhaps shopping, for agoraphobics, or having dirty hands, for people with OCD. With support from the therapist, they learn to tolerate it and see it as less threatening. Patients leave with homework to reinforce the lessons. Parents may be taught how to support a child’s progress.
How well do these approaches work? A 2017 meta-analyisis by Öst and Ollendick looked at 23 randomised controlled studies and found that “brief, intensive, or concentrated” therapies for childhood anxiety disorders were comparable to standard CBT. With the quicker therapies, 54 percent of patients were better immediately post-treatment, and that rose to 64 percent on follow-up—presumably because they continued to practice and apply what they had learned. With standard therapy, 57 percent were better after the final session and 63 percent on follow-up. The severity of symptoms and whether the patient was also taking antianxiety medication did not seem to impact outcomes.
An obvious advantage to quick therapy is that it accelerates relief. Making these briefer therapies more widely available could help address the sad fact that only about a third of patients with anxiety disorders get any kind of treatment. A weeklong therapy could be completed over a school or work vacation. Sufferers in out of the way places who cannot find CBT nearby could be treated during a short out-of-town stay. The intensive approach requires special training and a big shift for therapists—and health insurers— accustomed to the tradition of 50-minute blocks. But is there really anything sacred about that when it’s the person’s best interest at heart?
REFERENCES:
Lars-Göran Öst. One Session Treatment for Specific Phobias. Behaviour Research and Therapy, 1989, volume 27, issue 1, pages 1-7.
https://www.sciencedirect.com/science/article/abs/pii/0005796789901137
Lars-Göran Öst and Thomas Ollendick. Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 2017, October, pages 134-145.