Interview with Cognitive Therapist, Art Freeman (edited)

Just what does brief therapy mean?

Brief therapy is not a number of sessions. Brief therapy is a way of conceptualizing therapy, a way of developing a therapeutic relationship. It's got a number of aspects. It's directive, it's active, it's focused, it's solution-oriented, it's psycho educational, and it's lots of things done in the limited time that one can use.

What is your particular strategy or approach to brief therapy, and how does that work?

My basic orientation comes out of my work in cognitive therapy. And cognitive therapy and brief therapy are really synonymous. Cognitive therapy has always been a brief therapy. Looking at thinking and using our broad family name, cognitive behavioral therapy, looking at the way people think, looking at the way they behave, looking at the way they feel, and how these all interact.

And just how does that work? How do you operate as a cognitive behavioral therapist, brief therapist?

Well, one of the things we look at is how people understand their world, how people develop their ideas, how people see themselves in the context of their world and helping them to understand where these ideas come from, how they affect their interactions, and basically how they can learn to take better control of their lives.

What are the roots or the basis of this approach, and what influenced you to adopt this approach to therapy?

Well, I think cognitive behavior therapy has two distinct roots. One is dynamic root that goes back to the work of Freud, more specifically, the work of Alfred Adler. It also has a very strong behavioral root looking at the work of Andrew Salter, Jacob Sin, Joseph Wolpe certainly, and cognitive behavior therapy really serves as a meeting point for people from diverse schools because I think it has a strong dynamic component and a strong behavioral component. What influenced me was that it works and we have lots of data that says it works, and that's the best influence for why I do what I do.

Just how does change occur in this process?

That's a hard question John. Change occurs as we can understand the basic schema as one aspect of it, the basic rules we live by. Each of us learns certain rules of life, cultural rules, social rules, religious rules, family rules. And they influence how we think, how we behave, and how we feel, so that change occurs as we start to understand something of the rules we live by. No change also occurs as we directly change behavior because if you are doing something a certain way all of these years and you change it, it may also change the strength of your belief that I can't change.

So it begins with one way to bring about change is through what you call understanding or maybe insight, and then another is by actually doing something different.

Right. We discovered that insight in and or itself is not sufficient for change. That the fact that you have great insight doesn't mean that you develop the skills to change. So I've developed great insight into my golf swing. The insight is I do it wrong. But unless I can learn how to do it right, that insight isn't going to improve my game at all.

So just knowing why this is going on in your life isn't enough to change it?

It's not sufficient. It's interesting and important, but not sufficient.

So as a brief therapist, how do you bring about change? What are you focusing on?

I think two aspects are the directive nature of what I do, that the idea I have is that if the client and I are in my consulting room, one of us has to have an idea of where we are going, and I think that's got to be the therapist because if the client knew where they were going, they probably wouldn't be going to see us. That they would be doing other things with their time and their money. So, that's one piece. The other part is the activity of the client. They have to be willing and able to make a commitment to change which is very simple. I am willing to try to change. If they can't do that or won't do that, then I think brief therapy or long term therapy won't be very effective. So there are two parts then. Your really being able to take charge and to direct the change process . To structure it, and then the willingness on the part of the client.

So, what we would call mandated clients wouldn't really work in this approach, people who don't want to be there, people who the courts are sending?

I am often asked that. I am working with a client who doesn't want to be there, doesn't like therapy, doesn't like therapists, the court has said to either go to therapy or go to jail, and they always pick therapy interestingly. How do I make them change? And the answer is you don't. So a mandated client who comes in and says you know this drug habit is getting the best of me, I need to change it. My abusive behavior toward my spouse has got to stop. My anti-social activities have got to come to an end so I can build my life. They are very workable. The person who comes in and says do me something, change me. I think you can be in long term therapy with them forever, and there still won't be change.

So motivation is the key there.

I think motivation is the key for all therapies.

How does this compare with other brief approaches?

It's a hard question to answer. It depends on whose brief approach. There are many brief approaches. Some very close to what I do. I've watched other brief therapists. I've read of other brief therapists. And very often we are going the same thing and call it different things. I think the elements to brief therapy are very, very similar. I think the structure is essential. A real focus is essential. A real collaboration is essential. The directive nature is essential. Doing non-directive free associative work can be brief by definition. So I think there are lots of similarities. I think what makes what I do maybe different from others, maybe not all others, is the cognitive behavioral focus, and that doesn't exclude emotion. Clearly, if someone is depressed you want to change their depression. But the way into the system is understanding the way they think, process information, and certainly how they behave.

I am intrigued by the notion of the structure. Just how to do you structure an interview? Are there steps or stages that you go through?

Well, there is a beginning, middle, and end The beginning is involved in developing rapport. It's essential. Good therapy is good therapy, and a relationship is an essential piece. The brief therapist has to be especially skilled at developing a relationship fairly quickly that you don't have months to develop the relationship.Then to develop a problem list. Developing a problem list that is very focused is essential. One of the bywords for what I do is that vague goals lead to vague therapy, and vague therapy leads to vague results. So I try to avoid things like I want to work on my self esteem. It's too vague. I am having communication problems at home. Too vague. So very early in the session I want to try to focus, to get definitions, understandings, but to really focus. The mid part of the session is developing the theme. With about five minutes left to go in the session, what I want to do is then bring the session to a close. I don't want it to be abrupt - I'm sorry our time is up for today. I want to give the client time to come back together, to review the session. What did you learn? What are you taking home with you? So that the session isn't just something that rolls along but that I've got to take responsibility for maintaining a structure and a focus.

I think there is a lot of empirical data about cognitive therapy starting with the late seventies, the work on depression. There has been a huge amount of work on anxiety. The other work on depression by Beck. The work on anxiety by David Clark, Paul Sarcoscis at Oxford, the work on cognitive behavioral approaches with PTSD, Edna Foa, the work on personality disorders that Beck and others have done. So there is a huge body of data that talks to the issue of cognitive behavioral approaches as brief and empirically validated.

You talked about this need for motivation, for change. Other than that are there clients that this just doesn't work with, or are there specific kinds of clients that it works better with than others?

If you would have asked me that question in 1978, I would have said we work with depression because that's what we did. I would say at this point cognitive behavioral approaches are a general model for treatment, that we've seen cognitive therapy work as a pain management technique, as work with couples, families, in patients, out patients, children. I would think that with modification a cognitive behavioral approach would be useful with a broad range of clients, broad range of settings, broad range of modalities. Does it work better with some than with others? Yes, depending upon how you structure it. So, for example, if I was working with an individual with severe problems, I would be using more behavioral than cognitive. It just talks to how you structure the broad repertoire of cognitive behavioral work.

What about cultural differences?

Cognitive therapy cross culturally as a short term model has been very popular. I've done a good bit of traveling, and one indication is that I have had books on cognitive therapy translated into nine languages, and it is always interesting that people in Sweden say they like cognitive therapy because it fits into the Swedish cultural style, and people in China say they like cognitive therapy because it first into China's cultural style, and the reason is cognitive therapy as a basic approach is not content oriented but process oriented. So it's not that we have, there's an Oedipus complex that may not be cross-cultural. The goal is to help someone in their culture understand the rules or schema of their culture and how it affects their lives. It's a process.