Making a Case for Quick, Confrontational Therapy

Seated before a television set in his cramped Mission Valley office, psychiatrist Tom Trunnell watches a videotaped therapy session in which he persistently questions a middle-aged patient. The patient, an attorney, twists uncomfortably in his chair, obviously agitated by the line of questioning.

He had come to Trunnell after suffering from debilitating depression much of his life. A breakup with his high school girlfriend, his divorce, the deaths of his parents, all left him devastated, barely able to function.

The lawyer became severely upset each time he separated from someone close to him, and the latest bout of depression, which had lasted three years, came after the death of his mother, whom Trunnell said was a cold, harsh woman.

"When he broke up with his high school girlfriend and was sitting crying in the breakfast nook, his mother said to him, 'Big boys don't cry and there are plenty of fish in the sea.' How's that for motherly love?" the doctor said.

Trunnell began treating the lawyer with traditional psychotherapeutic techniques. But after four months, he could see the treatment was going nowhere.

During the middle of one session, he abruptly took a new tack. He confronted the attorney. Each time the man complained of feeling depressed, Trunnell asked him what he intended to do about it. The client became irritated. As each defense came up, Trunnell attacked it.

"How do you feel?" the therapist asked.

"I feel helplessly backed into a corner, and I don't know where to go to get relief," the lawyer answered.

"But how are you experiencing that? What does it feel like?"

"I'm angry."

"What can you do about that?"

"You keep telling me to do something about it, and I don't know what to do!" the man choked out angrily. Trunnell continued the questioning, and the lawyer, eventually worn down by it, burst into sobs, rocking in his chair like a child.

That confrontational technique helps patients get better more quickly, says Trunnell, who runs the San Diego Institute for Short-Term Dynamic Psychotherapy.

According to Trunnell, long-term therapy is usually unnecessary. Most people, he says, can overcome their specific emotional or behavioral problems in one to 40 weekly sessions, with the average patient requiring about 20 visits over six months.

"People don't want to wait around five years to be cured anymore," Trunnell said, adding that a handful of his patients have been cured in one visit. Scores of sessions can be avoided if the therapist forces the patient to seek a solution sooner. "Clients will take longer to resolve their problems if they know they can. One advantage of taking longer is that you can procrastinate facing your pain."

Others in San Diego's psychiatric community disagree. Short-term therapy is a useful tool, they say, but not the only tool. They hardly agree with Trunnell's assessment that "traditional psychotherapy is going to die like a brontosaurus."

"The therapy should be fit to the patients and their needs," said Dr. Haig Koshkarian, a La Jolla-based psychoanalyst. "I would be concerned or wary of any therapist who said they had a treatment that worked for all people and all problems, and who, in addition, is critical of what others do."

Trunnell considers short-term therapy to be on the cutting edge of psychiatric treatment, partly because clients' time and money is becoming more and more limited.

When patients begin traditional psychotherapy, there's no telling how long they will see their doctor. In some cases, the number of sessions is open-ended, or even never-ending. For a few patients, psychotherapy becomes as routine and essential as breathing.

Trunnell believes it might have taken months for the lawyer he treated to reach a similar breakthrough had Trunnell continued with traditional psychotherapeutic methods.

The lawyer broke down, Trunnell said, because he was finally forced to confront the sadness he felt when his grandmother died years before. Unlike his mother, the man's grandmother was warm, caring and concerned. They were close. She died when he was 19, yet he had never cried over her death.

The patient's failure to mourn his grandmother's death had depressed him his entire life. When his own mother died, he once again experienced the pain of her coldness and the emptiness of life without his grandmother's love. He learned he was angry at his mother for being insensitive, and at his father for never standing up to his mother's emotional cruelty.

Anger and sarcasm were the attorney's ways of unconsciously suppressing the overwhelming sadness he felt over his family situation. Previously unconscious feelings--as opposed to just thoughts--rose to the surface and could be drained away. There was no longer a reason to hold them back.

"He'd always been kind of cold and aloof. Now he's warm as a puppy dog," Trunnell said.

Koshkarian acknowledged that in recent years, psychiatrists have found that short-term therapy, once considered only "crisis therapy," is more beneficial than originally thought for solving emotional problems.

But for people who continue to play out issues from their past in their present lives, causing detrimental effects on love and work, long-term treatment is necessary, he said.

"It takes years to learn to play the piano or the violin," Koshkarian said, "so to think that most people can learn to change their personality in 20 weeks is somewhat unrealistic."

That mainstream opinion won't stop Trunnell from pushing short-term therapy. Considered a brilliant yet somewhat controversial figure among San Diego therapists, Trunnell believes the popularity of short-term therapy, which he switched to five years ago, will grow for several reasons.

Today's young adults are restless, he said. Raised on television and fast food, these "baby-boomers" want other forms of gratification just as quickly. A generation with a short attention span will choose short-term therapy to deal with its emotional problems, Trunnell believes.

Because people 25 to 45 make up a large portion of most doctors' practices, it's easy to see why Trunnell hopes that brief therapy will appeal to this age group.

Additionally, he said, many clients do not want to spend thousands of dollars to get relief, nor do insurance companies want to pick up the tab for three years of weekly sessions. Health care insurers continue to cut back on the number of psychiatric visits allowed per year. Many now allow only 20, rather than the unlimited number of sessions they have subsidized in the past.

Short-term therapy is not cheap; by the session, it costs the same as more traditional therapies. But with only a limited number of sessions, the total bill, about $2,500, is much lower than for long-term treatment.

"If you can afford to buy a used car, you can afford this treatment," Trunnell said.

The key difference between traditional psychotherapy and short-term therapy is the role played by the doctor.

During traditional psychotherapy, the therapist allows the patient to dictate what happens during a session. Unlike in Trunnell's 20-session regimen, it is non-directive, meaning the therapist follows the client's lead during sessions as the patient meanders through his maze of problems.

The therapist tries to establish an environment in which the client feels comfortable discussing his feelings and fears. Often, the therapy focuses on the belief that the patient is his own best therapist and, given time, will eventually find the best resolution to his problems.

But in short-term therapy, the doctor is in the driver's seat. He constantly steers the patient into his pain, never allowing him to veer away.

Trunnell claims that the pressure, while often excruciatingly uncomfortable, results in a breakthrough more quickly. Years of therapy are avoided, time and money are saved and more patients can be seen and helped.

"I think some patients can benefit from that kind of treatment," said Dr. Jay Shaffer, president-elect of the San Diego Society of Psychiatric Physicians, "but in 10 or 20 sessions, it's unlikely a lifelong pattern of being is going to be changed and changed for good."

Short-term therapy has been in vogue several times during the past century, Shaffer said. Sigmund Freud employed short-term techniques before developing psychoanalysis.

Shaffer said that the people who benefit most from short-term therapy usually have problems related to a single event or issue rather than longstanding emotional troubles that have followed them through life.

Shaffer, like many of San Diego's 350 psychiatrists, uses a mixture of therapeutic techniques as well as medication to treat clients, tailoring the treatment to suit each one. Sometimes, direct confrontation may be necessary to push a resistant patient toward resolution.

"But one-size-fits-all therapy isn't likely to solve the world's ills," Shaffer said. "To say short-term therapy is a panacea is just not the case. It's a worthwhile tool, but it's not the only tool we have."

Trunnell said that most people who seek short-term therapy complain of traditional mental illnesses: depression, anxiety, phobias, hysteria, obsessiveness, sexual problems, psychosomatic illness and chronic relationship failure. To achieve quick results, Trunnell uses aggressive techniques at the outset. He learns the person's history, makes a determination about the underlying cause of the problem, then works to make the patient see the problem and feel the pain it produced, which has been repressed.

Most short-term analyses focus on the patient's early childhood experiences. Trunnell said he usually discovers some suppressed trauma in the client's past that has not been resolved.

For example, a woman may be depressed because her father abused her when she was a child. However, the memory is so upsetting that she cannot bear to relive it. Instead, she turns the anger on herself, resulting in depression. Her unconscious protects her from feeling the pain, but it also stops her from feeling joy and happiness. She is miserable.

During therapy with such a patient, Trunnell systematically breaks down his client's defenses by hammering away at every smoke screen thrown up to hide the real issue: her father's abuse. Once the woman feels the pain associated with his treatment, her depression can lift.

Anger and sadness are the primary emotions most patients try to avoid, Trunnell said, and anger often doubles as a defense to feeling. Once their rage is drained away, clients experience an intense need for the tenderness and warmth they usually missed out on as children.

During therapy, patients unconsciously employ a variety of defensive techniques to stop the therapist's attempts to reveal the repressed feeling, Trunnell said. These include passivity, regression, denial, purported loss of memory, rationalization, attempts to shift attention to the therapist's behavior during a session and converting anxiety into physical symptoms. Most patients use all of them.

Whenever the patient unconsciously attempts to ignore or evade the issue, Trunnell said, he brings him back to it. The goal is to get the patient to feel the pain causing his distress rather than simply talk about it. Only then can the patient desensitize the event causing the misery and rid himself of his disorder, he said.

Trunnell practiced traditional psychotherapy for years, until the day he decided it didn't work. It was too intellectual; clients could dodge their feelings too easily, he said.

Disgruntled with the slow progress of psychotherapeutic techniques, he searched for an alternative. He found it in the short-term dynamic psychotherapy developed by Dr. Habib Davanloo, professor of psychiatry at McGill University in Montreal.

Davanloo began toying with the idea of short-term therapy during the early 1960s when he, like Trunnell, began to despair about the length of therapy and the long list of patients who couldn't get into psychiatric clinics. Over the next 10 years, Davanloo developed his short-term, confrontational technique using video cameras to review techniques he used during sessions. The tapes are now used to train others in short-term psychotherapy.

Trunnell spent several years attending Davanloo's seminars to learn more about the short-term technique, which he then began using in his San Diego practice. He said he's seen remarkable breakthroughs in patients, many of whom found little success with other types of therapy.

Whether short-term therapy catches on may have less to do with whether it works than with the fact that it saves time and is cost-effective. That alone may prompt patients to resolve their problems in six months rather than six years.

Still, Trunnell believes the strength of short-term therapy centers around its confrontational style, a style he maintains produces more effective results, and he is confident the coming years will bear out his prediction.

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