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The Importance of the
Psychiatric Evaluation in Determining the Efficacy of
Short-Term
Anxiety-Provoking Psychotherapy
Jeffrey W.
Braunstein, Ph.D.
The advent of short-term dynamic
psychotherapy has enabled certain patients who previously would have been placed
in long-term psychodynamic treatment to now be identified and treated with a
short-term model. Patients who suffer from specific psychological disturbances
and who meet specific selection criteria can now be offered a more affordable,
effective, and shorter treatment and may no longer have to endure the costly and
possibly unnecessary road of long-term therapy.
Even though the techniques utilized
in short-term dynamic therapy are primarily based in psychodynamic theory,
short-term dynamic therapy is differentiated from traditional psychoanalysis in
various ways (Demos and Prout, 1993). The authors report that most short-term
dynamic therapies stress the importance of implementing a strict patient
selection criteria. The ability for both the patient and therapist to decide on
one specific issue on which the therapy will focus as well as the types of
problems encountered are extremely important and directly affect the success of
treatment. The duration of short-term dynamic therapy is never longer than one
year, and most treatments are completed within six months. The authors
emphasize that unlike long-term psychodynamic psychotherapy, short-term dynamic
therapy requires the therapist to take a very active role during the course of
treatment. In contrast with long-term psychodynamic and psychoanalytic
psychotherapies, short-term dynamic therapists confront their patients often and
provide frequent interpretations.
Short-Term Anxiety-Provoking
Psychotherapy (STAPP) was developed by Peter E. Sifneos at the Psychiatric
Clinic of the Massachusetts General Hospital in the 1950’s (Budman, 1981). The
importance of the psychiatric evaluation in assessing a patients potential to
benefit from STAPP, and the efficacy of this treatment will be reviewed.
Sifneos (1992) stresses the
importance of the initial psychiatric evaluation in determining which patients
will benefit most from STAPP. There are five components of the psychiatric
evaluation: assessing the presenting problem, obtaining a systematic
developmental history, adhering to a strict selection criteria, acquiring the
patient’s agreement to cooperate in the resolution of their emotional conflict,
and constructing a specific dynamic focus. A thorough psychiatric evaluation
enables the therapist to construct a treatment program that is highly focused
and specific which is essential for the successful outcome of STAPP.
Patients who suffer from anxiety,
depression, grief reactions, chronic procrastination, monosymptomatic phobias,
and interpersonal difficulties are most amenable for STAPP (Sifneos,1992).
Investigating the symptomology, duration, and onset of the patient’s problem
should be the therapist’s first task. Physical symptoms that have a medical
etiology must be ruled out prior to the commencement of treatment (Davenloo,
1992).
Sifneos (1992) emphasizes the
importance of developing an extensive developmental history. Sifneos claims
that the origins of a patient’s psychological problems stem from both their
biological composition and interpersonal experiences during early childhood.
Acquiring an extensive developmental history helps the therapist to construct
the focus of treatment. Sifneos (1992, p.12) gives examples of questions that
are useful to illicit this information: “Which parent do you feel closest to?
Who was the favorite child”? Sifneos stresses that the developmental history
should include information regarding the patient’s relationships with their
siblings and parents. Information regarding a patient’s academic history,
pubescence, adolescence, and adulthood is essential and should be collected to
provide a detailed overview of the patient’s interpersonal functioning. He
emphasizes the importance of using both open-ended and forced choice questions
when inquiring about the patient’s past. Sifneos (1992) uses forced choice
questions to illicit specific information, especially when the information is
sensitive or traumatic in nature. He then uses an open-ended format to expand
on these topics when a therapeutic alliance is established and the patient
becomes more comfortable. Sifneos (1992) emphasizes the importance of following
a patient’s developmental history sequentially.
The extent to which a patient has
endured trauma must be assessed in the developmental history (Sifneos, 1992).
Patients who have endured traumatic experiences such as incestuous relations,
severe physical abuse in childhood, and emotional abuse may require long-term
psychotherapy and may be unamenable to STAPP. Substance abuse coinciding with a
history of trauma further decreases the likelihood that they will benefit from
STAPP. Davenloo (1992) explains that STAPP and other short-term psychotherapies
have a propensity to cause massive regressive deterioration in these patients.
Short term dynamic therapies exacerbate their symptoms and can possibly result
in unnecessary psychiatric hospitalizations. Patients who have attempted any
form of suicide (impulsive, manipulative, or planned) should be excluded from
STAPP and most likely require long-term psychotherapy, Sifneos (1992).
An inquiry concerning sexual
experiences during all stages of development is an integral part of the
developmental history (Sifneos, 1992). Sifneos (1992) believes that sexual
experiences during puberty and adolescence have a profound effect on
interpersonal relations in adulthood. Disruptions, such as incestuous
relations, during these developmental periods impede and hinder normal
characterlogical development. The resulting conflicts and pathology require
long-term psychotherapy.
“An assumption shared by most
experts is that the successful application of short-term dynamic psychotherapy
depends on careful preselection of patients” (Barth, Nielsen, Havik, Haver,
Molstad, Rogge, Skatin, Heiberg, Ursin, 1988, p.153). Sifneos (1992), has
devised five selection criteria that patients must satisfy to qualify for
STAPP.
The first criteria, circumscribing
the patient’s presenting complaints, requires the patient to prioritize and
determine the specific problem that will constitute the focus of therapy
(Sifneos, 1992). Sifneos points out that patients who can demonstrate this
ability have the capacity to compromise and choose. Sifneos has deemed these
abilities to be essential when conducting STAPP. Patients who display these
qualities demonstrate their flexibility and will be open and receptive to the
interpretations from the therapist when treatment commences (Budman, 1981).
The second criteria, the patient’s
involvement in at least one meaningful relationship during childhood, is defined
as, “altruism and the capability of expressing feelings for another person in a
give-and-take way are evidence that the patient reached a level of psychological
maturity at an early age” (Sifneos, 1992, p.23-24). Sifneos (1973) predicts
that a patient who fulfills this criteria is not likely to develop psychotic,
borderline, narcissistic or other severe characterlogical disorders, which are
not amenable for STAPP due to the brevity and duration of the treatment. The
therapist can determine if a patient fits this criteria by inquiring about their
relationship, preference, and closeness toward each parent during childhood.
Sifneos (1992) stresses that the patient must be able to demonstrate that they
have been altruistic in the past. A patient who has engaged in an altruistic
encounter confirms that a significant give-and-take relationship has occurred in
the past. Comparatively, patients who report extreme self-sacrificing behavior
exhibit profuse dependency and insecurity, making them unacceptable for STAPP
due to their characterlogical composition.
Criterion three, a patient’s ability
to interact flexibly with the therapist, requires a patient to have both an
awareness and flexible expression of feelings during the psychiatric evaluation
(Sifneos, 1992). Flexibility when interacting with the therapist demonstrates
that a working alliance has been formed. This working alliance will
subsequently lead to an eventual therapeutic alliance as therapy progresses. An
awareness that treatment is a collaborative experience is essential for the
success of short-term psychotherapy. Without a therapeutic alliance, a patient
will not be able to question and add information to tentative interpretations
and confrontations formulated by the therapist (Budman, 1981).
Criterion four involves the
therapist’s assessment of the patient’s intelligence and “psychologically
mindedness” (Sifneos, 1992). Patients who are psychologically minded have the
ability to associate fantasies and thoughts with their emotions. In contrast,
patients who are alexithymic are affect deficient. Alexithymics are usually
lonely, isolated and suffer from substance abuse problems. They feel isolated
from the world due to their affect deficits and are prone to develop
psychosomatic illness. If a patient is alexithymic, then they are unfit for
STAPP and require long-term psychotherapy.
Criterion five involves the
therapist’s assessment of a patient’s motivation and willingness for change
(Sifneos, 1992). Sifneos explains that patients who fulfill this criteria must
have the ability to realize that their problems are psychological and must
participate actively in therapy. Patients further satiate this criteria if they
both accept that they may have to experience loss or pain when resolving their
focal problem and have realistic expectations regarding the outcome of therapy.
Patients must have the capacity for introspection. Sifneos suggests that a
patient’s willingness to change can be measured and evaluated by their
willingness to take the time to participate in research. Their commitment to
therapy with no guarantees concerning the outcome of treatment further measures
willingness for change.
Sifneos (1973), has constructed a
forced-choice questionnaire that can be used by clinicians to evaluate a
patient’s capacity to fulfill the selection criteria. The questionnaire assess
a patient’s self esteem, and can determine whether the patient is experiencing
an emotional crisis or external stressor. Both Sifneos (1973), and Barth,
Havik, Nielsen, Havir, Molstad, Rogge, Skatun, Heiberg, and Ursin, (1988) agree
that a patient’s suitability for STAPP should be assessed along two dimensions:
resources and motivation. Barth et al. (1988) have determined that the resource
dimension is most affected by the first four selection criteria, and that the
fifth selection criteria, motivation and willingness to change, is a separate
dimension that measures the patient’s ability to function adequately in
treatment.
Barth, Havik, Nielsen, Havir,
Molstad, Rogge, Skatun, Heiberg, and Ursin (1988) suggest that the motivation
dimension should be split into 2 separate parts: motivation for psychotherapy
and motivation for change. The authors regard motivation for psychotherapy as a
patient’s desire to seek relief from the symptoms caused by their psychological
disturbance. Comparatively, motivation for change involves the patient to take
an active responsibility for the therapy (Barth et al., 1988). Patients who are
motivated to change rely on their own resources rather than depending solely on
the therapist. Barth et al. (1988), suggest that a patient’s motivation for
psychotherapy should not automatically imply that the patient exhibits a desire
and motivation to change. Patients who exhibit a great desire to change
increase the likelihood that they will benefit from STAPP (Danvenloo, 1992).
Viewing this dimension from this perspective will assist clinicians in further
determining the suitability for patients to benefit from STAPP .
After a patient satisfies the
requirements for selection criteria, the therapist then determines what main
conflict, otherwise known as the dynamic focus, underlies the psychological
difficulties affecting the patient (Sifneos, 1992). The foci that respond best
to STAPP are unresolved Oedipal or Triangular relationships, grief reactions,
and loss/separation issues. An agreement between therapist and patient
concerning the resolution of the determined conflict is essential for therapy to
commence. Sifneos mentions that the inability of a qualified and well trained
therapist to arrive at a dynamic focus by the conclusion of the third session is
indicative of a patient who is unamenable for STAPP.
During the course of conducting outcome research to determine the
efficacy of STAPP, Sifneos, Apfel, Bassuk, Fishman, and Gill (1980) have found
that patients who benefited least were those whose dynamic focus centered on
separation or loss. Sifneos et al. (1980) have observed that when the therapist
suggested the termination of treatment, the partially unresolved conflicts of
separation and loss re-emerged resulting in a relapse of symptomology. Sifneos
et al. (1980) have instead decided to conduct outcome research on patients whose
dynamic focus primarily involved unresolved oedipal conflicts due to their
success in treatment.
Sifneos, Apfel, Bassuk, Fishman, and
Gill (1980) conducted an experiment with 30 subjects in which their dynamic foci
were unresolved oedipal conflicts. 22 subjects were placed in an experimental
group and received STAPP. The other eight subjects were placed in a control
group and did not receive any form of treatment. Sifneos et al. (1980)
implemented a scoring system that utilized a nine point scale and specific
criteria to determine the outcome of treatment. “A score of 6 or 7 denotes
‘recovery,’ 4 or 5 signifies ‘much better,’ 2 or 3 means ‘a little better,’ and
-1,0 or 1 designates ‘unchanged’ or ‘worse’” (Sifneos et al., 1980 p.235). Upon
the completion of treatment, 14 out of the 22 patients in the experimental group
were classified as ‘recovered,’ four patients were classified as ‘much better,’
three patients were ‘a little better,’ and only one patient remained
‘unchanged’. Five of the subjects in the control group were unchanged and three
were classified as ‘a little better’. At the conclusion of the experiment, the
control group was treated with STAPP. Four of the patients in the control group
were ‘recovered’, and two were ‘much better’. The remaining two subjects
dropped out of the study and did not receive STAPP. This study provides
evidence that STAPP is a highly effective treatment for patients whose
unresolved oedipal conflicts are the focus of treatment.
Sifneos (1984), attempted to
determine the efficacy of STAPP with 14 neurotic patients who complained of
physical symptoms that did not have a medical etiology. The dynamic focus for
all the patients in this study involved unresolved oedipal conflicts. Sifneos
used nine outcome criteria for assessing improvement: changes in physical and
psychological symptoms, interpersonal relations, self-esteem, new learning,
problem solving, self understanding, development of new attitudes, and work
performance. The range of physical symptoms that these patients suffered from
were headaches, diarrhea, insomnia, impotence, pain, cystitis, overeating,
migraines, tremors, anorexia, and skin irritations. Results of this outcome
study indicated that a significant improvement was found for 13 out of 14
patients in both their psychological and physiological concerns. The
implications for this study are broad because 50% of all patients who visit
physicians complain of physical symptoms that are psychological in origin.
Sifneos suggests that if physicians are made aware of these findings, they can
refer future patients for STAPP instead of unnecessarily medicating physical
symptoms that are psychological in origin.
Short-Term Anxiety-Provoking
Psychotherapy is efficacious but has its limitations. The range of both the
psychological disturbances that STAPP can be used for and the populations that
are amenable to treatment are severely limited. Only if a patient is able to
“survive” the psychiatric evaluation, is he/she qualified to receive this form
of psychotherapy. Lowering the standards for preselection would most likely
lessen the impact and efficacy of STAPP but would allow more patients to qualify
for treatment.
References
Barth, K., Havik, O. E., Nielsen,
G., Brit, H., Molstad, E., Rogge, H., Skatan, M., Heiberg, N. A., & Ursin, H.
(1988). Factor Analysis of the Evaluation Form for Selecting Patients for
Short-Term Anxiety-Provoking Psychotherapy. Psychotherapy and
Psychosomatics, 49, 47-52.
Barth, K., Nielsen, G., Havik, O.E.,
Haver, B., Molstad, E., Rogge, E., Skatan, M., Heiberg, A. N., & Ursin, H.
(1988). Assessment of Three Different Forms of Short-Term Dynamic
Psychotherapy. Psychotherapy and Psychosomatics, 49, 153-159.
Budman, S. H. (Ed.). (1981).
Forms of Brief Therapy. New York, New York: The Guilford Press.
Davenloo, H. (Ed.). (1992).
Short-Term Dynamic Psychotherapy. Northvale, NJ: Jason Aronson Inc.
Demos, V.C., Prout, M.F. (1983). A
Comparison of Seven Approaches to Brief Psychotherapy. International Journal
of Short-Term Psychotherapy, 8, 3-22.
Sifneos, P.E. (1973). An Overview
of a Psychiatric Clinic Population. American Journal of Psychiatry, 130,
1033-1035.
Sifneos, P.E., Apfel, R. J., Bassuk,
E., Fishman, G., & Gill, A. (1980). Ongoing Outcome Research on Short-Term
Dynamic Psychotherapy. Psychotherapy and Psychosomatics, 33, 229-236.
Sifneos, P.E. (1984). Short-Term
Dynamic Psychotherapy for Patients with Physical Symptomatology.
Psychotherapy and Psychosomatics, 42, 48-51.
Sifneos, P. E. (1992).
Short-Term Anxiety-Provoking Psychotherapy. United States: Basic Books.
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