"Sometimes," Freud reportedly said, "a cigar is just a cigar."
In Freudian psychotherapy, however, it seemed that nothing else was what it appeared to be; finding and fixing the patient's problems could take years and years and years of analysis.
Increasingly, however, therapists now are saying that sometimes problem is just a problem. Pushed, perhaps, by a tight economy in which insurers are reluctant to underwrite an endless treatment schedule, and empowered by types of therapy aimed at faster action, they're setting some sore psyches on the road to recovery with "short-term therapy" -- which can mean anything from 20 sessions to one.
Just how quick short-term therapy is, of course, depends on patient, problem and approach, say psychotherapists. For example, someone with job-related difficulties or an irrational fear might be set on the road to recovery fairly quickly, while a victim of child abuse might require years of help.
"There's a continuum of problems," notes John Verleger, LCSW, whose clinical social work practice in Parkville is called the Family Counseling Center of Baltimore. At one end, where difficulties can often be resolved fairly quickly, are the "adjustment disorders," he says, referring to the distress that arises from a particular situation.
For more long-lasting problems -- a long-term depression, a severe personality disorder, or a psychotic disorder like schizophrenia -- therapy would also be on a longer-lasting schedule, he adds.
A prime proponent of short-term therapy is University of Colorado psychologist Bernard Bloom, author of a new manual titled "Planned Short-Term Therapy: A Clinical Handbook," which was published by Allyn & Bacon in August.
Helping the greatest number of people in the least amount of time is his goal, Dr. Bloom said in a telephone interview from his office in Boulder, Colo. And in a surprising number of cases, he said, he has set people on the road to recovery in a single session.
Other psychologists have had one-time successes too, although they are quick to say most therapy takes longer.
"I had someone come in who was afraid of being home alone," says Dr. Charles Citrenbaum, of Cross Keys. "She had been to other therapists to explore her fearfulness, to get into possible under-lying causes or sensitivities, and she felt frustrated because she still felt afraid.
"So I suggested she get a big dog, and she thought that was a great idea."
End of therapy. Fearfulness conquered. Problem solved. Over and out.
However, Dr. Citrenbaum adds, "It depends on the problem. Sometimes people come in with a dilemma for which they just need some problem-solving, and one good session could do the trick. But, of course, there are other issues, other problems, and other needs that clients present. And for those other things, just one session certainly is not indicated."
Psychologist H. Richard Waranch, director of the behavioral medicine and biofeedback clinic at Johns Hopkins Hospital tells the same kind of story. "A child came in with a sleeping problem; he was afraid of sleeping alone. So I told his parents to buy an intercom, and that was enough to reassure him."
But for another child with the same problem, the intercom didn't VTC help. "Sometimes you come up with an answer that works, but for others that answer doesn't work because everyone is not the same," Dr. Waranch points out.
"I think all therapists have had the light bulb go off, the aha! experience: The patient gets an insight and goes out and does something differently," says Susan Walen, Ph.D., whose practice called the Center for Cognitive and Rational-Emotive Therapy.
"Sometimes it's a simple slogan that you provide that is a way of conceptualizing the problem; the patients get what they came for and go away happy," she says. "But that's hardly the rule."
Moreover, when patients disappear after a single session, there's no guarantee they are better, notes psychologist Susan Kodish: "Even if you get some kind of really terrific change in the first session . . . how do you know it's carried out or maintained if the person never comes back?"
And even when something really seems to work, it's not necessarily a cure.
"A person can come in in real distress; if you can shift their frame of reference, you can get them out of distress, and you can do that in one session with some people," Mr. Verleger says. "But that doesn't mean there aren't other aspects of their personality that wouldn't benefit from more therapy."
Despite newer methods of short- er-termed therapies, the question of how much therapy is increasingly complicated these days. Rather than being strictly up to the therapist, says Dr. Waranch, "Now, most insurance companies require documented treatment plans, where the therapist has to say what the specific goals, techniques, and prognoses are, and then the insurer says, 'We will give you 10 sessions, or 20. . . ."