Long-Term Vs Short-Term Treatmen, Advantages And Disadvantages

Long-term treatment

The benefits of long-term treatment are undeniably apparent and indisputable. They include intensive engagement concerning objections and - through interpretation - reflection, clarification, dream analysis and early memories; creating a positive history and relationship between therapist and patient; providing a safe and consistent therapeutic space; compensation for past environmental failures through remedial experiences; and cooperative work such as raising awareness, self-reinforcement, changes in personality, as well as amplifying protective mechanisms to achieve the many objectives. All of these benefits and others improve patients’ quality of life.

An additional advantage of long-term treatment for the patient is the profound work done on the topics of transference and contra-transference.

In one of his final articles "An Outline of Psychoanalysis: The Psychoanalytic Technique", Freud writes that transference contains positive attitudes of affection and negative attitudes of hostility toward the analyst who usually takes the place of one parent. Transference becomes an engine of cooperation on the part of the patient, whose weak Ego is strengthened by this influence. The results are achievements that would have been otherwise impossible. By placing the analyst in place of the father, a patient also gives the superego control over the Ego. This new Super-ego now has the opportunity to correct mistakes attributed to the education received from patients’ parents (Freud, 2002).

Transference enables the patient to present us with a good deal of his resume. Under other circumstances information would be provided. Transference restores the patient’s attitude towards his or her parents, it takes on their ambivalence. It is almost impossible to avoid the positive attitude towards the analyst becoming negative and hostile. This position, too, is usually a repetition of the past (Freud, 2002).

During treatment transference becomes concentrated and very intense. This phenomenon is termed “Transference Neurosis”, when the patient retreats to earlier forms of attitude and behavior to the extent of repeating early childhood patterns in his or her treatment of the therapist. The advantage of such a development is concealed in conflicts, experiences and repressed memories are expressed in the neurosis of transference (Elizur et al., 2016).

However, Freud (2002) warns us of the possible confusion between true love and transference of love. This falling in love that appears during the analytical treatment is not true love, and it has a number of the following characteristics: it awakens as a result of an analytical situation only, from the power of resistance; it is less wise and ignores the ramifications it could have. In other words, it does not take reality into account.

Is long-term treatment from a practical perspective only suitable to people from the established psycho-social levels who are prepared to invest in it with two principle resources - time and money?

Along with the advantages of long-term treatment, there are two fundamental drawbacks to this type of care. First, the beginning is unknown. However, the end is also vague and undefined for both the patient and the therapist. The neurotic population for the most part has difficulty completing the processes, exactly when it is most important to conduct this in an orderly and defined framework. A clear start and end should be known in advance. Second, long-term treatment creates a dependency of the patient on the therapist, and/or between the patient and the therapeutic framework.

“Liberation of a human being from his neurotic symptoms, inhibitions and abnormalities of character—is a lengthy business”, this is how Freud (1937) begins his seminal article “Analysis Terminable and Interminable”.

How long does this have to be - two years, five, a decade, or open ended? In this article, Freud struggles in his responses without giving an opinion regarding the question “When is the end of the treatment?” When does the analysis achieve its goal and when is it supposed to end? On the one hand, Freud demands a date be set to end the treatment - “heroic remedy”, while on the other hand he claims “No doubt it is desirable to shorten analytic treatment”.

“Is there such a thing as a natural end to an analysis or is it really possible to conduct it to such an end?” (p. 203) Freud (1937) asks and drafts two conditions in which therapy could be completed. First, the patient must no longer be suffering from his or her former symptoms and overcomes anxieties and inhibitions. Second, the analyst has formed the opinion that so much repressed material has been brought into consciousness, so much that was inexplicable elucidated, and so much inner resistance overcome that no repetition of the patient's specific pathological processes is to be feared at this point (Freud, 2002).

At the end of the article, Freud (2002) returns to the question of the end of analysis, and writes that he has no intention to assert that analysis in general is an interminable business. Whatever our theoretical view may be, “I believe that in practice analyses do come to an end” (p. 224).

It is not easy to predict a natural end to the process, even if we do not look for impossibilities or ask too much of analysis. Every experienced analyst will be able to think of a number of cases in which he or she has taken permanent leave of a patient rebus bene gestis. Here it is not easy to predict a natural end to the process, even if we do not look for impossibilities or ask too much of analysis. The business of analysis is to secure the best possible psychological conditions for the functioning of the ego; when this has been done, analysis has accomplished its task (Freud, 2002).

The additional conclusion of Freud (2002) regarding the end of treatment is expressed in his article: “Observations on Transference-Love” that the solution for transference neurosis, also called love neurosis, is the end of therapy, as it is accompanied by the release of the mental conflicts that result from the suppression of urges directed towards loved ones.

According to Freud (2002) in order to conclude therapy and solve neurosis transference one is required to create conditions in which love transference is created, such as a stable environment, free conversation that is uninterrupted by the therapist, great attention given to childhood memories, and relations with the past and identifying defenses that awaken reactions to these disappointments from past loves. Freud referred to therapy as healing through love towards the therapist that is aroused, enabling the patient to experience the events whose repression had created the symptoms.

Indeed, Bergmann (2017) argues that termination of treatment does not result in resolution of the neurosis transference. According to him, preparation for termination of treatment does not constitute a prerequisite for termination of treatment, since it ends abruptly and interpersonal relationships become intra-psychic relationships that exist in the patient's psyche. Accordingly, many patients continue to love their therapists following treatment, even when the treatment ended in disappointment and dissatisfaction.

In other words, we have no definitive answer regarding the issue of termination of long-term analytic care and the resulting dependency that arises during treatment, which increases and the longer it continues.

Short-term treatment

In contrast to the long-term treatment, I will describe a number of focused and short-term treatment approaches that address the issues of dependency and end of therapy.

Franz Alexander proposed changing the frequency of sessions from daily to weekly, and temporary breaks in treatment as a tool to control the development of regression and dependence. Alexander used periodic pauses to make the patient aware of his or her feelings of dependence (Flegenheimer, 1977).

Malan (1976) developed a method with an emphasis on identifying a major conflict that will represent the focus of treatment. Malan's treatment allows for more appointments than any other short-term treatment (between 20 and 40 appointments), and allows for more dependency and reliance on a therapist. The end date is set at the beginning of the treatment, but despite limiting the predetermined time, the patient is told that he or she can meet the therapist on a regular basis following the treatment if so desired. Malan (1976) believes that leaving this option open for the patient does not in any way reduce the effect of termination.

During this period, Sifneos (1979) also developed a short-term treatment method that he called "short-term anxiety-provoking psychotherapy". Sifneos (1979) carefully adhered to criteria for selecting suitable patients for his method. In the first part of the treatment, Sifneos and his patients would come to an agreement on the central conflict. This technique is more emotionally intense and direct than Malan's. Sifneos also claimed that since his treatment does not use the free association technique, there is no room for transference neurosis. As such, the dependence level on his treatment seems to be relatively low.

As to the termination of the treatment, the patient is told at the beginning that the treatment will be short-term. Since no scheduled appointments have been made, no end date has been set.. When asked about the duration of treatment, Sifneos states that it will be as long as patient wants, but it will last for several months." From the beginning, the therapist lets the patient know that part of his or her responsibility is to decide when to finish. This partnership helps reduce the patient's passive and dependent feelings and prepares him or her to initiate termination (Sifneos, 1979).

The termination usually occurs after the patient has gained intellectual and emotional awareness of the hidden conflict, has shown signs of changing his or her behavior in current life situations, and has displayed an ability to utilize the knowledge gained in solving new problems. Schedules are usually set for one or two meetings after the termination is agreed upon, but they usually proceed in the same pattern of previous meetings while continuing to focus on the Oedipal conflict (Sifneos, 1979).

The short-term therapeutic approach that further defines the dimension of time and addresses the issue of dependence is Mann's (1973). Mann believes that the patient's problems are related to passivity, dependence, and self-esteem that result from the life span in which the child is required to separate from the mother. He argues that very little has been written about time in relation to psychotherapy, and both the therapist and patient avoid it unconsciously. The sense of time in infancy that accompanies the feelings of merging with the mother is more a sense of the absence of time than of time per se (Mann, 1973).

One of the developmental and therapeutic tasks according to Mann is to acknowledge and accept that time is indeed limited, everyone is mortal, and every process has an end, including treatment. Mann’s most notable innovation is the placing of a rigid and predetermined time limit. According to Mann (1973), it is only through setting a fixed time limit that the uncertainty regarding the end of treatment in psychotherapy can be eliminated.

According to Mann (1973) as a result of unconscious resistance to termination, most long-term psychotherapies do not end in a planned and mutually agreed upon manner, but instead end either by a move on the part of the patient or therapist. Other factors can also cause therapy to end abruptly, such as schedule changes, financial problems, or the higher frequency due to transference issues and countertransference issues that did not arise during therapy. Therefore, the treatments usually end without absorbing the separation and without completing the entire treatment, resulting in an insufficient process.

Mann argues that a predetermined time limit forces both the therapist and the patient to confront issues of termination with much less possibility for evasion. Specifically, he sets 12 appointments as the treatment length. In addition, Mann (1973) offers to focus on the central theme of treatment, which should reflect a motif that links current symptoms with other previously experienced difficulties in the patient's childhood, conflicts that the therapist may see as being dynamically related to current problems.

According to Mann (1973), separation is a universal experience and plays a role in any conflict, a certain aspect of the central issue can be tied to the actual end of the treatment. This is often as difficult for the therapist, Mann writes, as it is for the patient. This stage of therapy is usually an emotionally rich experience for both participants. The therapist continues to focus on the main issue, which he ties to emotional transference that arises as the end of treatment comes closer. “Active and appropriate management of the termination will allow the patient to internalize the therapist as a substitute or alternative for the early ambivalent object. This time, internalization will be more positive, with less anger, less guilt, and thus separation will become a true maturation event” (Mann, 1973, p.43).