Sept. 15, 1965

To: Don Jackson
From: Dick Fisch

1. Reason for proposal.

   The major, and almost sole, effort expended in out patient treatment Today is in long-term psychotherapy. This is not only among private Therapists, but also among most outpatient clinics. Even efforts of two Centers to alter this pattern in their "Brief Therapy Clinic" has done Period while at the same time extended the total duration of treatment. (Patients seen are usually ones regarded as "chronic" and for whom little active intervention is used to resolve their problems.) Thus, there is a need for a facility that will consistently provide imaginative, well planned, brief therapy and at the same time permit a more thorough study if the effectiveness of this approach in general, and of particular techniques more specifically. Discussions with those few therapists in the area who have experimented in the use of a variety of brief techniques indicates the promise of great and lasting effectiveness and of its applicability for most of the disorders met in outpatient practice. The opportunity to expand the use of these techniques and, at the same time, To get a more rigorous evaluation of their effectiveness would be most desirable. (The latter would involve a carefully designed follow-up and comparative study.)

2. Method

   In essence, the project would consist of a "clinic" consisting of a Core group of therapists who have been experienced in the use of various Techniques, or who have shown an interest and capability of learning and using such techniques under supervision. A group of 4 to 6 would be Preferable and this group would be supplemented by the nursing, secretarial, and other personnel needed for the administrative functions of the "clinic" And the operation of the evaluation of the project. The core group, as Well as other personnel, would work in the same physical plant since Opportunities for collaboration and integration of work are of utmost Importance in such an operation.

   Patients would be drawn from the usual sources within the community-- Physicians, public agencies, self-referral, ministers, other psychotherapists, etc. Since the clinic would be devoted to brief therapy exclusively, however, an automatic screening would be entailed and patients seeking such long-term therapy as psychoanalysis would not usually apply. Should the clinic be supported by public funds or endowments it would be possible to charge a scaled fee arrangement and such fees could be turned BACK into the operation of the clinic while full time personnel would be on a salary from the clinic.

   Recognizing the difficulties of evaluative criteria for therapy Effectiveness, modest standards would be used at first. Thus, a target Symptom would be focused upon in treatment and results evaluated solely In terms of the change in that symptom; e.g. a patient might come into Treatment because of a phobia and in the course of treatment might say That he also doesn't get along with his wife. Treatment results would be Based on the change in his phobia regardless of any change or lack of it In his relationship with his wife. While more refined methods of evaluation will be needed, it will desirable to determine whether a specific Treatment technique is effective with a specific difficulty (the target Symptom) even though such change is measured on the subjective report of The patient and the objective estimate of one or more therapists.

   The approach to treatment will be a symptom-oriented one; several Techniques can already be considered and have been used by various therapists in their own isolated work. These would include: hypnosis, Behavioral therapy (deconditioning), conjoint deconditioning (see Appendix I of Dr. J Terrill and Appendix II of Dr. Clemes), symptom manipulation as described by Jay Haley* and Don Jackson,** drug therapy including the use of psychedilics, limited goal conjoint marital interviews, and the use of lay therapists (e.g. an ex-patient who had a phobia has successfully worked with other phobics in a rapid time because of his ability to establish deep and quick rapport, the minimizing of resistance as a "professional expert" and as an example of success.) The use of lay people, under guidance, who have overcome their own difficulties is a whole unexplored field. Their use in treating others with similar afflictions has not been utilized with the exception of some groups such as A.A. which have the disadvantage of making it a lifelong membership sort of arrangement. In addition to those modalities, such techniques as home visits in a family crisis could be used to stabilize a family in the beginnings of an upheaval and could avoid hospitalization or the hardening of symptoms that might result in the need for long-term therapy.

   Also, the new technique being devised by C. Collinge, M.S.W., at the Mental Research Institute, of living in the patient's home for several Days seems to have great promise. Such emergency techniques could also be used to deal with the problem of suicide.

   In addition, the use of public facilities that are frequently overlooked by physicians and psychotherapists could be used along with or instead of a medical/psychiatric framework. For example, many people in the early stages of divorce could be referred to an organization like Parents without Partners where it is felt that his symptoms stem primarily from the jolt of adjusting to a new role function suddenly thrust on him.

   Private psychotherapists geared to doing long-term psychotherapy could also refer their patients for help in overcoming impasses in their regular treatment and the patient would then return to his own therapist. At the same time, the evaluation of these techniques would be carried out so that a follow-up study would be built into the operation of the Clinic. On the first contact with a patient, for example, such data as Social security number, next of kin, etc. could be obtained and this would reduce the chances of "losing" a patient in efforts to evaluate the duration of symptom change. The emphasis in the clinic would always be two-fold; the use of brief therapy and the importance of taking all measures to provide for their evaluation simultaneously.

   Other advantages of such an arrangement would be the opportunity for imaginative and experimentally-oriented therapists to collaborate with each other in developing new ideas for treatment, in the planning of strategies for particular cases, and for the purposes of multiple impact therapy. There would also be more than usual supervision when a case presents some particular problem. Some of the secretarial personnel could also be used to do literature research to discover unique and promising techniques reported by other therapists throughout the world. The clinic could also serve as an educational nucleus in the community by training volunteer therapists, allowing residents in psychiatry to affiliate for some period (allowing then to expand their perspectives of treatment), by creating a lecture or seminar series or monthly meetings. Noted innovators might be invited to address the staff and the professionals in the area.

3. Miscellaneous suggestions.

   It would be too early to detail specific operations for such a Clinic but several suggestions are included for consideration:

   (a)

   The director of the clinic should be responsible for "traffic Flow" so that a therapist is available at every hour during the Day in order to prevent the creating of a waiting list which is inimical to the whole idea of brief therapy.

   (b)

   The non-therapist personnel (secretaries, etc.) should be given some Training in brief therapy techniques so that they will be able to Follow the work better, to improve morale, and for their own uses In motivating patients to return questionnaires, etc. Also they might be used to make comparative studies of techniques when used by professionals and when used by lay individuals.

   (c)

   The pressures of patient load can often cut off the opportunity for Informal collaborative work by therapists and a mandatory "no Appointments" period during the day would be useful. That is therapists need not consult with each other during that period, but they Would not be inaccessible because of seeing a patient.

   (d)

   The temptation to extend treatment is often difficult to resist and Thus a limited number of sessions (10 to 20) would be set for all Patients and no extension could be made without a conference with the Clinic director and perhaps one other therapist. Arrangements could Be made with other agencies for transfer of "chronic" cases.

4. Summary

   The creation of a clinic for the purpose of providing brief therapy And its evaluation is an excellent opportunity not only to make a major Contribution to public service but to also contribute to a much needed Investigation of newer approaches to the alleviation of emotional problems In this country. It would accomplish this by:

   (a)

   Offering alternatives to patients of psychotherapy that is shorter and less costly.

   (b)

   Setting up a planned evaluation of this form of treatment.

   (c)

   Developing and testing newer methods.

   (d)

   Offering an educational focus in the community and an extension of training for psychiatrists and others just entering the field of treatment.

______
*Haley, Jay Strategies of Psychotherapy, New York, Grune & Stratton, 1963.
**Jackson, D. "Interactional Psychotherapy." Morris I. Stein (ed.) Contemporary Psychotherapies, Glenco, Ill: Free Press, 1959, Pp. 256-271.