From: Walter Watts (wlwatts@cox.net)
Date: Fri Apr 30 2004 - 11:50:18 MDT
Innovative Brief Pithy Psychotherapy: A Contribution From Corporate Managed Mental Health Care
Donna S. Davenport, Ph.D., and Kristin K. Woolley, M.Ed. Texas A&M University
As managed care has continued to expand and mature in the 1990s, several managed care corporations have begun to develop their own innovative clinical interventions and a treatment manual, generally with an emphasis on a brief but striking intervention. This article describes the essential aspects of modem managed mental health care psychotherapy, or pithy therapy, which is an effective approach to helping patients within a managed care service setting. Empirical studies indicate that providers find it therapeutic for themselves to provide it, and managed care organizations find it to be a cost-effective form of service delivery. Pithy therapy is logical, and it is somewhat reminiscent of both the older versions of Rational Emotive Therapy (RET) and Reality Therapy but without the burden of establishing a relationship with the patient. The focus of the therapy is to extinguish the patient's whining and to encourage behavioral change. The language used in pithy therapy is contemporary 90s-style, with a minim
um of psychological jargon. Therapists who become adept at this form of therapy will soon develop a reputation among their colleagues as being full of pith.
Selection and Training of Therapists
Therapist selection will proceed according to the following guidelines:
1. All therapists must have a high school diploma or the equivalent, unless they are to be "grandfathered in" under current management specialist criteria.
2. No preference is given to those with undergraduate or advanced degrees. Democrats should be screened out of the program.
3. Any PhD who has challenged the modem managed mental health care system decision-making process within the last 5 years will be considered ineligible for training.
Training and certification of therapists will follow traditional procedures. All training will follow the principles outlined in this manual and should take approximately 40 hours, including breaks.
At the end of this time, trainees will have mastered the basics and will be certified. Those therapists who are proficient in one-sentence interventions will supervise other therapists, with the eventual goal of reducing an entire therapy session to three-word, two-word, and finally one-word interventions. Therapists will be expected to obtain continuing education units on a regular basis from their original trainers in order to ensure that their skills and vocabulary remain up to date. Principles of Training
Stage I - Identifying Feelings
In the old days, therapists spent many hours helping patients label and explore something that was generically called feelings. This was a time- consuming and arduous task that was usually not fun for the therapist and typically led to patient self-preoccupation. Empathy for the patient is expected under the current model, but there is rarely a need for it to extend beyond a sentence or two. Patients will feel understood and supported if offered interventions such as: "I see you're feeling sorry for yourself today," "Today is a whiny day," or "You just want to sit on your rear and let others take care of you, huh?" If the patient seems especially fragile, more comfort can be offered, but again, keep it brief. After listening to a story, you may say, "Bummer!" or "Gotta hate it!" In the rare event that self-disclosure is used, the recommended empathic disclosing response is to nod and say, "Been there."
Stage Il-Assessment
Forget the DSM-IV manual. That was bulky and written by people who focused on minutia. Because everyone now gets the same treatment, there's little need to provide differential diagnoses, except when the patient persists in knowing what is wrong with him or her. Sigh heavily, as this is an unreasonable request. If necessary, you may say, "The lights are on, but nobody's home," "I think you got a string broke on your guitar," "You're one beer short of a six pack," or "You've gone bonkers."
Stage III-Identification of the Problem
It is important to figure out very quickly what the identified problem should be. Most patients need help in this area, so you may need to ask several questions. Do not let the patient waste valuable time describing irrelevant situations, family dynamics, or how hard he or she has tried to work things out. Interrupt. Say loudly, "Fast forward through the story. What is your problem?" ; "So, what's your point?" (may squint eyes); "What are you smoking?" "Please identify your major malfunction"; or "So what did you want me to do about it?"
Stage IV-Providing Direction
Patients have a tendency to make the same mistakes over and over. They get in the same stupid relationships, they whine, they procrastinate, and so forth. This is not because of unconscious schemas or other polysyllabic rationalizations. They do this because no one told them they couldn't. This stage requires strong, confident direction from the therapist. Do not encourage patients to think for themselves; they'll just screw it up again. Appropriate interventions for this stage are, "Don't get on that bus," "Get used to it!" "Build a bridge!" "Move on already!" "That dog don't hunt," or "Too much information!" Again, some patients, those fragile flowers we mentioned earlier, need a gentler touch. Don't yell at them, at least not in the first session. With these patients, subtle direction is indicated when it becomes apparent they are headed down the wrong path. You may say, "Let's get both oars in the wafrr for a change, OK?" or "Someone in this room is losing it again. Just thinking aloud here... This ma
y be another time for self-disclosure, to help lighten the confrontation. Here we get elegant, with differential approaches. For those patients who tend to be more cognitive, your self-disclosure will be "I'm thinking you should.. ..." For those who deal at a more affective level, say, "I feel you should. . ..." This is an old NLP trick that will make them feel like you're speaking their language.
Stage V-Confrontation
If, after your providing appropriate direction, patients still persist in their old nonsensical ways of doing things, you'll need to take stronger steps. Raise your voice. Say clearly, "Not too user-friendly, are you?" or "No wonder you feel inadequate!"
Stage VI-Accepting Responsibility
The core of pithy therapy is getting the client to accept responsibility for having gotten his or her life in such a mess. The key at this stage is to refuse to reinforce whining and to demand a change in behavior. We believe that after a session or two of usual pithy therapy, ultra pithy therapy is more efficient, because patients no longer expect to be coddled and are ready for briefer interventions. We offer the following three-word, two-word, and one-word interventions from our ultra pithy therapy handbook for your edification:
3-word interventions
Get a grip!
Get over it!
Blaming mom again?
Let it go.
Give it up!
Abort/Retry/Fail
Have a clue!
Right. I'm sure.
Your point is?
Get over yourself!
Get a life!
Don't go there.
Shake it off!
Suck it up!
Just do it!
Wah, wah, wah!
2-word interventions:
Lighten up!
Grow up!
There's more?!
Yeah, and?
Tough luck!
Objection overruled.
Spare me.
So? Next?
1-word interventions:
So...?
Duh...!
Seriously?
Whatever (make W with fingers)
Hel-LO?
Still?
Puh-leeze.
Again?
Stage VII-Reinforcing Change
Assuming the patient ever does anything right, it is important to reinforce him or her. This will be done in a way that does not increase dependency, not that there's a hell of a lot of danger at this point that the patient will be wanting to include you in his or her life anyway. As usual, keep it brief. Appropriate interventions are, "Get outta here!" (may shove patient); "I'm thinkin'!"; "Yay you!"; "Go you/boy/girl!"; "Whoa!"; or "Wow!"
Conclusion and Discussion
The goal of pithy therapy is to achieve a briefer and briefer clinical intervention that can be delivered at the lowest possible cost by the least expensive provider. Traditional precertification procedures are utilized, with between 1 to 3 units of a quarter of an hour initially authorized. Brief joint therapist-patient reports requesting additional sessions may be completed as part of the final initially authorized session, but such requests should rarely exceed 12 words. Empirical studies have shown that few patients require more than three 15-minute sessions of pithy therapy to successfully resolve their problems, as reflected by the fact that fewer than 2.81% of patients request additional sessions of service. Move on already! Grow up! There really is nothing further to discuss.
Appendix A
Fillers
All therapists occasionally get blocked. If you find that you've been planning your dinner menu or having unnecessary heavy thoughts and haven't caught a word the patient has said for 5 minutes, you'll need something to regain your focus. Appropriate fillers are, "So you're feeling, uh-whatever," "Let's look at your entitlement issues," or (our favorite) "Existence precedes essence.
Appendix B
Diversity Issues
You will want to embrace diversity. For the patient over 55 or so, use phrases like, "Gimme a break!" "Fat chance!" "Say it ain't so, Joe!" "Nuts!" or "Neat-o!" African Americans can be told to "Chill out!" Mexican Americans will respond well to "Ay, caramba!" With women, add".. . OK?" at the end of every sentence. With kids under 10, say "No candy for you." Be flexible and creative.
Appendix C
Typical Session
As an example of a session of pithy therapy, the following verbatim script for your study is of one of our seasoned therapists (Th) working with a patient
(Pt). Note the combination of direction and patience offered, with no wasted moments:
Th: Hi. Name?
Pt: Uh, my full name is Jonathon Michael Smith, but I guess you can call me Jonathon. My mom calls me Johnnie, but...
Th: I'll call you John, it's shorter. Why are you here? How do you feel about being here? What other feelings do you have?
Pt: Well, I guess I've been a little depressed. At least my wife says I'm depressed. I guess I am. I'm not eating, not sleeping, I don't go to work...
Th: (interrupts) Bummer. Life sucks. What else?
Pt: Well, I'm about to get fired, our 15-year-old ran away, and my wife says she's in love with someone else. (cries)
Th: Hold up! Get a grip! What are you doing wrong?
Pt: I beg your pardon?
Th: Well, this is someone's fault, John. Probably yours. What's your major malfunction?
Pt: (confused) I thought you were supposed to be nice to me. My mother was in therapy and her shrink was really nice.
Th: Must have been years ago. So what is your problem? How come everyone hates you?
Pt: Well, I think maybe I have a self-esteem problem. My dad used to call me really bad names and he beat me whenever I made a mistake, so maybe I'm a little too dependent on others to make me feel good. Sometimes...
Th: Keep it brief, keep it brief. So you're a wimp. I'd say it's time to get off that bus.
Pt: Well, I've really tried. I've been to men's groups; I've read some books on assertiveness; I've seen another therapist; nothing seems to work. (cries) I just feel so bad about myself... Th: Build a bridge!
Pt: I'm sorry, what?
Th: That's old stuff, that self-pity crap. That dog don't hunt here. Just grow up.
Pt: But what am I supposed to do? I don't know what to do! (getting upset)
Th: Have a clue. Move on already.
Pt: (confused, silent)
Th: Pouting?
Pt: No, I just didn't expect this. I think you should help me feel maybe a little better about myself before I move on.
Th: Objection overruled. No wonder you feel inadequate!
Pt: So you don't think my problems stem from early influences? I thought all therapists thought that. I've read some books...
Th: Spare me.
Pt: No, really, I've really thought about it. Every time someone gets mad at me, I remember my dad's face! Are you saying I should just stop feeling that way?
Th:Duh...!
Pt: You mean just like myself?! Just like that? No middle steps?
Th: (looks bored, raises eyebrows)
Pt: (brightens) Maybe you're right! Maybe I can just say no to the bad feelings!
Th: You're on it!
Pt: Maybe I can quit being a wimp and stand up for myself, huh?
Th: I'm thinkin'! Go boy!
Pt: (springs from chair) Yes! I'll do it! I'll be my own man! I'm the master of my fate, the captain of my...
Th: Yay you. Next?
©11997 American Psychological Association. Reprinted by permission of the copyright holder from Professional Psychology: Research and Practice, 1997,28 (2), 197-200. 16 Journal of Polymorphous Perversity
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