Over the course of my personal life – including as part of my own vocational training – I have been privileged to receive both brief and long-term psychotherapy. In 2012, through my Employee and Family Assistance Program (EFAP), I received five (5) sessions of solution-focused psychotherapy (SFT). In late 2013 and early 2014, at the Vancouver Association for Survivors of Torture (VAST), I received about twenty (20) sessions of brief integrative psychotherapy, combining expressive arts therapy (EXAT) (McNiff, 1992) and Focusing (Gendlin, 2007). Lastly, as part of my own training as an expressive arts therapist, I completed a long-term course of open-ended EXAT, lasting approximately three years and more than sixty (60+) sessions.
Each of these psychotherapeutic experiences and encounters have been positive. In retrospect, I would say that the short-term therapies that I received were no less positively impactful in my life than the long-term expressive arts therapy. Not only did these brief psychotherapies connect me to invaluable personal and social resources, but just as importantly, they allowed me to process and integrate intergenerational and early life traumas. More than this, and taken together, I have internalized both the therapies and the therapists who helped cultivate both around me, and indeed within me, a felt-sense of safety, self-worth, and newfound vitality (Dewan et al., 2018).
As an expressive arts therapist who now works at the complex intersection of clinical, cultural, and ethical considerations at VAST, the purpose of this paper is to reflect on the benefits and limitations of brief psychotherapy in the rehabilitation of trauma and torture survivors. This paper will also outline and expand upon my preferred brief integrated dynamic psychotherapy framework and provide a clinical rationale for this choice. Ethical and cultural considerations will also be addressed.
Benefits of Brief Psychotherapy
As an organization of devoted volunteers, community engagement staff, social workers, psychologists, psychiatrists, and other clinical staff, VAST works alongside settlement agencies, primary care providers, legal representatives, and various government bodies and agencies to support the complex psychosocial and mental health needs of refugees residing on the unceded First Nations territories of British Columbia, Canada. VAST offers free and integrative group and individual psychotherapy. Individual psychotherapy is typically limited to between 8-15 sessions. As such, the application of brief psychotherapy models is foundational to the psychotherapeutic services that VAST provides.
In this context, there are several benefits to using brief psychotherapy. Firstly, brief psychotherapy modalities are cost-effective. This is critical to operating a not-forprofit organization like VAST ethically, responsibly, and viably. Secondly, the brevity of treatment means that treatment becomes more accessible to a greater number of persons in need, which in turn supports equitable service delivery. Thirdly, brief therapies focus on the present and the future, both critical loci of change in any psychotherapeutic process (Dewan et al., 2018). Fourthly, brief psychotherapies are guided in many ways by the butterfly effect, namely by the principle that in non-linear systems, such as the human nervous system, a small present-moment change can produce surprising and significant impacts on the system (Iwakabe, 1999; Weiss et al., 2015). Fourthly, brief psychotherapies tend to be focused, realistic, specific, and concrete in their treatment goals; these are therapy characteristics that have been shown to promote positive psychotherapeutic outcomes (Dewan et al., 2018). Fifthly, brief psychotherapies can offer corrective experiences and remedy attachment injuries and traumas so common among therapy-seeking populations (Fosha, 2021a). Lastly, intelligently integrated brief psychotherapy modalities, alongside astute case conceptualization, can offer ethically designed and culturally safe psychotherapeutic encounters among culturally diverse and heterogeneously traumatized and under-resourced clinical populations. From an ethical perspective, brief psychotherapy can integrate trauma-informed bestpractices to minimize the risk of re-traumatization. While culturally sensitive practice can foreground the importance of collaboration, client-centred exploration and meaning-making are part of each psychotherapeutic intervention. In the context of working at VAST, this means avoiding, as much as possible, the top-down imposition of western, euro-centric modes and models of understanding human nature, including, but not limited to, human pain and suffering.
Limitations of Brief Psychotherapy
There are several limitations to brief psychotherapy. Brief psychotherapies can be limited in terms of the therapeutic gains achieved within such a limited time. Clients with complex presenting issues – including complex developmental trauma histories – are likely to benefit in only a limited way from brief psychotherapy (Dewan et al., 2018). Secondly, in terms of therapy duration, the one-size-fits-all model fails to recognize complex client needs beyond symptom reduction. For instance, helping support the basic interpersonal need for authentic connection may be difficult for some persons to develop or maintain outside of a formal therapeutic encounter. Also, brief psychotherapies may be limited in terms of addressing the complex needs that clients may have in association with especially protracted and painful life experiences, such as the complex grief associated with the sudden death of a spouse or child, significant or sudden disability, chronic pain, or otherwise significant vocational or occupational transitions. Thirdly, complex presentations involving recurring and protracted childhood trauma, neglect, and/or attachment injury may require prolonged – and focused – psychotherapy to adequately integrate, through both process and contentcentred corrective experiences, the massive dose of disavowed and dissociated psychic content often associated with these presentations (Schimmenti et al., 2016).
Many clients at VAST – especially, and not surprisingly, those clients with histories of secure attachment – benefit from the brief integrative dynamic psychotherapies that VAST offers. However, clients who report histories of torture and developmental trauma and clients who must cope with the heightened stress of on-going financial hardship and family separation may require longer-term psychotherapy and clinical monitoring.
The EFASS-Framework of Brief Integrative Dynamic Psychotherapy
The core and foundational framework that I learned as a client at VAST, and which I am now expanding upon as part of my own educational development as a clinician, is a brief integrative dynamic psychotherapeutic framework that integrates principles, techniques, and best-practices from various somatic-experientialpsychodynamic modalities, incorporating elements from EXAT (Mcniff, 1992), Focusing (Gendlin, 2007), Accelerated-Experiential Dynamic Psychotherapy (AEDP) (Fosha, 2021a), Somatic Experiencing (SE) (Levine, 2010), and Sensorimotor Psychotherapy (Ogden, 2006), and which taken together one could call EFASS-Brief Integrative Dynamic Psychotherapy.
Additionally, I am also interested in exploring the potential of MDMA-Assisted Psychotherapy (MA-PT), which has been shown to effect significant and safe treatment gains for treatment-resistant posttraumatic stress disorder (TR-PTSD) (Barone et al., 2019; Ching et al., 2022; Illingworth et al., 2021; Jerome et al., 2020; Mithoefer et al., 2011; Mithoefer et al., 2013). Since TRPTSD tends to be over-represented among torture survivors (Baker, 1992; Hárdi et al., 2011; Miller, 1992; Sapporta et al., 1992; Somnier et al, 1992), MDMAAssisted EFASS Brief Integrated Dynamic Psychotherapy may better support individuals who experience difficulties accessing treatment gains with other psychotherapeutic approaches and modalities.
Each of these brief psychotherapy modalities, on their own and in various degrees of best-fit-for-client integration, can be generalized by the following therapeutic ethos: “make the implicit explicit, and the explicit experiential” (Fosha, 2021b, p. 33).
Each of these brief psychotherapy modalities, wholly or in part, are also characterized by the following shared therapeutic modus operandi:
• Inviting the client to stay present with their own inner experience. • Fostering willingness to explore new and unexpected perceptions.
• Cultivating attention to the client’s account of their inner experience.
• Observing a delicate balance between focusing on inner experience in an open-ended way.
• Co-creating a therapeutic space where therapist and client can surrender to the process without controlling or over-determining its outcome.
• Cultivating in the therapist and client a recognition that therapy is a non-linear process that may shift and resolve in unexpected ways.
• Abiding by the foundational principle that a human being’s inner healing intelligence, in conjunction with the ‘medicine,’ will bring forth whatever experiences are needed for healing and growth so that anything that arises is viewed as part of the healing process.
• Recognizing that the therapist’s role is often to follow rather than guide.
• Abiding by the core belief that facing painful experiences is a path towards healing. (Ruse et al., 2008)
Additionally, each of these modalities, individually or within the proposed integrative framework, is specifically designed, in one way or another, to produce in-session innovative moments (IM). IMs are markers of clinical change in which the patterned problem or problems related to a client’s suffering are challenged by in-session experiences (Nasim et al., 2019; Nasim et al., 2021). Research has found that therapy sessions for recovered clients have more IMs than therapy sessions for unchanged clients. Also, it has been found that IMs and outcomes improve over the course of treatment and have been positively correlated with client session impact ratings (i.e., client perceived session positivity, smoothness, and depth), as well as with therapist positivity ratings of sessions.
The EFASS-Brief Psychotherapeutic Integrative framework Dynamic combines psychotherapeutic techniques and processes to activate and transform implicit memory systems and schemata. It does so in a way that powerfully and effectively fosters IMs of resourcefulness and corrective experience. This basic and guiding clinical ethos and method run countercurrent and in clear opposition to two (2) broadly related etiological currents in the pathogenic process:
1. The pathogenic survival-based disavowal and dissociation of both implicit and explicit psychic experience (Schimmenti et al., 2016), and
2. The pathogenic experience of “overwhelming aloneness in the face of emotionally overwhelming experience” (Tunnel et al., 2021, p. 89).
Clinical Rationale for Use of the EFASS-Brief Integrative Dynamic Psychotherapy Framework in the Rehabilitation of Refugees and Torture Survivors
Congruent with expert prediction on the future of psychotherapy (Norcross et al., 2022), the clinical rationale for offering EFASS-Brief Integrative Dynamic Psychotherapy at a center for the rehabilitation of refugees and torture survivors, is based primarily on the common factors model of psychotherapeutic treatment efficacy (Dewan et al., 2018).
Firstly, this integrative framework offers a diverse array of therapeutic interventions that, much as like tailored pharmacology, can offer activities and experiences that are more congruent with intrinsic client strengths, resources, interests, skills, and manners of organizing and processing information and present-moment phenomenological experience (Ogden et al., 2006). The capacity to tailor treatment in this way can foster more deeply culturally congruent, collaborative, trusting, and open experiences between client and therapist, which has been shown to improve treatment efficacy (Dewan et al., 2018). Secondly, psychodynamic interventions that promote IMs have been shown to predict positive treatment outcomes, and this may be especially the case with primary and secondary presentations of unresolved trauma, which have been shown to be over-represented in implicit memory structures and systems (Gregoire et al., 2020). Lastly, EFASS-Brief Integrative Dynamic Psychotherapy can foster client hope (Dewan et al., 2018) by providing a core rationale or myth/story of healing. For example, by conceiving and communicating to the client that healing is connected to an exploration of the embodied emotional imagination in the context of a supportive, kind, and accepting therapeutic relationship.
Return to Tepaza
In the aftermath, and in the still reverberating destruction of the Second World War, the Algerian-born French writer Albert Camus, returned to the town of Tepaza, where he had spent the best days of his youth (Than, 2014).
From there, as he gradually regained a better sense of himself, he wrote a letter to a friend. “In the middle of winter,” he wrote, “I have discovered within me an invincible summer.” (p. 60). Such has been not only my experience as a fortunate recipient of brief – but potent – integrative somatic, imaginative, and attachment-based psychotherapy, but I have also had the privilege – through effectively integrated brief dynamic psychotherapies – of witnessing clients at VAST reconnect to the shared and invincible summer within themselves, and this amidst the softening thaw of so many seemingly endless winter.
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