Ultra-Brief Cognitive Behavioral Interventions

A New Practice Model for Mental Health and Integrated Care

Len Sperry, Vassilia Binensztok

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351202459
• Edition: 1
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

Ultra-Brief Cognitive Behavioral Interventions showcases a new practice model to address both physical and psychological health issues in mental health and integrated care settings, utilizing focused interventions in brief treatment formats.

This unique text offers a toolkit of effective interventions and methods – including cognitive behavioral therapy (CBT) methods that can be used in a very brief time frame of 10–20 minutes – that can be quickly and efficiently applied to ameliorate specific symptoms. The 20 most common interventions in short-term therapy practiced in mental health and integrated care settings are illustrated in session transcriptions of the full course of focused therapy, with common presentations such as depression, anxiety and acute distress, pain, sleep problems, and weight problems.

This book prepares emerging and experienced counselors and therapists to provide short-term therapy for their clients and equips them with the necessary skills to meet the challenges facing mental health care today and in the future.

Part I

Ultra-Brief Interventions and the Cutting Edge of Clinical Practice

1

Ultra-Brief Interventions in Mental Health and Integrated Care Practice

Today, mental health and behavioral health clinicians face several challenges brought on by the pervasive changes in health care and the need for a new practice model. As noted in the Introduction, these challenges include: (1) significant shifts in the current practice patterns and the demise of the “50-minute hour;” (2) that the majority of those seeking medical care have related psychological conditions that trigger, exacerbate, or perpetuate their medical conditions. If these patients were to seek conventional psychotherapy, such conditions would likely be ignored by therapists, which might complicate their psychological or medical conditions or both; and (3) that reimbursement and even employment is increasingly dependent on mental health clinicians, particularly psychotherapists, having the requisite training and competence for this new practice model. To meet these challenges, this book advocates for a new model of practice that addresses both the physical and psychological health of clients in both mental health and integrated care settings. Consistent with this new model is short-term therapy consisting of very brief sessions that necessitate the use of focused interventions, which we call ultra-brief interventions.

This chapter begins by describing published predictions for the future of mental health practice in mental health settings. Next, it introduces integrated care settings as a viable practice option for mental health clinicians. Since this option is not well known, a typical day in the life of such clinicians, as a member of the health care team, is described. Then evidence-based practice is described, along with ethical considerations. Finally, it describes ultra-brief interventions and their role in both mental health and integrated care settings.

A New Model of Mental Health Practice in Mental Health Settings

Several predictions have been published about the future of mental health and psychotherapy practice that suggest a new model of mental health practice is emerging in mental health settings. This section discusses three sets of predictions and briefly addresses a key feature of the new model: treatment and session duration.

The first set of predictions is an empirically-based group of prognostications (Norcross, Pfund, & Prochaska, 2013). Norcross and associates have been conducting Delphi polls on future trends in psychotherapy every ten years for the past three decades. Most notable has been the uncanny accuracy and specificity of their predictions. In 2012 they empaneled 70 psychotherapy experts to forecast psychotherapy trends in the next decade. The polling focused on five areas: theoretical orientations, therapeutic interventions, psychotherapist background, therapy formats, and forecast scenarios (Norcross et al., 2013).

In terms of theoretical orientations, they predicted that mindfulness, cognitive behavioral, integrative, and multicultural approaches would increase the most, while Jungian therapy, classical psychoanalysis, and transactional analysis were expected to decline the most. That prediction for transactional analysis has already been borne out in the USA. With regard to therapeutic interventions, they forecasted that technological, self-change, skill-building, and relationship-fostering interventions would be most utilized. In terms of psychotherapist background, they expected that master’s degree practitioners would be the dominant providers of therapy services. Regarding therapy formats, they predicted that internet programs and telephone therapy would increase dramatically. Forecast scenarios with the highest likelihood centered on expansion of telepsychology, evidence-based practice, and psychopharmacotherapy. Finally, they concluded that four themes were responsible for driving these trends: technology, economy, evidence-based treatment, and innovative ideas and practices (Norcross, et al, 2013).

In a nutshell, here is their overall prediction of the future of psychotherapy:

In 2022, we expect briefer episodes of individual, group, and couple treatments increasingly conducted by master’s-level professionals involving evidence-based methods and relationships; theoretical formulations and clinical methods more associated with the cognitive, integrative, multicultural, and mindfulness orientations; and progressively more on the Internet, smart phones, and social networking. (Norcross et al., 2013, p. 369)

That same year, Wade Silverman, then editor of the journal, Psychotherapy, predicted four trends in psychotherapy’s future. He described the first trend as the “new diversity.” By this he meant that therapy would be identified by levels of technological sophistication in both providers and clients rather than by race, ethnicity, or sexual orientation. The second trend he foresaw was the expanding use of the technology itself, encompassing social networking and other online communication platforms. The third trend would be the development of new forms of health care service delivery that would reward successful efforts in disease treatment and prevention, be evidence-based, require documentation of clinical outcomes, and focus research on discovering successful treatments. His fourth trend is the emerging markets for consumers interested in performance enhancement and quality of life (Silverman, 2013).

Three years before, Thomason (2010) identified evidence-based practice and empirically supported treatments as the main trend influencing the future of psychotherapy practice. He made several specific predictions about evidence-based psychotherapy practice. Most notable were that evidence-based practice and non-evidence-based psychotherapy would diverge. Eventually, only evidence-based practice would be reimbursed and covered by liability insurance, while other forms would not. He also predicted that psychotherapy would become briefer and more integrated into primary care practice (Thomason, 2010).

Common to all three sets of predictions is that the practice of psychotherapy and mental health would be briefer, evidence-based, and account for health issues or be integrated in health care settings. Accordingly, this chapter reflects these three common predictions. In fact, this entire book elaborates clinical practice consistent with these predictions.

Treatment and Session Duration

The Current Procedural Terminology (CPT) codes for billing insurers for mental health services including Medicare and Medicaid took effect on January 1, 2013. Before then the CPT code 90807 was used to bill for the 50-minute hour. There is no longer a code for 50-minute sessions. Instead, there is the CPT code 90834 for coding 45-minute sessions. Reportedly, the Centers for Medicare and Medicaid Services made these code changes to more accurately represent the way clinicians provided services. However, clinicians feared that reducing session length would reduce treatment effectiveness and that insurers would use the changes to justify reducing reimbursement rates (Miller, 2012). While research has not borne out the loss of treatment effectiveness, reimbursement has been reduced.

Besides the CPT code changes, other previously mentioned factors have contributed to the demise of the 50-minute hour, and expectations to integrate physical and psychological health concerns in mental health settings. The result is that a new model of mental health practice in mental health settings is emerging. Some of the more telling indicators of this new model involve treatment duration and session duration. Instead of the usual 12–20 psychotherapy sessions as the norm, the expected duration of treatment will more likely be four to six therapeutic encounters. Instead of 50-minute sessions, the length of the therapeutic encounter will last for 15–30 minutes. These changes were predicted by Nicholas Cummings (Cummings & O’Donahue, 2008). Over the past 30 years, Cummings and others have advocated that psychotherapists should be able to assess, diagnose, and begin treatment with clients within 15 minutes, just like physicians (Thomason, 2010). We would add that ultra-brief interventions can be delivered in 10–20 minutes.

These durations are surprisingly similar to those from the Delphi polling results. The consensus among the 70 experts polled was that by 2022, treatment duration will no longer be unlimited sessions or even 20 sessions. The expectation is that short-term therapy (5–12 sessions) and very short-term therapy (1–3 sessions) will increase, while long-term therapy (longer than 20 sessions) will significantly decline (Norcross, Pfund, & Prochaska, 2013 p. 367).

Table 1.1 and Table 1.2 provide summaries of these various projections.

Table 1.1 Treatment Duration

long-term therapy short-term therapy very short-term therapy

longer than 20 sessions 5–12 sessions 1–3 sessions

Table 1.2 Session Duration

conventional therapy sessions brief sessions with focused interventions brief sessions with ultra-brief interventions

50 minutes 30 minutes 10–20 minutes

Outcomes Assessment and Technology

Incorporating clinical outcome measures is an essential component of the new practice model (Meier, 2015). The challenge will be for clinicians to not only utilize clinical outcome measures and progress monitoring, but to incorporate the feedback from these measures to modify treatment. A related challenge will be to document and report such clinical outcomes. Without measurable outcomes, psychotherapy can deteriorate to a friendly interchange between clinician and client that is costly, ineffective, inappropriate, and likely unethical.

Another component of the new model is the use of alternate formats, i.e., technology, for the delivery of mental health services in mental health settings. For instance, a meta-analysis of several internet studies supported the adoption of online psychological interventions as a legitimate therapeutic activity. In fact, no differences were found between face-to-face and internet interventions (Barak, Hen, Boniel-Nissim, & Shapira, 2008). Even with these promising findings, internet interventions will require further research (Cottone, ...