Time Limited Therapy: A Necessary Evil in Contemporary Mental Health Provision?

Brief Therapy and Group Therapy- Assignment two 

Time Limited Therapy: A necessary evil in contemporary mental health provision?’ 

Within this assignment the theatrical framework and assumptions regarding to brief therapies will be analysed and evaluated. The analysis will be based on topics such as political, social, economic and technological factors. Also, within this analytic assignment factors such as issues affecting brief therapy will critically analysed. Also, as ethical challenges a practitioner may face will be explored.  

A necessary evil indicates an act of evil is needed to be done. This will then lead to a beneficial outcome. The expression contemporary mental health provision is an overall term 
for public services such as the NHS (national health service), IAPTS (improving access to psychological therapies) or brief therapies.  

There are many terms used for “time limited therapy” such as brief therapy or short-term therapy (Sledge et al., 1990, Steenbarger, 1992).  These are umbrella terms. The term time limited therapy specifies there will be a time limit on the amount of sessions an individual will receive. Sessions could be between 1 to 25 sessions (Sledge et al., 1990, Steenbarger, 1992). The client will be aware of this from the beginning as it would be stated with the contract at the start (Sledge et al., 1990, Steenbarger, 1992). Time limited therapy tends to have a specified focus. However, Schacht et al (1984) stated even time limited therapy always requires a focal point nonetheless it is not inflexible and the theme can change. He specified it 'does not explain everything 'it is a map, not the territory itself’ (Schacht et al. 1984).  

There are many ways contemporary mental health services have been affected. Factors that have affected mental health services include political, social, economic and technological. These factors have caused issues for individuals when gaining access to therapy. Due to these factors IAPTS was created.  Political activist within psychotherapy such as Bagnall- Oakeley and Juliet Lyons state that with the last 20 years there has been a revival of activist with psychotherapy/ counsellors and psychotherapist due to economic and political pressures such as cutback within mental health funding, the effects of austerity policies and limited jobs for trainee counsellors (Bagnall-Oakeley and Lyons, 2018). This leads to limited support. Researchers such as Elizabeth Cotton (2017) predicted that within the United Kingdom jobs that involve therapeutic professions are rapidly decreasing and mental health services have become more of a “tick box” services (Cotton 2017). Mental health services within the United Kingdom are facing a crisis. However, the government tend to ignore the issue as well the professionals within the sector. Juliet Lyon stated, “If we are constantly badgered into being more money efficient, we will lose the basic security and trust in what we do that enables therapeutic practice to flourish.” (Bagnall-Oakeley and Lyons, 2018)  

Other factors such as the austerity program have caused many issues within the mental health services as well as issues for gaining accesses to these services. Due to the cutbacks within the mental health services and the increased awareness around mental health issues such as there are small number of professionals and an increasing number of patients/clients (CQC 2017). This could be potentially harmful. In May 2017 the Care Quality Commission stated “34% of independent core services were rated as requires improvement for safe” (CQC 2017). Other organisations such as The Kings Fund concluded that the “NHS mental trust are struggling to staff existing staff services on a day-to-day basis and while the action to implement safe staffing levels….” (Gilburt 2018. This could lead to ethical issues due to clients/patients potentially being harmed within the process and practitioners not fulfilling the ethical principle non maleficence (Gilburt 2018). Non-maleficence is a pledge a practitioner will make to ensure the client is not harmed in any way (BACP 2018).  

Another issue the austerity program the level of inequality individuals diagnosed with mental health faced. Austerity occurred due to the conservative party starting a campaign on buget cutting within the UK (Muellar 2019). It was introduced in 2010. This increased levels of unemployment and caused a financial crisis (Muellar 2019) This led to many people developing mental health issues (Muellar 2019). This was due to not being able to get into employment due to their diagnosis or when they did, they would face discrimination within the workplace. The Marmot Review (2010) discovered that there is a major link with poverty and mental health. Wilkinson and Pickett (2009) stated economic equality leads to social solidity, decrease within crime levels and trust within societies.  These factors have an effect on individual's mental health due to feeling insecure about their economic status they may avoid getting any help as they may feel embarrassed or have a fear they may get rejected. They may feel this way due to the negative stigma around mental health diagnosis despite the awareness around mental health has increased individuals still face inequality (Hatzebuehcer et al 2013).  

 Recently, there has been a newfound emergence of counselling which involves technological advances. It involves clients having sessions over; video call, over the telephone or online (Geldard, Geldard and Foo, 2004). Though it has many advantages such as it provides security and extra levels of autonomy to the client and boosts the clients confident when disclosing (Geldard, Geldard and Foo, 2004). It also allows clients to feel powerful as they have control and a sense of balance within the client and counsellor relationship (Geldard, Geldard and Foo, 2004). Another advantage would be it is time efficient and cost effective. However, there may be some advantages to this form of counselling there are just as many faults (Geldard, Geldard and Foo, 2004). One of them being the therapeutic relationship could be affected due to not having face to face contact (Geldard, Geldard and Foo, 2004). Other issues such as emotions could be misunderstood or if a counsellor and client were having a session over text the exchange with information could be slow. This could lead to it being less time efficient which could impact the effectiveness of the counselling process (King et al 2006, Bambling et al 2008, Fukkink and Hermanns 2009). Another issue could be technology is not the most reliable source and could issues (Hanley 2012). Also, online counselling may not be beneficial or suitable for some clients for example clients who are suicidal (Chester and Glass 2006).   

 There are many advantages of time limited therapy. Jenkins (1996) suggested time limited therapy gives the propositions of being able to access help promptly when it is needed for a client. It also gives clients to have flexibility to have sessions as of when they needed or not. Also, time limited therapy allows a client to deal with presenting issues that may be causing sorrow for the individual quickly (Allez & Glyn 1997). Also, practitioners within big organisations such as the NHS and other settings where there is funding is being provided want clients issues and suffering to be dealt with quickly so by offering clients time limited ensures they have emotional support which will be beneficial providing a positive insight (Feltham 2010).    

Practitioners who provide short term therapy will focus on the here and now (Feltham 2010).  Most therapist who offer time limited therapy will either work as a person-centred therapist (PCT) or cognitive behavioural therapist (CBT) (Feltham 2010).  Therapist who work alongside the person-centred therapy will give the client autonomy by allowing them to set the pace as well as the length of the process (Feltham 2010).  Therapist who follow the psychoanalytic process tend to gain profit from the lengthy sessions and believe it is necessary however, psychodynamic and PCT therapist strongly believe in following the therapeutic process and steer away from using technical shortcuts (Feltham 2010).    

 Another beneficial factor of using time limited therapy would there is funding available for big organisations such as the NHS, so this allows the service to be provided to a vast majority (Feltham 2010). However, if longer therapy was available on the NHS many would suffer, their issue may become more sever due to the long waiting list (Feltham 2010).  

On the other hand, the disadvantages of time limited therapy are in most cases by a client opening up and talking about one issue they are facing this could lead to other unresolved issues to become apparent (Feltham 2010). Also, some clients may need a handful of sessions before they start to trust and open up and discuss repressed emotions to their therapist (Feltham 2010). Within the short sessions that are being provided the client may start opening up towards the end of the number of sessions which could be harmful for the client because once the sessions are over the client may be in ore of a vulnerable state this then could become an ethical issue as the counsellor did not fulfil the ethical issue of being non-maleficence  (Feltham 2010).   

 Another issue could be the sessions could be inefficient for some clients due to big organisations like the NHS they only have a limited amount of funding so providing short term interventions may be beneficial for the system it could be harmful towards to client and could cause clients to relapse in the future (Feltham 2010). Services such as IAPTS offer ‘stepped care’. This form of therapy follows the cognitive behavioural approach (Feltham 2010). IAPTS follow the NICE guidelines. Other forms of therapy tend to be more concentrated and long term however IAPTS offers services which are quick and reach the client to their goal (Feltham 2010).  This could sometimes feel rushed. It also may require clients to complete “homework” some clients may not like this form of therapy (Feltham 2010).  This could cause issues such as tainting the clients experience (Feltham 2010).  

The best solution is to offer therapy and allow the client to determine the time span of the therapy. Whether they chose to have short term, one off, one and off sessions or long-term therapy (Feltham 2010).  

 Dialectical behaviour therapy is a form of therapy for individuals who experience emotional dysregulation (Brodsky and Stanley 2013). It is structured however provides a map for both the counsellor and the client. It focuses on crucial issues such as self-harm and suicide. By using this form of therapy helps the client stay focuses and prevents the client from getting off track from reaching the clients goal (Brodsky and Stanley 2013). DBT involves skills training these will help the individual maintain their emotions (Brodsky and Stanley 2013). Within the process a counsellor may use interventions such as; mindfulness. DBT is best suited for individuals who have; borderline personality disorder, depression, suicidal thoughts, binge eating disorders, anxiety, individuals who have experienced sexual abuse/PTSD and substance abuse (Brodsky and Stanley 2013). The main focus of DBT is helping clients learn principles, this will involve operant and classic conditioning (Brodsky and Stanley 2013). DBT is effective for individuals who have borderline personality however, this form of therapy isn’t fit for all (Brodsky and Stanley 2013). Another limitation could be DBT is demanding for example, it requires daily forms/homework and hours of therapy (Brodsky and Stanley 2013).  

Another form of brief therapy is cognitive behavioural therapy (CBT). CBT is a talking therapy which pay great attention on an individual's thoughts, beliefs and behaviour (Mind 2015). CBT is solution focused and helps an individual gain skill’s which will help them deal with issues (Mind 2015). The main theory of this form of counselling is highly based on how an individual perceives a situation then focuses on how their perception will affect the way they will behave within the situation (Mind 2015). CBT will help an individual identify issues which affect their behaviour and change negative thinking/behaviour patterns to positive ones (Mind 2015). Some of issues CBT will be beneficial for are; anxiety, phobias, PTSD, depression, borderline personality disorder ect ect (Mind 2015). CBT uses interventions such as graded exposure, homework, mindfulness and skills training. The strengths of using CBT would be it is beneficial for clients who have been prescribed medicine however it hasn’t worked (NHS 2019). Another advantage would be it helps individuals gain skills which they can use in everyday life even after the counselling process (NHS 2019). However, there are some disadvantages such as it requires an individual to commit to the process to ensure they get the best results this can take away the clients autonomy as they don’t have a choice as and when they want their sessions (NHS 2019). Another disadvantage would be it is not time efficient (NHS 2019).   

There are many ethical issues with using brief therapy. One ethical issue would be there may be peripheral burdens which force a client to choose brief therapy (Charman 2004). For example, a client has gone to their doctor regarding wanting to go to counselling and have been referred to IAPTS (Charman 2004). Due to cutbacks IAPTS is a short-term process which often offer 6 sessions max. This could cause issues such as taking away the client’s autonomy (Charman 2004). Also, due to being solution focused this may restrict the client from exploring other issues this could potentially be harmful as they may talk about a topic however, due to the session being so restricted it may be left unresolved (Charman 2004). This will then become an ethical issue as the counsellor is not following the ethical principle of being non-maleficence. Brief therapy is seen as unethical because and individual needs to explore deeper to make sense of the symptoms. However brief therapy does not allow this due to limited time (Macdonald 2011). Clients may be pleased about this as they can avoid talking about distressing topics however this could be potentially harmful as the issue is left unresolved (Macdonald 2011). 

Personally, I'm on the fence about brief therapy. I feel as if it is needed as it better for an individual to experience even if it is short. This will then open their eyes as to how beneficial counselling which will encourage them to gain further help. However, on the other hand I feel as it could be potentially harmful. For example, if a client's talks about an issue however due to the sessions being restricted it left unresolved. This could potentially cause more distress for the client and taint their perception of counselling. It’s a sense of opening a can of worms and leaving the client to deal with it alone.  Within the counselling degree I have experienced brief therapy. We did a case study which included six sessions. I personally didn’t feel as if it helped. It was nice to off load however I didn't feel as if it helped. Due to being in a safe space I felt comfortable talking about my issues however, if a client who has never had counselling will find it difficult to open up easily as they need to build and maintain a relationship with their counsellor over time. 

Overall, there has been evidence proving the effectiveness of brief therapy however there are some faults in this form of therapy. The evidence found there has been factors which have put into place that have affected contemporary health services which have led to the government implementing services such as IAPTS in place to resolve the issue. This too is beneficial however has it flaws.  

References  

• Bacp.co.uk. (2018). BACP Ethical Framework for the Counselling Professions. [online] Available at: https://www.bacp.co.uk/events-and-resources/ethics-and-standards/ethical-framework-for-the-counselling-professions/ [Accessed 1 Nov. 2019]. 
• Bagnall-Oakeley, R. and Lyons, J. (2018). Navigating a sea of change. Therapy today. 
• Brodsky, B. S. and Stanley, B. (2013). Introduction. In The Dialectical Behavior Therapy Primer (eds B. S. Brodsky and B. Stanley) 
• Charman, D.P., 2004. Core processes in brief psychodynamic psychotherapy advancing effective practice, Mahwah, N.J.: Lawrence Erlbaum. 
• Cotton E. The future of therapy. E-book. Surviving Work; 2017. https:// thefutureoftherapy.org/eBook 2. Psychologists Against Austerity. The psychological impact of austerity: a briefing paper. nline. sychologists Against Austerity; 2015. https:// psychagainstausterity.files.wordpress. copaabriefingpaper.pdf accessed  ctober . 
• Cqc.org.uk. (2017). The state of care in mental health services 2014 to 2017. [online] Available at:https://www.cqc.org.uk/sites/default/files/20170720_stateofmh_report.pdf [Accessed 31 Oct. 2019]. 
• Feltham, C 2010, Critical Thinking in Counselling and Psychotherapy, SAGE Publications, London.   
• Geldard, K., Geldard, D. and Foo, R. (2004). Counselling adolescents. 2nd ed. London: Sage. 
• Gilburt, H. (2018). Funding and staffing of NHS mental health providers. [online] The King's Fund. Available at: https://www.kingsfund.org.uk/publications/funding-staffing-mental-health-providers?gclid=CjwKCAjw3qDeBRBkEiwAsqeO7uG_PlToXv99dQEOMJcQKm8FYQ7iKmJjNpz7yhv7oupFSpv_A0vikhoCkqkQAvD_BwE [Accessed 1 Nov. 2019]. 
• Hatzenbuehler M., Phelan J., Link B. Stigma as a fundamental cause of population health inequalities. Am. J. Public Health. 2013 
• Hudson-Allez, Glyn. Time-Limited Therapy in a General Practice Setting: How to Help within Six Sessions, SAGE Publications, 1997.   
• Macdonald, A 2011, Solution-Focused Therapy: Theory, Research & Practice, SAGE Publications, London.  
• Marmot M. Fair Society, Healthy Lives, The Marmot Review. Department of Health; London, UK: 
• Marsh, L. (2015). Making sense of cbt. [online] Mind.org.uk. Available at: https://www.mind.org.uk/media/1892486/making-sense-of-cbt_2015.pdf [Accessed 31 Oct. 2019]. 
• Mueller, B. (2019). What Is Austerity and How Has It Affected British Society? [online] Nytimes.com. Available at: https://www.nytimes.com/2019/02/24/world/europe/britain-austerity-may-budget.html [Accessed 31 Oct. 2019]. 
• nhs.uk. (2019). Cognitive behavioural therapy (CBT). [online] Available at: https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/#targetText=Some%20of%20the%20disadvantages%20of,a%20lot%20of%20your%20time [Accessed 31 Oct. 2019]. 
• Sledge, W. H., Moras, K., Hartley, D., & Levine, M. (1990). Effect of time-limited psychotherapy on patient dropout rates. American Journal of Psychiatry, 147, 1341–1347.  
• Steenbarger, B. N. (1992). Toward science-practice integration in brief counselling and therapy. The Counselling Psychologist, 20(3), 403-450.  
• Wilkinson R., Pickett K. The Spirit Level: Why Equality is Better for Everyone. Penguin; London, UK: 2009.