“In Pattern Focused Therapy, Dr.

Sperry offers another remarkably timely, practical,

easy-to-read contribution for both students and professionals in health and mental
health care professions. In our current healthcare marketplace clinicians must
provide brief, evidence-based, practical, and efficacious treatments for their clients
and this new book will help them to do so. It represents the new third wave of
cognitive behavioral therapy that addresses six compelling trends in the field just
perfectly. Clearly, this book should be in the hands of all practitioners today and is
likely to become a classic.”
– Thomas G. Plante, Ph.D., Santa Clara University and Stanford University
School of Medicine

“Pattern Focused Therapy is one of the most practical texts available on how to do
brief CBT evidence-based practice therapy. This book provides all the necessary
tools for assessment, case conceptualization, technique selection, and outcomes
monitoring in clear step-by-step procedures and therapy session examples.
Beginners and experts alike will benefit from a special chapter dealing with
practical strategies for preventing premature termination. If you want to learn
how to do effective therapy in 4–6 sessions, this book will show you how.”
– Brian A. Gerrard, Ph.D., Western Institute for Social Research, Berkeley,
and University of San Francisco

“Dr. Sperry’s book is a valuable addition to third wave cognitive-behavioral therapy.

Pattern Focused Therapy is a clear and accessible presentation of Sperry’s brief, rela-
tionally focused, and evidence-based approach to progressive cognitive-behavioral
therapy. It is an essential resource for therapists-in-training, therapy educators, and
seasoned clinicians.”
– Richard E. Watts, Ph.D., distinguished professor, Sam Houston
State University
Pattern Focused Therapy

Pattern Focused Therapy incorporates brief cognitive behavioral therapy (CBT)

interventions for symptom reduction and a step-by-step therapeutic strategy for
effectively changing clients’ maladaptive patterns and increasing their well-being.
Integrating research, clinical expertise, and client needs and values, Pattern
Focused Therapy is a highly effective third-wave CBT approach that can be
applied to a wide range of clients. This text guides therapists through the pattern
focused approach, facilitating learning through session-by-session transcriptions
and commentaries from the first to the final session. Interventions for optimizing
treatment and indicators of successful therapy are included along with a chapter
on Pattern Focused Therapy in integrated care settings.
Seasoned and beginner therapists alike will benefit from this invaluable method
for learning and mastering this evidence-based approach.

Len Sperry, M.D., Ph.D., is a Professor at Florida Atlantic University. He has

practiced, taught, and written about CBT for four decades. Among his 1000+
professional publications are six other CBT books.
Pattern Focused Therapy

Highly Effective CBT Practice in Mental

Health and Integrated Care Settings

Len Sperry
First published 2021
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Taylor & Francis
The right of Len Sperry to be identified as author of this work has been
asserted by him in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Sperry, Len, author.
Title: Pattern-focused therapy : highly effective CBT practice in mental
health and integrated care settings / Len Sperry.
Description: New York : Routledge, [2020] | Includes bibliographical
references and index. | Identifiers: LCCN 2020007191 (print) |
LCCN 2020007192 (ebook) |
ISBN 9780367429300 (hardback) | ISBN 9780367429317 (paperback) |
ISBN 9780367429331 (ebook)
Subjects: LCSH: Cognitive therapy.
Classification: LCC RC489.C6 S64 2020 (print) | LCC RC489.C6 (ebook) |
DDC 616.89/1425–dc23
LC record available at https://lccn.loc.gov/2020007191
LC ebook record available at https://lccn.loc.gov/2020007192

ISBN: 978-0-367-42930-0 (hbk)

ISBN: 978-0-367-42931-7 (pbk)
ISBN: 978-0-367-42933-1 (ebk)

Typeset in Perpetua
by Taylor & Francis Books
Contents

Acknowledgments viii
Introduction ix

1 Pattern Focused Therapy and Psychotherapy Practice: Today and

Tomorrow 1
2 Pattern: Assessment and Case Conceptualization 16
3 Practicing Pattern Focused Therapy 44
4 Ultra-Brief Therapeutic Interventions 63
5 Outcomes Assessment and Indicators of Successful Treatment 80
6 The First Session 98
7 The Middle Sessions 120
8 The Final Sessions 141
9 Interventions for Optimizing Treatment 156
10 Pattern Focused Therapy in Integrated Care Settings 184

Index 204
Acknowledgements

I am deeply grateful to those who have mentored me over the years in the fine
points of psychotherapy practice. Of particular note are Rudolf Dreikurs, M.D.,
Kenneth I. Howard, Ph.D., Richard Cox, Ph.D., and Barry Blackwell, M.D.
Special thanks to the editorial staff of Routledge, particularly my editor Nina
Guttapalle, for their valuable input. Finally, I want to acknowledge two of my
former doctoral students. Vassilia Binenstzok, Ph.D. who collaborated with me on
some related projects, and Gerardo Casteleiro, Ph.D. for editorial assistance with
this project.
Introduction

There is little doubt that psychotherapy practice today is changing and changing rather
dramatically. It is much different than it was 10 years ago, and it is expected to change
even more in the near future. Several factors account for this change, but three stand out.
The first is reimbursement. Reimbursement of psychotherapy and related
mental health services increasingly requires that therapists document the use of
evidence-based approaches and interventions. Currently, all clinical psychology
graduate programs require their students to master at least one evidence-based
treatment approach. Unfortunately, very few other graduate therapy training
programs emphasize evidence-based approaches or require the teaching and
learning of evidence-based practice and interventions.
The second is that treatment is getting shorter. Not only is the duration or length
of therapy getting shorter, but therapy sessions are getting shorter. Instead of the
usual 12-20 sessions as the norm, the typical course of treatment will more likely to
be 4-8 therapeutic encounters. Instead of 50 minutes sessions, the length of the
therapeutic encounter will last as little as 15-30 minutes.
The third is that is that where it takes place, the treatment context, is beginning to
change. It is predicted that much of psychotherapy practice will shift from dedicated
mental health settings to integrated primary care medical settings. Here, the therapist
will function as part of a health care team which includes physician, nurse, medical
assistant, and a therapist in the role of behavioral health consultant. While at first this
may seem alien to many therapists, it may actually be a welcome change. For starters,
integrated primary care is more compatible with psychotherapy’s focus on strengths and
prevention in addition to pathology. For another, there is little or no need to seek
authorization for treatment or provide extensive documentation for counseling services
in a medical setting. Finally, working as a salaried member of a team beats competing
with other mental health professionals for HMO panels and insurance reimbursement.
These three anticipated changes are very real and will require significant changes in
how therapists are trained and practice. There is little doubt that therapists will be
expected and required to practice new or greatly revised treatment approaches that
x Introduction

are evidence-based. What is needed is a learning resources to help both trainees and
practicing therapists to learn and begin to master evidence-based approach and
interventions that will ensure they meet the demands for accountable care and be
reimbursed for counseling/therapy services rendered.
Pattern Focused Therapy: Highly Effective CBT Practice in Mental Health and Integrated
Care Settings is an invaluable resource for learning a very brief, evidence-based therapy
approach. It was developed, researched, and used successfully to train graduate students
in cutting-edge psychotherapy approaches and interventions at Florida Atlantic Uni-
versity since 2012. It provides an in-depth description of Pattern-Focused Therapy, and
how it is practiced effectively in both mental health and primary care settings.
Pattern Focused Therapy is a third wave Cognitive Behavior Therapy (CBT)
approach which include Acceptance and Commitment Therapy, Cognitive Beha-
vior Analysis System of Psychotherapy, Dialectical Behavior Therapy, and Mind-
fulness-based Cognitive Therapy. Like other third wave approaches, Pattern
Focused Therapy emphasizes the therapeutic relationship, effecting deep change,
but unlike other approaches.it is applicable to nearly every clinical presentation,
and is designed to be practiced in both mental health and integrated care settings.
Pattern Focused Therapy incorporates brief CBT interventions for symptom
reduction and a step-by-step therapeutic strategy, called the Query Sequence, for
quickly and effectively changing personality and pattern. In my experience, Pattern
Focused Therapy is relatively easy to learn, master, and apply to a very wide range
of clients. Practicing this approach is illustrated in two completed and successful
clinical cases. The first is a six-session therapy, 45-minute sessions, with tran-
scriptions and extensive commentary. The second case illustrates how Pattern
Focused Therapy is practiced in an integrated care setting in four sessions of 30-
minute duration. In short, the book is an accessible and practical resource for
learning and mastering an evidence-based therapy approach that is brief, effective,
reimbursable, and applicable to mental health and integrated care settings.
This book will be of clinical value to psychotherapists and other clinicians in both
mental health and integrated care settings. It will also serve as a main or companion text
for graduate and undergraduate psychotherapy and counseling techniques courses,
advanced therapy intervention courses, and introduction to counseling/psychotherapy
courses in professional counseling, human services, and psychology programs; as well as
for psychotherapy and counseling practicum and internship courses.

Overview of the book

The first chapter discusses the six professional trends that are increasingly
impacting the practice of psychotherapy and related clinical services. It then shows
the timeliness of Pattern Focused Therapy and how it dovetails with these trends.
 Introduction xi

Chapter 2 begins by defining pattern and its centrality in Pattern Focused Therapy
and then describes the assessment process and the place of case conceptualization
in this therapy approach. Chapter 3 details the origins, components, and clinical
aspects of this approach including the Query Sequence which is its core ther-
apeutic strategy for achieving deep therapeutic change. Chapter 4 describes 12
ultra-brief CBT interventions for reducing symptoms and stabilizing the client.
Pattern Focused Therapy combines both of them in tandem to effect therapeutic
change: ultra-brief interventions for first order change, i.e., symptom reduction
and stabilization, and the Query Sequence for second order change, i.e., pattern
or personality change. Chapter 5 details how brief measures, including screening
instruments, are utilized to assess and monitor progress throughout the therapy
process. Next, Chapters 6, 7, and 8 describe the treatment process of Pattern
Focused Therapy with a completed and successful six session therapy that illus-
trates its application with extended transcriptions and commentaries. Two final
chapters round out the book. Chapter 9 provides some advanced therapeutic
interventions for dealing with complicating situations that can derail the ther-
apeutic process. These include transference-countertransference enactment and
common therapy interfering behaviors. Finally, Chapter 10 addresses and illus-
trates the application of Pattern Focused Therapy to health and mental health
issues in integrated care settings. A completed and successful four session therapy
illustrates its application with extended transcriptions and commentaries.
My hope is that by encountering the content of this book readers will come to
appreciate the value of this third-wave CBT approach, particularly how it is
practiced from an insider’s perspective—through transcriptions and commentaries
—and how Pattern Focused Therapy can quickly and easily effect change in a
wide range of clients.
Chapter 1

Pattern Focused Therapy and

Psychotherapy Practice
Today and Tomorrow

The Introduction to Pattern Focused Therapy: Highly Effective CBT Practice in Mental
Health and Integrated Care Settings highlighted three significant changes already occur-
ring in psychotherapy practice: (1) increasing expectations and demands for reimbur-
sement of psychotherapy services rendered; (2) shorter durations of treatment length
and session length; and (3) changes in where therapy will be provided. Yet, these are
just the tip of the iceberg. Other major changes are also impacting practice today and
will inevitably impact it tomorrow. This chapter will highlight six predicted trends that
are influencing and will continue to influence psychotherapy practice. Each of these
trends will be described. Then, Pattern Focused Therapy is suggested to be one of the
few contemporary therapeutic approaches that dovetails with or meets the demands of
all six of these trends. Before all this, a word on these prediction sources.

Professional Prognostication and Psychotherapy Research

Two extraordinarily accurate sources of the status of psychotherapy practice are
worth reviewing. The first involves prognostications by well-regarded professionals
in the field, and the second is the implications of recent psychotherapy research.
Both portrayals are briefly introduced before turning to the predicted trends.

Professional Prognostication
The recent Delphi study results reported by Norcross, Pfund, and Prochaska (2013)
are discussed first, followed by some additional prognostications. For the past three
decades, at intervals of 10 years, Norcross, Pfund, and Prochaska (2013) have con-
ducted Delphi polls on the future trends in psychotherapy practice. Their predictions
can be characterized as specific and uncannily accurate. Some 70 psychotherapy
experts were empaneled in 2012 to forecast trends for the next decade. The five areas
of focus were: theoretical orientations, therapeutic interventions, psychotherapist
background, therapy formats, and forecast scenarios (Norcross et al., 2013).
2 Pattern Focused Therapy, Psychotherapy

The Delphi study predicted that cognitive-behavioral, integrative, mindfulness,

and multicultural theoretical orientations would increase the most. On the other
hand, Jungian therapy, classical psychoanalysis, and transactional analysis were
expected to decline. The prediction regarding transactional analysis has already been
realized in the United States. Regarding therapeutic interventions, technological,
skill-building, self-change, and relationship-fostering interventions were predicted to
be most utilized. As far as psychotherapist background, master’s degree practitioners
were predicted to be the dominant group of providers of mental health services.
Therapy formats such as teletherapy, comprised of either web-based or telephone-
based programs, were predicted to increase dramatically. It was concluded that the
four driving themes for these trends are: (1) the economy of technology; (2) evi-
dence-based treatment; (3) innovative ideas; and (4) practices (Norcross et al.,
2013).
They summarized their predictions as:

In 2022, we expect briefer episodes of individual, group, and couple treat-

ments increasingly conducted by master’s-level professionals involving evi-
dence-based methods and relationships; theoretical formulations and clinical
methods more associated with the cognitive, integrative, multicultural, and
mindfulness orientations; and progressively more on the Internet, smart
phones, and social networking.(Norcross et al., 2013, p. 369)

Similarly, Silverman (2013) predicted four trends in the future of psychotherapy. The
first trend identified four levels of sophistication in technology for both providers and
clients, rather than by ethnicity, race, or sexual orientation. The second trend indi-
cated addressed the expansion of technology such as social media (e.g., Twitter,
Facebook, etc.) and other online service platforms (e.g., Skype, Slack, etc.). Third, the
development of new forms of healthcare would surface, rewarding successful efforts
in evidence-based practice, prevention, and disease treatment, requiring documenta-
tion of clinical outcomes, and a focus on the discovery of successful new treatments.
The fourth trend addressed emerging markets for individuals seeking increased
quality of life and enhancement of performance (Silverman, 2013).
Just prior to Silverman’s prognostications, Thomason (2010) made several
predictions about evidence-based practice. He predicted a chasm between evi-
dence-based and non-evidence-based practices. Essentially, reimbursement would
be contingent on evidence-based practice, while non-evidence-based practices
would not qualify. Finally, Thomason (2010) predicted that psychotherapy would
become briefer, as well as integrated with, primary care practice.
 Pattern Focused Therapy, Psychotherapy 3

The common themes among all three professional prognostications are that
treatment will become much shorter, be evidence-based, and have increased levels
of accountability for health issues in both mental health and integrated care.

Psychotherapy Research
Research on developments in the practice of psychotherapy has steadily increased
in the past decade. Much of it has been summarized in a recent text (Wampold &
Imel, 2015). Six of these research findings are reported here.
For the past seven decades psychotherapy has focused on two questions: is
psychotherapy effective?; and how does it work? Research has verified that psy-
chotherapy is not only effective but is very effective. In fact, the effects of psychother-
apy are greater than the effects of many medical practices. Psychotherapy has been
found to be as effective as medication for most mental disorders, without the side
effects. Furthermore, psychotherapy is longer-lasting than medications and is less
resistant to additional courses of treatment (Wampold & Imel, 2015). This finding is
incredibly important since its effectiveness was seriously questioned by Eysenck’s (1952)
influential study. The second question of how it works initially focused on specific fac-
tors—interventions—or on common factors, and now on what some consider an even
more important independent variable: therapist expertise (Castonquay & Hill, 2017).
Instead of moving the psychotherapy profession forward, this question fragmented the
field, leaving outcomes unchanged for many decades. The result of this fragmentation is
that the field has not created new generations of highly effective therapists. The “way
out” of this dilemma is for research and clinical practice to focus on the therapist’s
contribution to treatment outcome and the acquisition of therapist expertise and a
commitment to using client feedback to inform therapy and to deliberate practice. In
short, highly effective therapists are able to tailor treatment to their clients (Castonquay
& Hill, 2017).
Therapists vary in their expertise and effectiveness: Some therapists consistently
achieve better outcomes with their clients than do other therapists, in both clinical
trials and in everyday practice (Wampold & Imel, 2015). Approximately 15–20% of
therapists are highly effective, 15–20% are relatively ineffective, and the remainder
are average (Barkham, Lutz, Lambert, & Saxon, 2017).
Therapists do not get better with time or experience. On average, over the
course of their professional careers, it appears that therapists do not improve, in
terms of achieving better outcomes. The exception are those therapists who
engage in deliberate practice and utilize client feedback to inform the ongoing
therapeutic process (Rousmaniere, 2019).
Specific therapeutic factors are clearly related to successful treatment out-
comes. These include the therapeutic alliance, empathy, realistic expectations,
4 Pattern Focused Therapy, Psychotherapy

psychoeducation about the disorder, and other “common factors.” Of particular

importance is that therapists who can effectively form an effective therapeutic alliance
with a range of clients, who have a sophisticated set of facilitative interpersonal skills,
who work to maintain their effectiveness, and who engage in deliberate practice, these
are the therapists who achieve better outcomes (Wampold & Imel, 2015).
Providing information about client progress improves the quality of psychotherapy,
primarily by reducing the likelihood of treatment failures for clients not making
the expected progress. Monitoring client progress to improve the quality of ser-
vices, which is often called practice-based evidence, is becoming more widely
used (Rousmaniere, 2019).
It appears that “treatments” with no structure are less effective than treatments
that are structured and focused on the client’s problems. Therapists delivering
non-structured treatments are not able to share with the client an explanation in
the form of a case conceptualization for two aspects of therapy that seem to be
important for producing benefits. First, to explain why they became distressed,
and, second, how their engagement in the therapeutic process will help them with
their problems (Wampold & Imel, 2015).
In short, psychotherapy research finds that psychotherapy is very effective, and
highly effective therapists tend to monitor outcomes, utilize client feedback to tailor
treatment and align the therapeutic alliance to engage the client in the treatment
process, apply focused interventions, and achieve positive therapeutic outcomes.

Predicted Trends of Psychotherapy Practice

1. Short-Term Therapy Practice

This prediction is that the practice of psychotherapy will be for more short-term
therapy practice. It was also predicted that the duration of therapy and session
length would be considerably shortened.
In January 1, 2013, the Current Procedural Terminology (CPT) codes for billing
insurers for mental health services, which includes Medicare and Medicaid, took effect.
Prior to that date, the 50-minute hour was billed, using the code 90807. Currently,
there is no code that can be used to bill a 50-minute session. The Centers for Medicare
and Medicaid Services implemented a CPT code of 90834 to bill for a 45-minute
session, reportedly to represent more accurately the way clinicians provide services.
Presumably, shortening of a session by 5 minutes was expected to lower session fees.
Furthermore, clinicians worried that shortening session length would be detrimental to
both treatment effectiveness and reimbursement (Miller, 2012). To date, researchers
have not confirmed a loss of treatment effectiveness. Not surprisingly, the expectation
that reimbursement rates would be reduced was met.
 Pattern Focused Therapy, Psychotherapy 5

Other considerations, besides the previous CPT code changes, have contributed
to the shortening of psychotherapy sessions and the push for the integration of
physical and psychological services. A new model of mental health practice is
emerging as a result. Some indications of the new model involve a treatment
duration of 4–6 treatment sessions, instead of the previous 12–20 norm. The
length of new therapeutic encounters will span 15–30 minutes, greatly differing
from the prior 50-minute standard. Cummings and O’Donohue (2008) predicted
these changes. Cummings and others have advocated for the last 30 years that,
just like physicians, psychotherapists should be able to assess, diagnose, and begin
treatment with clients within 15 minutes. In my experience ultra-brief interven-
tions can be delivered in as little as 10–20 minutes.
The projected durations are similar to the Delphi polling results. Experts polled
reached a consensus that, by 2022, treatment duration would not be unlimited, and
would likely not exceed 20 sessions. Instead, it was expected that there would be an
increase in short-term therapy (5–12 sessions) and very short-term therapy (1–4 ses-
sions), with long-term therapy (longer than 20 sessions) resulting in a significant decline
(Norcross et al., 2013, p. 367). Table 1.1 provides a summary of these projections.

2. Health Issues and Integrated Care Practice

The prediction is that the practice of psychotherapy will increasingly incorporate
health issues and that integrated care settings will become the main setting for
the practice of psychotherapy.
The most significant change predicted for mental health practice is that
increasingly more of it will be provided in integrated care settings. In such set-
tings, the mental health provider will assume the role of behavioral health con-
sultant as part of a team, including a physician and a nurse, at minimum. While it
may be an alien concept for most mental health clinicians, many advantages can be
predicted, such as focusing on prevention as opposed to pathology, requiring less

Table 1.1 Treatment duration and session duration

Treatment duration
Long-term therapy 12–20 sessions
Short-term therapy 5–12 sessions
Very short-term therapy 1–4 sessions

Session duration
Conventional therapy session 45 (previously 50) minutes
Brief therapy or consultation session 15–30 minutes
6 Pattern Focused Therapy, Psychotherapy

extensive documentation to be provided, and working as a salaried member of a

team. This would be a welcome change to ongoing competition with other pro-
fessionals for Health Maintenance Organization (HMO) panels and extensive
documentation requirements for insurance reimbursement. Therapists practicing
in integrated care settings, as opposed to mental health settings, can expect less
stress, less paperwork, as well as increased variety and knowledge about medical
and other health conditions (Noonan, 2018).
Called the triple aim, three primary goals for providing mental health services in
primary care settings have been established: (1) increase the quality and satisfaction of
the patient’s healthcare experience; (2) increase prevention and therefore the overall
health of the population; and (3) reduce healthcare costs (Berwick, Nolan, & Whit-
tington, 2008). Reduced emergency room and hospital admissions are the factors that
reduce cost of services, if mental health services are provided in integrated health
settings. Additionally, patients are more likely to receive appropriate and necessary
services due to the identification of undiagnosed conditions and concerns.
The Delphi survey found that psychotherapy practice in integrated primary care
settings would steadily increase. This was predicted not only to provide higher
quality care but also to control costs. It was also predicted that, in addition to
providing psychological services in integrated care settings, psychotherapists in
mental health settings would also routinely treat the behavioral components of
health problems and chronic illnesses (Norcross et al., 2013).

3. Evidence-Based Approaches
This prediction is that evidence-based approaches will survive the major changes
occurring in healthcare. It will replace non-evidence-based approaches, and it will
be the only one that will be reimbursable.
While graduate mental health training programs intend that their trainees will
inform their clinical decisions with research evidence, few programs can claim this
achievement. Most programs require one or more research courses, but trainees
are seldom taught how to use research clinically. Statistics and research methods
courses are necessary to inform clinical practice, but insufficient for establishing
this competency. Specific training in critical thinking is needed to utilize research
as a basis for clinical practice. That is, the capacity to apply research to inform
clinical decisions. In the past two decades, evidence-based practice has surfaced to
address such transactional issues. This section focuses on the core features of
evidence-based practice and the implications for psychotherapy practice.
Evidence-based practice is defined as the integration of three elements for inter-
ventions: (1) a high degree of evidence, such as research support, has been identified;
(2) the results are individualized to clients’ needs, values, and expectations; and (3)
 Pattern Focused Therapy, Psychotherapy 7

the outcomes are expertly planned and implemented by trained clinicians. The
underlying premise is that evidence will be the basis for informing clinical
decision-making and clinical practice once these three elements are present
(Williams, Patterson, & Edwards, 2014).
Sackett et al. (1996) originated the concept of evidence-based practice. It was
formally defined by the Institute of Medicine in 2001 and subsequently adopted by
the American Psychological Association in 2006. Providing the best individualized
treatment that is both effective and accountable, i.e., measurable and reportable, is
the basic intent of evidence-based practice. “Evidence-based treatments” and
“empirically supported treatments” are terms that are commonly confused with evi-
dence-based practice. While both have varying levels of research support, they are not
expertly applied by clinicians, nor are they individualized to a specific client.
Historically, clinicians commonly made treatment decisions based on their theoretical
orientation. That began to change in the 1990s with the emergence of evidence-based
practice (Margolin, Shapiro, & Miller, 2015). Evidence-based practice was originally
described as a process of inquiry for the purpose of helping therapists and their clients
make important treatment decisions. Throughout the process, a clinician selects inter-
ventions after considering research evidence, their experience and expertise, ethics,
situational circumstances, the availability of resources, as well as the client’s preferences
and values (Gambrill, 2011). This differs greatly from decision-making derived from
espoused orientations, which give secondary importance to what can be considered
safe, effective, and appropriate.
Some clinicians have mistakenly assumed that the “evidence” in evidence-based
practice “requires” the use of empirically supported treatments. In part, this may
be due to Division 12 of the American Psychological Association promoting a list
of empirically supported treatments. However, this was not the intention of the
originators of evidence-based practice (Sackett et al., 1996). They indicated that
two kinds of evidence exist: internal and external. External evidence is quality
empirical research. On the other hand, internal evidence involves gathering
information about the client and applying external evidence with expert accuracy
and specificity. Therefore, empirically supported treatments may be chosen, but it
is “the ethical responsibility of all clinicians regardless of orientation to be guided
by current empirical research as well as their own specific areas of competence,
experience, and limitations when making treatment recommendations” (Sookman,
2015, p. 1295).
Unfortunately, some practicing clinicians maintain an anti-empirical research
bias and antipathy toward evidence-based practice, despite increasing expectation
among third party payers (Lilienfeld, Ritschel, Lynn, Cautin, & Latzman, 2013).
However, a new generation of therapy trainees is emerging and is eager for sci-
entifically informed treatment interventions. Trainees are asking “‘What does the
8 Pattern Focused Therapy, Psychotherapy

research say about that treatment approach or intervention approach in addressing

problem X?’ Their assumption is that there should be research to support what we
do” (Williams et al., 2014, p. 206). Additionally, they are “most motivated to learn
evidence-based practice when the evidence-based practice skills help them with their
own clients” (Williams et al., 2014, p. 236). Regardless of experience, clinicians who
succeed in integrated or specialized mental health settings will be those who adopt
ultra-brief interventions and evidence-based practices.
Therapists may question if there are ethical implications in evidence-based
practice. However, there is an inseparable link between professional ethics and
evidence-based practice. Many believe that the realm of ethical practice is confined
to issues with confidentiality, informed consent, and conflicts of interest. However,
these considerations––while important––are secondary to beneficence and non-
maleficence, which are essential to ethical decision-making. The real test of whe-
ther clinical decisions and practice are ethical is whether they meet three criteria:
the treatment is safe, effective, and appropriate for a given client and his or her
needs and concerns (Sperry, 2018b).
Few current therapeutic approaches report empirical support. The risk is that
approaches that do not demonstrate empirical support will lose eligibility for third
party reimbursement. This is a result of increasing demand for evidence-based
interventions. On the other hand, a few approaches do provide sufficient empirical
evidence to inform clinical decision-making and they are the most likely to receive
third party reimbursement.
The Delphi study predicts that evidence-based practices will be incorporated in
at least two ways. The first is that evidence-based practices will be required by
healthcare systems, and, second, that practice guidelines will become a standard
part of everyday psychotherapy practice. They also predicted that psychotherapy
research will provide prescriptive treatments of choice and emphasize the
importance of fostering meaningful therapeutic alliances, expressing warmth, and
providing interpersonal support (Norcross et al., 2013).
They also forecast that therapy approaches with the most controlled research will
increase in stature and use, while those with the least controlled research are expected
to be less widely practiced. Furthermore, they predicted that approaches and inter-
ventions with the highest impacts will be those that are data-driven, both in terms of
using data gathered to tailor interventions to clients but also to report outcomes data
that demonstrate that clinical change was effected (Norcross et al., 2013).

4. Clinical Outcomes Monitoring

The prediction is that clinical outcomes monitoring with feedback incorporated
into treatment process will become the norm for psychotherapy practice. An
 Pattern Focused Therapy, Psychotherapy 9

essential component of current clinical practice is incorporating clinical outcome

measures (Meier, 2015).
The collecting and monitoring of clinical outcomes data are receiving con-
siderable attention today. Without an objective means of evaluating their clinical
outcomes and their effectiveness as therapists, how are clinicians able to evaluate
their work and their effectiveness? Research shows that clinicians tend to hold
overly optimistic views of their effectiveness and treatment progress made by
their client in relation to actual measured change (Walfish, McAlister, O’Donnell,
& Lambert, 2012). Clinicians typically overlook negative changes and have diffi-
culty accurately gauging the benefit that clients have received during treatment,
particularly for clients who are failing to improve (Hannan et al., 2005). Clinical
outcomes of more than 6,000 clients treated in everyday practice settings showed
that only one-third improved (Hansen, Lambert, & Forman, 2002).
In an attempt to reduce negative outcomes, some therapists have begun to use
routine and continuous outcome monitoring. This involves regularly measuring
and monitoring client progress with standardized self-report scales over the
course of treatment with routine feedback provided by therapists before and after
each session (Lambert, Hansen, & Finch, 2001; Newham, Hooke, & Page, 2010).
Such feedback provides information to the therapist that goes beyond what
therapists observe and understand about client progress without such information.
This helps therapists recognize problematic treatment response and provides
problem-solving tools that improve collaborative efforts in cases where positive
response to therapy is in doubt. Because certain monitoring methods have been
shown to enhance client outcome, the American Psychological Association has
recommended routine outcome monitoring to be a part of effective treatment
(APA, 2006).
In short, therapists will increasingly be challenged not only to utilize clinical
outcome measures, but also to incorporate feedback and modify treatment
accordingly. Reporting and documenting such clinical outcomes will be an
additional challenge. Reporting and documenting are crucial because, without
measurable outcomes, psychotherapy can devolve into friendly conversations
between clinicians and clients, resulting in treatment that is costly, inappropriate,
ineffective, and likely unethical.

5. Core Therapeutic Strategy

The prediction is that therapeutic approaches with effective core therapeutic
strategies that are applicable to a higher percentage of clients and presentations
will be favored over those that do not. Presumably this means that such approa-
ches are more likely to be reimbursable.
10 Pattern Focused Therapy, Psychotherapy

While some 400 different therapeutic approaches have been developed, there are
only seven different core therapeutic strategies which inform those various approa-
ches (Sperry, 2018a). Core therapeutic strategy is the action plan for focusing and
implementing specific interventions to achieve specified treatment goals. The seven
different core therapeutic strategies that underlie evidence-based treatments are: (1)
modification of behavior; (2) skills training; (3) cognitive disputation; (4) cognitive
restructuring; (5) interpretation; (6) distancing; and (7) replacement. Predictably,
each one of these therapeutic strategies is associated with a given therapeutic
approach. Each is described below (Sperry, 2018). Table 1.2 lists these strategies and
the corresponding therapeutic approaches.

 Cognitive disputation. Cognitive disputation is a core therapeutic strategy for

changing troubling thoughts or beliefs. It involves directly questioning the
validity of clients’ thoughts and beliefs that underlie and maintain their
anxiety, so they become more adaptive and psychologically healthier. This
strategy is the hallmark of Rational Emotive Behavior Therapy.
 Cognitive restructuring. Cognitive restructuring is another core therapeutic strat-
egy for changing troubling thoughts or beliefs. Various tactics or techniques are
utilized in restructuring troubling thoughts or beliefs. These include guided
discovery, Socratic questioning, and examining the evidence. This strategy is the
hallmark of Cognitive Therapy and cognitively-oriented CBT.
 Interpretation. Interpretation is a hypothesis or guess about the connection
between an individual’s thoughts, behaviors, or emotions and his or her
unconscious emotions or thoughts. Interpretation remains the core strategy

Table 1.2 Core therapeutic strategies and representative therapeutic

approaches
Core therapeutic strategy Therapeutic approaches
Cognitive disputation Rational Emotive Behavior Therapy
Cognitive restructuring Cognitive Therapy
Cognitive Behavior Therapy
Interpretation Psychoanalytic Therapies
Modification of behavior Behavior Therapy, i.e., Exposure Therapy
Skills training Dialectical Behavior Therapy
Distancing Acceptance and Commitment Therapy
Replacement Pattern Focused Therapy
Cognitive Behavioral Analysis System of Psychotherapy
Reality Therapy
Narrative Therapy
 Pattern Focused Therapy, Psychotherapy 11

in the various psychoanalytic therapies, starting with classical psychoanalysis

and extending to the brief psychodynamics therapies.
 Modification of behavior. Modification of behavior is the basic therapeutic strategy
in Behavior Therapy. Currently, exposure is one of the key interventions for
modifying behavior. It involves intentional and prolonged contact with a feared
object combined with actively blocking undesirable avoidance behaviors. Even
though the client will experience increased anxiety in the short term, in the long
term, after repeated and incremental exposure to that feared stimulus, the anxi-
ety and the avoidance response are extinguished.
 Skills training. Skills training is a broad therapeutic strategy of educating and
training individuals experiencing psychological disturbance to increase their
knowledge, coping capacity, and skills required to solve their presenting problems.
Skills training is an intentional way to increase specific skill sets, such as assertive
communications training, emotion regulation training, and distress tolerance
training. Skills training is a central intervention strategy in some Behavior Ther-
apy and CBT approaches but is central in Dialectic Behavior Therapy practice.
 Distancing. Distancing from a particular thought is the core strategy for
dealing with distressful habitual thinking. Rather than engaging in the more
challenging and lengthier process of interpreting, disputing, or restructuring,
the client can be quickly guided to step back from a particular thought with
relative ease. Also known as cognitive defusion, it is a major core therapeutic
strategy of Acceptance and Commitment Therapy.
 Replacement. Replacement is a core therapeutic strategy for intentionally
replacing hurtful behaviors and thoughts with healthier ones. Therapists assist
clients to find alternative thoughts and behaviors. This process is much quicker
than interpreting, disputing, restructuring thoughts or beliefs, and modifying
behaviors. Replacement is the core therapeutic strategy in the Cognitive
Behavioral Analysis System of Psychotherapy (CBASP), Reality Therapy, and
Narrative Therapy. In the latter, re-storying or re-authoring replaces a less
healthy story or narrative with a more healthy one. In addition, therapists who
espouse other therapeutic approaches will also use replacement as an adjunc-
tive strategy when there may not be sufficient time in the session to process a
compelling issue with an interpretation, disputation, or cognitive disputation.

The first five core therapeutic strategies have been on the therapy scene the longest,
while the last two are more recent. Optimal outcomes of some of these therapeutic
strategies require a certain degree of client capacities and are not as effective for those
with lesser degrees. For example, the core therapeutic strategies of cognitive disputation,
cognitive restructuring, and interpretation are better employed with clients who can
relatively easily engage in rational thinking, i.e., formal operations and post-formal
12 Pattern Focused Therapy, Psychotherapy

thinking, but are not as effective with clients who typically engage in emotional thinking,
i.e., pre-operations. Techniques consistent with the modification of behavior core ther-
apeutic strategy may require considerable distress tolerance and emotion regulation to
face feared objects or situations as in the context of exposure therapy. In contrast, skills
training, distancing, and replacement require less cognitive development and emotion
regulation coping skills. In fact, one of the hallmarks of third-wave CBT approaches is
that these were developed for use with a wide range of therapeutic indications. Pattern
Focused Therapy, which incorporates a key component of CBASP, has only two contra-
indications: acute psychosis and cognitive blunting, as in moderate dementia, delirium or
acute substance intoxication or withdrawal.
While not specifically mentioning core therapeutic strategies, the Delphi survey
identifies a number of therapeutic approaches that reflect the core therapeutic stra-
tegies that are most likely to be employed in clinical in the future. These included
Acceptance and Commitment Therapy, Exposure Therapy, Dialectical Behavior
Therapy, and other third-wave CBT approaches. In contrast, the Psychoanalytic
Therapies were predicted to have limited usage (Norcross et al., 2013).

6. More Targeted, Briefer, and Effective Interventions

The prediction is that approaches that incorporate more targeted, briefer, and effective
interventions will be favored over those that do not. The Delphi survey identified 45
interventions in current usage and predicted that 19 would increase in use while the
remaining 26 would decrease. Those predicted to increase were largely targeted,
briefer, and research-supported interventions. They include relapse prevention, home-
work, assertive communication, meditation, and self-therapy—as in third-order
change efforts. They also forecast that aversive conditioning, free association, and
dream interpretation would diminish the most (Norcross et al., 2013).

Pattern Focused Therapy in Psychotherapy Today and

Tomorrow
The chapter began with a set of prognostications and psychotherapy research findings
followed by six trends. Pattern Focused Therapy seems to be well suited to the temper
of the times. In the section on professional prognostication, three common themes
emerged: (1) treatment will become much shorter; (2) treatment will be evidence-
based; and (3) treatment will have increased levels of accountability for health issues in
both mental health and integrated care. From a review of recent psychotherapy
research, these following themes stand out: psychotherapy is very effective; highly
effective therapists tend to monitor outcomes; they utilize client feedback to tailor
 Pattern Focused Therapy, Psychotherapy 13

Table 1.3 Predicted Trends and Pattern Focused Therapy

Predicted trends Pattern Focused Therapy
More short-term therapy practice Well suited for short-term therapy practice
Account for health issues and/or practice in Well suited for health issues and practice in
integrated care settings integrated care settings
Evidence-based approaches will be Evidence-based
reimbursable
Outcomes monitoring with feedback incorpo- Emphasizes outcomes monitoring and incor-
rated into treatment process porating feedback
Core therapeutic strategy is applicable for a Core therapeutic strategy has broadest
greater percentage of clients and presentations applicability for clients and presentations
More targeted, briefer, and effective Emphasizes ultra-brief interventions
interventions

treatment and align the therapeutic alliance to engage the client in the treatment pro-
cess; and they apply focused interventions and achieve positive therapeutic outcomes.
In terms of the six trends, Pattern Focused Therapy seems to be one of the few
current therapeutic approaches that dovetails with or meets the demands of all six
trends (Table 1.3). It is a short-term therapy can be practiced in both mental health
settings and integrated care settings. In either setting it is well suited to effectively
deal with the psychological or behavioral aspects of the most common health condi-
tions. It is also an evidence-based approach incorporating key components from
CBASP and motivational interviewing. It emphasizes outcomes monitoring and the
incorporation of client feedback to better inform and tailor treatment. Its core ther-
apeutic strategy has perhaps the broadest applicability among other contemporary
approaches for clients and presentations. Finally, it easily incorporates ultra-brief
interventions.

Conclusion
These are exciting times to start or continue practicing psychotherapy. With the
excitement is also a sense of the unknown and with it a measure of fear. Nevertheless,
recent research findings and Delphi predictions about what therapy practice will be
like in 2022 offer a measure of hope. This chapter introduced Pattern Focused
Therapy in the context of expert predictions about the future practice of psy-
chotherapy as well as recent research in psychotherapy practice. Chapter 2 further
discusses Pattern Focused Therapy and the centrality of pattern in it.

References
APA (American Psychological Association). (2006). Evidence-based practice in psychology: APA
Presidential Task Force on evidence-based practice. American Psychologist, 61(4), 271–285.
14 Pattern Focused Therapy, Psychotherapy

Barkham, M., Lutz, W., Lambert, M. J., & Saxon, D. (2017). Therapist effects, effective
therapists, and the law of variability. In L. G. Castonguay & C. E. Hill (Eds.), How and why are
some therapists better than others?: Understanding therapist effects. Washington, DC: American
Psychological Association.
Berwick, M., Nolan, A., & Whittington, J. (2008). The triple aim: Care, health and cost. Health
Affairs, 27, 759–769.
Castonquay, L. G. & Hill, C. (Eds.). (2017). How and why are some therapists better than others?:
Understanding therapist effects. Washington, DC: American Psychological Association.
Cummings, N. A. & O’Donohue, W. T. (2008). Eleven blunders that cripple psychotherapy in.
America. New York, NY: Routledge.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology,
16, 319–324.
Gambrill, E. (2011). Evidence-based practice and the ethics of discretion. Journal of Social Work,
11(1), 26–48.
Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., &
Sutton, S. W. (2005). A lab test and algorithms for identifying clients at risk for treatment
failure. Journal of Clinical Psychology, 61, 155–163.
Hansen, N. B., Lambert, M. J., & Forman, E. (2002). The psychotherapy dose-response effect and its
implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329–343.
Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research: Using patient out-
come data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159–172.
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many
clinical psychologists are resistant to evidence-based practice: Root causes and constructive
remedies. Clinical Psychology Review, 33, 883–900.
Margolin, G., Shapiro, L. S., & Miller, K. (2015). Ethics in couple and family psychotherapy.
In J. Sadler, B. Fulford, & C. Van Staden (Eds.), Oxford handbook of psychiatric ethics, vol. 2
(pp. 1306–1314). New York, NY: Oxford University Press.
Meier, S. (2015). Incorporating progress monitoring and outcome measures into counseling and psychotherapy:
A primer. New York, NY: Oxford University Press.
Miller, D. (2012). The end of the 50 minute hour?: Will the new CPT codes change mental
health practices? Psychology Today. December 2, 2012. Retrieved from www.psychologytoday.
com/us/blog/shrink-rap-today/201212/the-end-the-50-minute-hour.
Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2013). The outcome of psychotherapy:
Yesterday, today, and tomorrow. Psychotherapy, 50(1), 88–97.
Newham, E., Hooke, G. R., & Page, A. C. (2010). Progress monitoring and feedback in psychiatric
care reduces depressive symptoms. Journal of Affective Disorders, 117, 139–146.
Noonan, D. (2018). Integrated care: Perspectives from a behavioral health consultant. Psychiatric
News, 53(15). https://doi.org/101176/appi.pn.2018.8b11.
Norcross, J. C., Pfund, R. A., & Prochaska, J. O. (2013). Psychotherapy in 2022: A Delphi poll
on its future. Professional Psychology: Research and Practice, 44(5), 363–370.
Rousmaniere, T. (2019). Mastering the Inner skills of psychotherapy: A deliberate practice manual.
Seattle, WA: Gold Lantern Books.
Sackett, D., Richardson, W., Rosenberg, W., & Haynes, R., & Brian, S. (1996). Evidence based
medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72.
Silverman, W. H. (2013). The future of psychotherapy: One editor’s perspective. Psychotherapy,
50(4), 484–489.
 Pattern Focused Therapy, Psychotherapy 15

Sookman, D. (2015). Ethical practice of cognitive behavior therapy. In J. Sadler, B. Fulford, & C.
Van Staden (Eds.), Oxford handbook of psychiatric ethics, vol. 2 (pp. 1293–1305). New York,
NY: Oxford University Press.
Sperry, L. (2018a). Achieving evidence-based status for Adlerian therapy: Why it is needed and
how to accomplish it. Journal of Individual Psychology, 74(3), 247–264.
Sperry, L. (2018b). Mindfulness, soulfulness, and spiritual development in spiritually oriented
psychotherapy. Spirituality in Clinical Practice, 5(4), 225–230.
Thomason, T. C. (2010). The trend toward evidence-based practice and the future of
psychotherapy. American Journal of Psychotherapy, 64(1), 29–38.
Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment
bias in mental health providers. Psychological Reports, 110, 639–644.
Wampold, B., & Imel, Z. (2015). The great psychotherapy debate, 2nd ed. New York, NY:
Routledge.
Williams, L., Patterson, J., & Edwards, T. M. (2014). Clinician’s guide to research methods in family
therapy: Foundations of evidence-based practice. New York, NY: Guilford Press.
Chapter 2

Pattern
Assessment and Case Conceptualization

This chapter introduces pattern and its relationship to assessment and case con-
ceptualization. It presumes that case conceptualization is a “cognitive map” of the
client’s maladaptive pattern of perceiving and responding that can be ther-
apeutically “shifted” to an alternate pattern that is more adaptive (Sperry, 2010a).
It also presumes the pattern is the “heart” of case conceptualization and that “the
primary focus of clinical assessment is pattern recognition” (Sperry & Sperry,
2012, p. 33). The chapter begins with a description of pattern and its central role
in Pattern Focused Therapy. Then, it describes the components of assessment in
Pattern Focused Therapy. Finally, it describes the role of case conceptualization in
Pattern Focused Therapy. The recurring theme of this chapter is that pattern is
the central concept in Pattern Focused Therapy.

The Centrality of Pattern in Pattern Focused Therapy

In everyday language, pattern is understood as a recurrent way of thinking and
behaving in a given situation. Patterns are quite powerful in that they can set
expectations, make connections, and impact one’s relationships and overall well-
being They also engender a sense of predictability and continuity. Recognizing pat-
terns is like looking through a telescope for the first time and viewing reality in a
new way. In the past, pattern recognition helped our ancestors stay alive by identi-
fying edible plants and predatory animals and interpreting weather and sea condi-
tions. Today, pattern recognition is useful in diagnosing health conditions and
identifying ineffective and harmful personal and relational behaviors.
In short, most people are quite comfortable with the notion of patterns and
with some practice most can learn to recognize and even change their own pat-
terns. Germane to the practice of psychotherapy, Livesley (2003) notes:

Most patients readily accept the idea that there a “pattern” underlying their
behavior. The word is reassuring, for it suggest that there is order and meaning
 Pattern 17

to behavior and experience. Educating patients about these patterns helps them
to distance themselves from events and promotes self-observation. At the same
time, pattern recognition promotes integration connecting events, behaviors,
and experience that were previously assumed to be unconnected.
(p. 274)

In the technical language of Pattern Focused Therapy, a pattern is defined as a

succinct description of a client’s characteristic way of perceiving, thinking, and
responding (Sperry, 2010a). It is the predicable, consistent, and self-perpetuating
style and manner in which individuals think, feel, act, cope, and defend themselves
(Sperry, Brill, Howard, & Grissom, 1996; Sperry, 2006).
Pattern is what links client presentation with the precipitant and makes sense
of the situation. Patterns are “driven” by the client’s predispositions and reflect the
client’s personality dynamics or style (Sperry, 1989). Patterns can be adaptive or
maladaptive. An adaptive pattern tends to be flexible, appropriate, and effective,
and is reflective of personal and interpersonal competence. In contrast, a mala-
daptive pattern tends to be inflexible, ineffective, and inappropriate, and causes
symptoms, impairment in personal and relational functioning, and chronic dis-
satisfaction. If the maladaptive pattern is sufficiently distressing or impairing, it
can be diagnosed as a personality disorder (Sperry, 2010a).
Is it possible to change from a maladaptive to an adaptive pattern? Yes, it is
possible and typically requires a course of focused psychotherapy. It is a change
process that involves three steps. First, identify the maladaptive pattern. Second,
relinquish the maladaptive pattern and replace it with a more adaptive pattern.
Third, maintain the adaptive pattern (Beitman & Yue, 1999).
In Pattern Focused Therapy, this second step is called pattern shifting, which is the
therapeutic process for relinquishing the maladaptive pattern and replacing it with a
more adaptive pattern. The successful shift to a more adaptive pattern indicates that
second-order change has been achieved (Sperry & Binensztok, 2019b).
Patterns may be situation-specific or longitudinal. Situation-specific maladaptive
patterns provide an explanation that is unique to the current situation. In con-
trast, longitudinal patterns provide an explanation that is common to the current
as well as to previous situations. In short, a longitudinal pattern reflects a lifelong
pattern that provides a reasonable explanation or set of reasons for the client’s
situation (Sperry, Blackwell, Gudeman, & Faulkner, 1992; Sperry, 2005; 2010a).
Furthermore, the client’s pattern reflects and is reflected in all elements of a
Pattern Focused Therapy informed case conceptualization, particularly in pre-
cipitant, presentation, perpetuants, and predispositions or predisposing factors.
These factors are common to most case conceptualization models (Kendjelic &
Eells, 2007). Pattern analysis is the process of examining the interrelationship
18 Pattern

among five factors: (1) precipitating factors; (2) predisposing factors; (3) perpe-
tuating factors; (4) presentation factors, including relational response factors; and
(5) pattern (Sperry et al., 1992).
While it may appear that predisposing factors, such as traumatic events, mala-
daptive beliefs or schemas, defenses, personality style, or systems factors primarily
“drive” one’s thoughts, feelings, and actions, both individual and systemic dynamics
are a function of all four factors, and so are included in a pattern analysis.
Including both individual and systemic dynamics, pattern analysis provides a sys-
tematic and comprehensive basis for developing and articulating a clinically useful
case conceptualization (Sperry, 2010). Table 2.1 provides a capsule summary of
the key terms related to pattern.

Assessment in Pattern Focused Therapy

Therapists use assessments in order to select interventions that are useful in the least
amount of time. Thorough assessments inform the therapist of mental health disorders,
seek out the pattern or personality style of the client, determine the client’s level of
functioning and how the presenting problem affects it, and evaluate risk to self or others.
Such an assessment is essential to Pattern Focused Therapy. This section describes the
key components of a Pattern Focused Assessment: (1) pattern identification; (2) diag-
nostic assessment; (3) functional assessment; (4) risk and protective factors; (5) assess-
ment of goals; (6) use of screening instruments; and (7) outcomes assessment.

Pattern Identification
The client’s pattern is a crucial component in guiding treatment and determining
interventions. Pattern is defined as the style and manner in which individuals think,
feel, behave, manage their lives, and protect themselves in ways that are predictable,
consistent, and self-perpetuating (Sperry, Brill, Howard, & Grissom, 1996; Sperry,
2006). Patterns are adjudged to be adaptive or maladaptive. Maladaptive patterns

Table 2.1 Key concepts

Key concept Definition
Presentation The individual’s presenting problem, i.e., symptom or conflict. Typically, it is
a response to a precipitant that is congruent with the client’s pattern.
Precipitant Triggers that activate the client’s pattern, leading to the presenting problem
Predisposition Factors that foster and lead to either maladaptive or adaptive patterns
Pattern The predictable, consistent, and self-perpetuating style and way individuals
think, feel, act, cope, and defend themselves
Perpetuants Factors that maintain the presenting problem and pattern
 Pattern 19

are characterized as ineffective and inflexible. These patterns, if left unaddressed,

can lead to the presenting problems reappearing or the emergence of a related
problem once the client’s pattern is triggered in the future.
Pattern identification is a process involving clues from both formal assessment
and informal observation. Gathering clues to the pattern begins with the first
contact with the client. Observed informal data includes the client’s unique
demeanor, language usage, and posture, as well as data from the diagnostic and
functional assessment, as well as formal questioning. Pattern is derived from these
various data sources and clues throughout the assessment process. This includes a
focus on the client presentation, precipitating factors, predisposing factors, risk
and protective factors, as well as perpetuants. The pattern can be identified after
eliciting the presentation, precipitants, perpetuants, and predispositions.
It is critical to note that maladaptive pattern and adaptive pattern rather con-
sistently reflect an individual’s core personality dynamics. Accordingly, it can be helpful
for therapists to identify an individual’s basic personality style or personality disorder.
Then, the therapists can develop hypotheses about corresponding maladaptive patterns.
It is important to specify a corresponding adaptive pattern since this will be reflected
in the second-order treatment goal. These hypotheses can be checked against the
common patterns associated with specific personality styles and disorders.
Formal questioning begins by eliciting the client’s self-description as well as how
others describe the client. At times, clients present with more than a single pat-
tern, one of them being more prominent or defined than the other. The presence
of a personality disorder will inevitably be reflected in an impairing maladaptive
pattern which predictably complicates the treatment process. Accordingly, it is
essential that a DSM-5 personality disorder is formally ruled in or out.
In Pattern Focused Therapy, the process of pattern identification is facilitated
by connecting the client’s movement and activity, personality style/disorder, and
purpose with prototypic or likely maladaptive and adaptive patterns. Table 2.2
provides a summary of movement—activity, purpose, personality style, as well as
prototypic or likely patterns, both adaptive and maladaptive. With formal
instruction and appropriate supervision, it is a reasonable expectation for trainees
to develop the competency of identifying an accurate maladies pattern within 30
minutes of the initial session.

Examples of Pattern Recognition

One example of pattern recognition is shown in the case of Geri (Sperry, 2010b).
Geri presented with depression and an avoidant personality style. Her pattern was
identified as: avoid or disconnect when feeling unsafe. This is a common theme
among those with an avoidant personality or an Avoidant Personality Disorder,
Table 2.2 Pattern identification in Pattern Focused Therapy
Movement/activ- Personality Purpose Likely adaptive [A] or maladaptive
ity level style/disorder [M] pattern
Toward/active Histrionic Get attention [A] gets attention AND feels
worthwhile[M] gets attention,
BUT pays a high price and/or
becomes compromised
Toward/passive Dependent Enlist others’ [A] pleases others by meeting
help/be pleasing their needs AND one’s own needs
[M] pleases others by meeting
their needs BUT not meet one’s
own
Against/passive Narcissistic Get special [A] is self-confident AND
treatment respectful of others[M] elevates
self BUT uses or belittles others
Against/active Paranoid Anticipate harm [A] sizes up AND careful in
and retaliate relating to others[M] sizes up
BUT expects to be harmed by
others
Against/active Antisocial Harm others/ [A] lives by own internal code
protect self AND is law-abiding[M] lives by
own internal code BUT is not
law-abiding
Away/active Avoidant Avoid harm [A] feels safe AND safely connects
with others[M] feels safe BUT
avoids/isolates/disconnects
Away/passive Schizoid Avoid [A] limited need for companion-
involvement ship AND more comfortable
alone[M] limited need for compa-
nionship BUT actively avoids
others
Away/passive Schizotypal Act differently/ [A] indifferent to social conven-
distance others tion AND relates with familiar
people[M] indifferent to social
convention BUT wary of unfami-
liar people
Ambivalent/active Obsessive- Be perfect/do [A] reasonably conscientious AND
compulsive things right/ somewhat emotionally close[M]
conscientious overly conscientious/perfectionis-
tic BUT emotionally distant
Ambivalent/ Passive- Resist demands [A] agrees to do what is expected
passive aggressive of them AND will do that only
[M] agrees to do what is expected
of them BUT will not do it
Variable Borderline Pattern reflects the decompensated version of the
underlying personality (dependent, histrionic, or pas-
sive-aggressive)
 Pattern 21

but because of individual differences the wording of the pattern may differ slightly.
A pattern focused case conceptualization was developed, and her maladaptive
pattern informed how treatment was subsequently focused. Geri presented with
social isolation and depressive symptoms, and by replacing her maladaptive pattern
with a more adaptive one, these issues were resolved (Sperry, 2010b).
Another example involves a client who presented with a dual pattern, a situa-
tion that can both confuse the therapist and complicate the treatment process.
While a single maladaptive pattern is the most common presentation, occasionally
clients present with a secondary pattern. Recognizing this secondary pattern is
necessary in reducing confusion and effecting therapeutic change. The case of
Aimee is an example of this dual pattern. Aimee’s primary maladaptive pattern
was identified as: meet the needs of others but not meet her own needs. Her
secondary pattern was identified as over-conscientiousness. Taken together, her
dual pattern was identified as being over-conscientious in taking care of and
pleasing others. Through a brief course of effective psychotherapy, Aimee was able
to replace this dual maladaptive pattern with more adaptive one, while also
resolving her presenting concerns (Sperry & Carlson, 2014).

Diagnostic Assessment
Clients referred for clinical mental health conditions, such as anxiety and depression,
among others, require a diagnostic evaluation. Similar to traditional mental health
assessments, this evaluation targets the presenting problem or another area that is
warranted. Clients who are referred for medical concerns or noncompliance may also
experience mental health symptoms, concurrently or as a result. Diagnostic evalua-
tions are thus indicated to rule out potential mental health disorders. Presumably
therapists will use Diagnostic and Statistical Manual DSM-5 (American Psychiatric
Association, 2013) criteria to rule out possible symptom diagnoses and personality
disorder diagnoses. They may also use screening instruments to ascertain the direc-
tion of diagnostic evaluations and determine if risk assessment is warranted.
Table 2.3 provides a set of general and specific screening questions that trainees have
found clinically useful in structuring a diagnostic assessment. These questions are keyed
to nine diagnostic categories in DSM-5 (Frances, 2013), plus additional screening ques-
tions for harm to self or others. The ability to follow up with more specific questions to
rule in and rule out specific diagnoses depends on experience, clinical sensitivity, and
careful listening. Typically, in their practicum and internship experiences, trainees can
complete a diagnostic evaluation guided by these screening questions.
Table 2.3 Diagnostic screening questions: General and Specific
Reason for treatment Screening question
ANXIETY DISORDERS
General/Specific Screening Q’s Would you say you’re a nervous person?
Panic Disorder Have you experienced fear so intense that you thought you
might die, have a heart attack, or couldn’t catch your
breath?
Agoraphobia Are there any things you’re afraid to do and many places
you’re afraid to go?
SAD Are there activities that you’re afraid to do in public, like
giving a presentation?
Specific Phobia Do you have particular fears that cause you special trouble,
like flying, heights, the sight of blood, or getting an
injection?
GAD Are you a worry wart, unnecessarily anxious all the time
about a lot of different things?
OCD Do you have recurring thoughts that bad things will happen
or repetitive behaviors that you feel driven to perform?
PTSD Have you experienced a traumatic event that keeps haunt-
ing you with terrible memories, flashbacks, or nightmares?
Anxiety Disorder––Medical Have you had symptoms of anxiety associated with a
Condition medical condition like an overactive thyroid?
DEPRESSIVE AND BIPOLAR DISORDERS
General/Specific Screening Q’s How would you describe your mood?
Major Depressive Episode Do you ever get so depressed that you can’t function?
Persistent Depressive Disorder Are you almost always depressed?
Bipolar Disorder I Do you have mood swings––sometimes way up, other
times way down?
Bipolar Disorder II Do you have mood swings––sometimes going up, other
times going down?
Cyclothymic Disorder Do you have constant mood swings, alternating from high
to low?
Substance-Induced Depressive Might your depression be related to your use of alcohol
Dx (drugs, or medications)?
PSYCHOTIC DISORDERS
General/Specific Screening Q’s Have you ever had unusual or strange experiences?
Schizophrenia Do you ever hear voices, believe that people mean to harm
you, or lose touch with reality?
Schizoaffective Disorder Do you ever hear voices, believe that people mean to harm
you, or lose touch with reality? Do you have mood swings?
Delusional Disorder Do people say you have really strange ideas?
Substance-Induced Psychotic Dx Do you have strange experiences when you are under the
influence of drugs or alcohol?
 Pattern 23

Table 2.3 (Cont.)

Reason for treatment Screening question
DISSOCIATIVE DISORDERS
General/Specific Screening Q’s Does your mind ever play tricks on you?
Dissociative Amnesia Are there parts of your life that you can’t remember?
Depersonalization Disorder Do you ever get the weird detached feeling that you are
watching yourself go through the motions of life?
EATING DISORDERS
General/Specific Screening Q’s Is food or eating a problem for you? Do others think or
say it is a problem for you?
Anorexia Nervosa Do you feel fat even when others think that you’re much
too thin?
Bulimia Nervosa Do you often lose control and find yourself taking in a
really large amount of food in a very short time?
ADJUSTMENT DISORDERS
General Screening Q Are you having problems dealing with stresses in your life?
MEMORY: DEMENTIA & NEUROCOGNITIVE DISORDERS
General Screening Q Have you had a big decline in memory?
SUBSTANCE-RELATED & ADDICTIVE DISORDERS
General/Specific Screening Q’s Tell me about your use of alcohol and drugs
Alcohol-Related Disorders Have you gotten in trouble because of alcohol?
Substance-Related Disorders Have you gotten in trouble because drugs?
PERSONALITY DISORDERS
General Screening Q Do you have a way of doing things and relating to others that
gets you into the same kind of mess over and over again?
HARM TO SELF OR OTHERS
General/Specific Screening Q’s Have you had thoughts of harming yourself?
Have you had thoughts of harming others?

Functional Assessment
A functional assessment should be completed on each client, regardless of whether
a diagnostic evaluation is indicated. Through functional assessments, therapists
gather information about ongoing problems and how they are affecting the client’s
life (Sperry, 2014). Presenting problems can become obstacles in client’s vocational
and/or educational functioning, ability to maintain intimate relationships, social
functioning, and capacity for maintaining self-care and personal responsibilities,
such as household tasks. Clients may worry about their finances, how well they
24 Pattern

can maintain the care of dependents, or other stressful situations. Presenting

problems also typically affect cognitive and emotional responses. For example, a
client who presents with insomnia may experience increased irritability, self-cri-
ticism, and difficulty with focusing on certain tasks. The functional assessment
ascertains the manner in which the presenting problem effects on the client’s daily
life (Sperry & Binensztok, 2019a). This also allows the therapist to make more
accurate decisions on whether a diagnostic evaluation is needed.
It is important to determine how clients adjust to their presenting problems, as
individuals react variously to problems, contingent on their personality, environment,
and other factors. For instance, two people struggling with chronic pain may respond
extremely differently to their circumstances. One may choose to adapt their lifestyle
to include healthy nutrition and exercise while the other resorts to substance use to
cope with the agony. The client who resorts to medication or substance dependence
will likely experience a compounding effect of problems. The client who copes by
adopting a healthier and more active lifestyle is unlikely to experience these unwanted
outcomes. Understanding the client’s responses to their problems uncovers informa-
tion about their strengths and need for improvement or further inquiry.

Structure of the Assessment

Prior to beginning an assessment, the therapist must clarify the reason for the
referral in order to assess the reason for seeking psychotherapy. This also facil-
itates an assessment of the client’s understanding of the problem and a collabora-
tive introduction of the context of psychotherapy. Some clients may disagree with
the reasons why they were referred and may experience some resistance to
treatment. The therapist must assess the duration, triggers, and frequency of the
presenting problem as well as intensity. A client struggling with chronic pain may
not be experiencing pain during that meeting. Therefore, the therapist must assess
for the presentation of the problem during that specific session and how it fluc-
tuates through time (Sperry & Binensztok, 2019a).
Subsequently, the therapist must assess how the problem affects the client in other
settings or while the client engages in other activities. Common areas of exploration are:
social relationships, household duties, and performance at work, hobbies, exercise, or
other enjoyable activities. Other symptoms resulting from the presenting problem, such
as decreases in appetite, sleep, or energy, should also be assessed, particularly in clients
presenting with low mood. They should also be assessed for suicidal and homicidal
ideation, two risk factors covered in more detail in the section on risk assessment.
As part of the health history, the therapist can assess for over-the-counter
medications, supplements, alcohol, tobacco, or the use of caffeine. For example,
Monica is a 43-year-old mother of two. She presents with low mood, difficulty
 Pattern 25

sleeping, and decreased energy throughout the day. She states that she is stressed
and finds it difficult to fall asleep almost every night. On average, she sleeps for
about four hours until her children wake her up. When the therapist asks her
about her caffeine use, she reports that due to her irritability, sleepiness during
the daytime, and difficulty concentrating on tasks, she has been coping by drinking
4–6 cups of coffee daily. She has been drinking coffee until 6 or 7 p.m. some days
in order to complete all of her tasks. As a result of this information, and later
when appropriate, the therapist can explains that the caffeine may be a significant
contributing factor in her insomnia and further exacerbate her depressive symp-
toms (Sperry & Binensztok, 2019a).

Risk and Protective Factors Assessment

Risk factors are factors associated with the increased likelihood of experiencing or
developing a medical or clinical condition (Masten & Garmezy, 1985). Self-harm is a
key risk factor in therapy. Clients should be assessed for self-harm and suicide risk
whenever they present with symptoms resulting from trauma, anxiety, or fluctua-
tions in mood. Furthermore, because clients with chronic pain are three times as
likely to report suicidal thoughts than the normal population (Tang & Crane, 2006),
they must be assessed for risk. Given client reports of suicidal ideation, past suicide
attempts, or history of self-harm, a more thorough assessment of risk is necessary.
Client ideation may be characterized as passive or active. Passive suicidal ideation is
indicated when the individual states that they would not mind if life ended but they
are not keen on ending it and their ideation does not include a plan. On the other
hand, active suicidal ideation includes thoughts of doing self-harm and intentionally
ending one’s life. Suicide assessment must include evaluating any potential plan for
self-harm, the means to carry out such a plan, and history of prior attempts. Sui-
cidal thoughts must be assessed for frequency, duration, and intensity.
In contrast to risk factors, protective factors are factors associated with
decreased likelihood of experiencing or developing a medical or clinical condition
(Rutter, 1987). Common protective factors are a secure attachment style, coping
skills, religiosity, a social support network, and the experience of leaving and
never returning to an abusive relationship.
Protective factors are related to strengths which are “psychological processes
that consistently enable a person to think and act so as to yield benefits to himself
or herself and society” (Rutter, 1987, p. 3). Examples of strengths include resi-
lience, self-confidence, and self-control. Pattern Focused Therapy is a strength-
based approach and emphasizes identification and incorporation of protective
factors in the case conceptualization and treatment plan.
26 Pattern

Assessment of Goals
Assessing goals directs the treatment focus for the course of treatment. Goals are
variable and contingent on presenting problems and the client’s resources or
motivation. However, they all share common elements. Goals must be specific.
Specificity helps clients stay on track and they are more likely to attain goals that
are measurable and concrete. There are three types of treatment goals: first-order
change, second-order change, and third-order change. The first-order and second-
order goals are set in the first session.
Goal-setting that is collaborative is the norm. Clients are more likely to attain
their goals when they are actively involved in setting them. Attaining small goals
results in an increase in self-efficacy, which helps to compound and work toward
larger ones (Bodenheimer & Handley, 2009). Ultimately, clients respond more
positively to goals that are directly applicable to their daily lives than those that are
not Clients are more likely to follow through with goals related to social relation-
ships, daily functioning, and the regulation of their emotions (Lenzen, van Dongen,
Daniels, van Bokhoven, van der Weijden, & Beurskens, 2016).

Use of Screening Instruments

Screening instruments are used to assess the client and gain useful insight into clients’
presenting concerns. These can be easily administered and scored. They can also help
with determining a diagnosis. Clients are prompted to rate their symptoms by
intensity and severity. The validity and reliability of screening instruments are of the
utmost importance. Instruments must demonstrate that they consistently measure
what is intended, and instruments must be appropriate and relevant to the presenting
concern. Typically, they are administered prior to each session to aid in ongoing
monitoring and tracking the client’s progress. For example, the Patient Health
Questionnaire-9 (PHQ-9) would be appropriate for monitoring a client presenting
with depression. This instrument would provide useful details about the effectiveness
of the treatment. Chapter 5 provides specific information on the PHQ-9 and other
screening instruments.

Outcomes Assessment and Progress Monitoring

Increasingly, therapists are being held accountable for the effectiveness of their
treatments, progress monitoring has become increasingly predominant in the field of
counseling (Meier, 2015). Persons and Mikami (2002) have estimated that treatment
fails in up to 50% of cases. Therapists must remain vigilant of client progress, espe-
cially with the added challenge of effecting change in short-term therapy. Monitoring
and tracking the client’s progress can guide the treatment and indicate when different
 Pattern 27

interventions are needed. Therapists can utilize standardized instruments prior to

each session in order to assess outcomes and monitor progress. Client logs, the Mood
Scale, the Subjective Units of Distress Scale (SUDS), and various screening instru-
ments can be helpful throughout this process. Client logs can provide information,
such as activity, nutrition habits, compliance with out-of-session tasks, and frequency
of relaxation. Chapter 5 provides more information on outcomes assessment and
progress monitoring.

Conducting the Assessment

As discussed in prior sections, assessment in Pattern Focused Therapy tends to be
focused and skillfully conducted in both mental health and integrated care and set-
tings. A focused diagnostic evaluation can be conducted in approximately 10 minutes
while other pertinent assessment information can be gathered in 15–20 minutes.
Thus, it is possible to accomplish both and begin developing a therapeutic alliance in
as short a time as 30 minutes.

Implications for Treatment Planning

Accurate and appropriate assessment can largely influence effective treatment
planning and quantifiable results in short-term therapy. A greater understanding of
the consequences of the presenting problem and how they influence the client’s
functioning is crucial for determining ultra-brief interventions. For instance, a
client with heightened anxiety or symptoms of panic can benefit from ultra-brief
interventions, such as controlled breathing. On the other hand, a client struggling
with depression and social isolation would necessitate interventions to increase
their engagement and activity, such as behavioral activation.
A key factor that helps therapists select treatments is the identification of the
client’s pattern. This allows therapists to determine how to approach a client and
predict potential barriers to treatment. For example, a client who presents with
paranoia or has difficulty trusting others may demonstrate increased resistance to
working with a therapist. This type of client requires validation and the percep-
tion of control within the context of therapy. These treatments are achievable
through interventions, such as motivational interviewing and a patient, empathic,
and collaborative demeanor from the therapist.
An adequate assessment may at times indicate that further evaluation is neces-
sary. Risk screening or exploring for medication misuse can lead to uncovering the
need for a more thorough evaluation. Assessment can also help the therapist
determine if culturally sensitive treatments are needed. A thorough assessment is
essential to providing highly effective intervention in short-term therapy.
28 Pattern

Putting It All Together

Assessment is a crucial component of the effective provision of Pattern Focused Ther-
apy. Assessments aid in gathering information about the client’s presentation and its
consequences on the client’s functioning. It also aids in collaboration and establishing the
therapeutic relationship. In order to complete this in a 30-minute session, therapists
must demonstrate interest and concern toward the client while simultaneously deciding
on appropriate assessments. Every client needs to be assessed for functioning, including
the problem’s impact on social, personal, academic, and vocational functioning. Func-
tional assessments are structured and consist of short, closed-ended, questions. In the
case that the presentation includes one or more mental health symptoms, a diagnostic
evaluation is necessary. Therapists must determine if diagnostic evaluations are neces-
sary in other cases as well.
Identifying the client’s pattern is of crucial importance. Understanding the client’s
pattern is necessary to plan treatment and anticipate obstacles. It is also helpful in
focusing the session toward the disruption, shift, or change of the maladaptive
patterns. This resulting focus can lead to increased likelihood of the client remaining
compliant with medical treatment and the prevention of relapse back into behaviors
that maintained or contributed to the presenting problem.
Clients presenting with mental health conditions, such as depression, post-traumatic
stress, anxiety, or others do require risk assessment. Additionally, therapists must
screen for risk with clients who are suffering with chronic pain, as they are higher risk
for suicidal ideation. If ideation is reported, the therapist must follow up with a more
thorough and complete risk assessment.
Another important assessment is the cultural assessment, which includes gathering
information about cultural factors which may be salient for many clients. Therapists
must remain cognizant that cultural factors influence symptom presentations and
treatment planning. The client’s family in different cultures can largely influence their
treatment. They can function as supports or protective factors. On the other hand,
they can become barriers and a detriment to ongoing treatment. In lieu of emotional
display, clients from collectivistic cultures have a higher likelihood of demonstrating
somatic symptoms. Therapists must maintain awareness that somatic symptoms may
surface and indicate conditions, such as depression and anxiety.
Finally, clients must all be assessed for both long- and short-term treatment goals.
Short-term goals are especially important as they are practical and achievable.
Therapists must connect treatment goals to the client’s goals while avoiding technical
or jargon-like language. Goal setting should be a pragmatic and collaborative process.
The progression of goals and symptoms can be tracked through progress monitoring.
Assessment and progress monitoring can use standardized screening instruments.
Given the time constraints, a lot is compacted into the assessment sessions in
short-term therapy. The use of screening instruments and questions can guide the
 Pattern 29

focus of assessment and ensure timely completion. Therapists must establish a caring
relationship through expressions of concern in their interactions and the role-induc-
tion of the assessment sessions, especially since so many of the questions are closed-
ended and there are so few opportunities for reflection.

Case Conceptualization in Pattern Focused Therapy

Case conceptualizations provide therapists with a coherent treatment strategy for plan-
ning and focusing treatment interventions in order to increase the likelihood of achieving
treatment goals. While many therapists develop conceptualizations to guide their prac-
tice, not all therapists explicitly articulate these conceptualizations. There are a number
of reasons for developing and articulating a case conceptualization, but the most cogent
reason is that a conceptualization enables therapists to experience a sense of confidence
in their work (Hill, 2005). Hill (2005) believes that this confidence is then commu-
nicated to the client, which strengthens the client’s trust and the belief that the therapist
has a credible plan, and that therapy can and will make a difference. In other words, an
effective case conceptualization increases “clinician credibility” (Sue & Zane, 1987).
Case conceptualization is the clinical strategy for obtaining and organizing client
information, identifying maladaptive patterns, focusing treatment, and anticipating
challenges and roadblocks throughout treatment, as well as preparing for termina-
tion (Sperry, 2010a).
The case conceptualizations also provide a tool for therapists to coherently plan and
focus treatment interventions to increase the likelihood of favorable outcomes (Eells,
2007; 2010). Case conceptualization is undoubtedly the most important competency in
psychotherapy. In my graduate courses and workshops, I have used a nautical metaphor
that really drives home the importance and clinical value of case conceptualization for
trainees and therapists and makes sense of case conceptualization: “A therapist without a
case conceptualization is like a ship’s captain without radar or rudder and thus aimlessly
floats about with little or no direction.”
Case conceptualization is fundamental to effecting therapeutic change (Sperry, 2010a).
On average, therapists are able to conceptualize cases or formulate conceptualizations
after initial evaluations are finalized and the therapist has evaluated diagnostic and other
pertinent information. Following the interview, these therapists review the available
information and begin to consider goals and interventions for treatment. For therapist
trainees, this process can be more arduous, lengthy, and may require supervisor invol-
vement and input. However, my experience with trainees is that with formal training and
effective supervision this time can be reduced to 30 minutes or less.

Interpersonal, intrapersonal, and contextual factors are key components in

the process of effecting change. A case conceptualization has four components:
30 Pattern

diagnostic, clinical, cultural, and treatment formulations. The ability to specify

these components with accuracy is essential to the process of identifying and
modifying an existing pattern or implementing a new adaptive pattern. This is
the core of effecting therapeutic change. This section provides an overview of
the four components.

Diagnostic Formulation
The diagnostic formulation is an evaluation of the client’s presentation, pattern,
and precipitants (Sperry, 2010a). This component answers the question: “What
happened?” The therapist describes the lived experience of the client’s presenting
concerns, as well as assesses cross-sectionally the client’s unique pattern and
circumstances.

Presentation
The presentation is comprised of the client’s response to the precipitant(s). At
times referred to as the presenting problem, the presentation also describes the
category and severity of the client’s symptoms, level of impairment or functioning,
and its history. This component also includes DSM diagnostic information and
medical history.

Precipitant
The client’s precipitant conveys the triggers or stressors that resulted in the cli-
ent’s presenting problem or presentation. Another way of thinking about the
precipitant is “the spark that ignites the fire.” This component can also refer to
antecedent conditions present and coinciding with the onset of the presentation.
Key features of the precipitant focus on context: where did it happen?, when did
it happen?, who was around?, and what was done about it?

Pattern
As previously noted, pattern is the heart or central element of a case con-
ceptualization. The client’s pattern is a concise depiction of the client’s manner of
thinking, perceiving, and responding. The client’s pattern is the link between the
presentation and precipitant, and normally explains the situation. Adaptive pat-
terns are characteristic of flexibility, effectiveness, and appropriateness. On the
other hand, maladaptive patterns are typically rigid, inappropriate, and inter-
personally ineffective. Maladaptive patterns routinely result in mental health
 Pattern 31

symptoms and disorders, low levels of interpersonal functioning, and chronic

discontent (Sperry & Sperry, 2012).
A client’s pattern may be long-lasting or situation-specific. A situation-specific
pattern that is maladaptive explains only the current and unique situation. Con-
versely, longitudinal patterns explain current as well as previous difficulties or
circumstances. Essentially, a lifelong pattern offers a consistent explanation for the
client’s personality (Sperry et al., 1992; Sperry, 2005; 2010a).
Typically, the pattern is derived from a full consideration of all the other ele-
ments of a case conceptualization. However, what is known as a very brief case
conceptualization (described in more detail below) can also be quickly derived
from finding the link between the presentation and precipitant. The link, of
course, is the pattern and the pattern will also reflect the client’s personality style.
Cf. Table 2.2.

Clinical Formulation
The clinical formulation explains the client’s pattern. It essentially answers: “Why
did it happen?” Through the clinical formulation, the therapist appraises the pre-
disposition and perpetuants. An explanation is also provided for the client’s pre-
senting problem and pattern (Sperry, 2010a). This central component of the case
conceptualization also provides a link between diagnostic and treatment
formulations.

Predisposition
The predisposition is also known as predisposing or etiological factors. This is a
summary of all factors that inform and influence the client’s pattern. The therapist
must examine the developmental, social, and health history for clues about
potential predisposing factors. The client’s biological, psychological, and social
vulnerabilities must also be reflected in the predisposition. Biological vulner-
abilities are comprised of current health status, medical history, medications,
substance abuse, and health behaviors (e.g., smoking). This section will also
include personal and family history for suicide or suicidal behaviors and self-harm,
and substance abuse. Psychological vulnerabilities include interpersonal, intra-
personal, and other personal dynamics, such as intelligence and temperament. The
client’s personality style, maladaptive beliefs and schemas, resilience, self-concept,
self-efficacy, and character structure are explored. Additionally, behavioral deficits
and excesses are listed and assessed, as well as the client’s self-management, pro-
blem solving, relational, communication, and conflict resolution skills. Social vul-
nerabilities include family dynamics. These are made up of sibling characteristics
and interaction styles, educational achievement, family secrets, religious
32 Pattern

involvement, sexual experiences, and early neglect and abuse in the forms of
verbal, emotional, sexual, physical, or financial. The family’s level of functioning is
also considered in this component. So too are family stressors, divorce, separation,
job stressors, peer associations, support system, and other environmental factors.
For instance, factors such as living in poverty, associating with drinking friends, or
working in a hostile work environment, as well as personal or familial vulner-
abilities to depression and impulsivity, would be important to identify.

Perpetuants
Perpetuants are also called maintaining factors. These are processes that reinforce
and preserve the client’s maladaptive pattern. Perpetuants serve to guard the
client from experiencing conflict, symptoms, or others’ demands. For instance, for
introverted individuals, who are sensitive to rejection, a likely pattern is to live
alone or maintain solitude in order to avoid others’ rejection or interpersonal
demands. Given the overlap of some of these factors, it is at times difficult to
differentiate with certainty the predisposing from the perpetuating factors.
Common examples of perpetuants are skills deficits, unfavorable work environ-
ments, relational difficulties with others, etc. There are other times in which a cli-
ent’s predisposition also functions as a maintaining factor, such as in the case of
avoidant personality styles. Individuals with an avoidant style are likely to isolate
socially and distance themselves from others in efforts related to safety. These indi-
viduals are therefore unlikely to develop appropriate or effective social skills, as they
have little to no contact with others, demonstrating the “maintenance” nature of the
cycle of the client’s predisposition. This can result in self-confirmation of beliefs
about being unworthy, unlovable, or defective.

Cultural Formulation
The cultural formulation can support the clinical formulation and inform the focus
of treatment as well as chosen interventions. The cultural formulation is com-
prised of a systematic exploration of the client’s cultural dynamics and factors and
answers the question: “What role does culture play in the life and problems of the
client?” (Sperry, 2010a). More specifically, the formulation outlines the level of
acculturation, the client’s cultural explanation, and the cultural identity of the
client (Sperry, 2010a). The level of acculturation is the degree to which an indi-
vidual can assimilate to the dominant culture. That is, to what degree can they
integrate new cultural patterns into their original cultural identity and dynamics?
On the other hand, the client’s cultural identity is the individual’s self-identified
sense of belonging to a particular culture. The cultural explanation is the client’s
perceived reason for the presenting problem or the client’s conditions, as well as
 Pattern 33

the assessment of whether the client’s personality or cultural dynamics are most
prevailing in explaining the presentation. The cultural formulation forms the basis
for anticipating cultural elements that could potentially affect the therapeutic
relationship with the client; it also helps identify if culturally sensitive treatment is
warranted (GAP Committee on Cultural Psychiatry, 2002; Wu & Mak, 2012).
The cultural formulation is made up of four key elements: cultural identity,
level of acculturation and acculturative stress, model of cultural explanation, and
the effects of cultural versus personality dynamics. A more in-depth review of
these elements is provided in the second edition of Case Conceptualization: Mas-
tering This Competency with Ease and Confidence (Sperry & Sperry, 2020).

Treatment Formulation
The treatment formulation functions as a blueprint for planning interventions.
Logically, it is an extension of the clinical, diagnostic, and cultural formulations.
The treatment formulation essentially answers: “What can be done to change it?”
This component is comprised of treatment goals, treatment focus, treatment
strategy, and precise interventions. It also takes into account treatment challenges
and obstacles that the therapist may foresee in achieving the formulated goals.
Master therapists take into account the following treatment formulation elements.

Treatment Goals
Treatment goals are made up of what the client hopes to achieve within their
treatment. Other common designations for treatment goals are treatment targets
and therapeutic objectives. Goals are the basis for the work therapists and clients
collaborate on (Sperry & Sperry, 2012). For treatment goals to be clinically useful,
they must be measurable, achievable, and realistic. They must also be effective and
mutually agreed upon by the client and therapist. The client must adequately
understand the goals, commit to them, and believe they are attainable. Goals are
generally designated as short- and long-term. Short-term goals are typically com-
prised of first-order change: symptom reduction, increased interpersonal func-
tioning, and return to baseline functioning. For example, for a client who is
suffering from anxiety, short-term goals may be to practice grounding or breathing
techniques in order to decrease their discomfort. On the other hand, long-term
goals are second-order change goals. These take the form of pattern change and
replacement of specific maladaptive patterns with more adaptive ones. For example,
in the aforementioned example with the client suffering from anxiety, long-term,
second-order, change could take the form of uncovering and modifying patterns that
exacerbate or maintain the anxiety (e.g., avoidance and procrastination). In short,
treatment goals become the statements of what the treatment means to accomplish.
34 Pattern

Treatment Focus
The treatment focus is the central therapeutic emphasis that guides and main-
tains the direction in treatment. It aims to replace a maladaptive pattern with a
more adaptive one. Not only does the treatment focus provide direction, it also
maintains the treatment’s stability and focuses on change (Sperry & Sperry,
2012). Therapists who are skilled in tracking a treatment focus have higher
rates of positive outcomes. Unsurprisingly, master therapists routinely and reli-
ably maintain a productive focus in treatment.
Conversely, trainees can easily be side-tracked into unproductive discussions
with clients. For instance, in a session where a client comes in without having
finished their assigned out-of-session task, a novice therapist may launch into an
examination of all of the reasons why the client failed to complete the task. The
therapist may ask several questions about the circumstances under which the
client ended up doing something else instead. Therefore, the trainee unwittingly
colludes with the client, discussing reasons and excuses, rather than taking action.
Typically, once the situation has been discussed and the client has exhausted their
excuses, the session can shift topic and something else is discussed. Situations such
as these result in the trainee following a different track, leading to the conclusion
of the session with little or no change effected.
When therapists are guided by a specific approach, or therapeutic orientation, the
direction has been established through specific guidelines and protocols on how to
address or process the situation therapeutically. For example, the Cognitive Behavioral
approach to working with a client who has failed to do their agreed homework is to
focus on troublesome situations which are triggered or exacerbated by the client’s
maladaptive beliefs or behaviors. Thus, the therapist may recall from their con-
ceptualization that one of the client’s intermediate beliefs purports that she is worthless
if she tries and fails, therefore, she does not try (Sperry & Sperry, 2012). Accordingly, it
is no surprise why the client has not accomplished the assigned task. Informed by his or
her conceptualization, the therapist can process the maladaptive beliefs or behavior
therapeutically. Given the chosen treatment focus, the therapist may still decide to
follow the directive, or choose a different path toward reaching the therapeutic goals.

Core Therapeutic Strategy

The core therapeutic strategy is the plan of action toward focusing precise treat-
ment interventions. Chapter 1 described the seven commonest core strategies. It
was noted that the core therapeutic strategy for Pattern Focused Therapy and a
number of other third-wave CBT approaches is replacement. Chapter 3 elaborates
the process of pattern change or, more accurately, pattern shifting.
 Pattern 35

Treatment Interventions
Treatment interventions are deliberately designed actions that affect the client’s
issue or problem in a positive manner. There are three considerations under
which treatment interventions are formulated: (1) the treatment targets; (2) the
client’s willingness or ability to complete the intervention; and (3) the client’s need
for culturally sensitive treatment. Although there are many treatment interven-
tions, those that are effective in changing the client’s pattern necessarily involve
interventions that operationalize a treatment strategy. Considering a metaphor for
a journey, the treatment intervention is akin to choosing the right fuel grade, tires
to match the terrain, as well as sufficient money, food, and water.

Culturally Sensitive Treatment

Culturally sensitive treatment considers the following factors in the client: culture, cul-
tural identity, and level of acculturation. The therapist’s awareness of the potential cul-
tural variables that may affect the client’s treatment is their cultural sensitivity (Sperry,
2010a). Although it is a common belief in most therapists that cultural sensitivity and
culturally sensitive treatment are necessary to effect favorable treatment outcomes, few
therapists actually provide culturally sensitive treatment. The most prevalent reason for
this state of the field is that not very many therapists have had formal training and
experience in this component. The kind of training that explicitly prepares therapists to
provide culturally sensitive treatment addresses factors of cultural identity and level of
acculturation, knowledge, and experience with culturally sensitive treatment, and a
protocol for assessing and deciding when, and if, culturally sensitive treatment must be
utilized. The three types of culturally sensitive treatments are: (1) cultural interventions;
(2) culturally sensitive interventions; and (3) culturally sensitive therapies.
Culturally sensitive therapies are comprised of interventions that address the
cultural characteristics of diverse clients directly. That is, their beliefs, customs,
attitudes, and socioeconomic status are addressed with the client deliberately.
These therapies are appropriate and particularly effective with clients who have
lower levels of acculturation.
Culturally sensitive interventions are conventional interventions in psy-
chotherapy, commonly CBT, that have been adapted to particular clients and
their cultural characteristics. Given their structured and educational focus,
cognitive behavioral interventions are often modified to be culturally sensitive
(Hays & Iwamasa, 2006); diverse clients often seem to find these interventions
acceptable. For instance, given a client with lower levels of acculturation, a
culturally sensitive therapist would seldom choose an intervention such as cog-
nitive disputation or restructuring of maladaptive beliefs. On the other hand,
36 Pattern

problem solving, skills training, or a replacement approach, i.e., Pattern Focused

Therapy, would be more appropriate.

Treatment Obstacles and Outcomes

The success of the treatment plan and the achievement of the desired outcomes
can be limited, depending on a number of factors. These include the therapist’s
ability to anticipate obstacles and treatment challenges. Factors that may impede
the therapeutic progress may originate in the client, in the practitioner, or the
client-practitioner fit. Otherwise, impeding factors can be related to the ther-
apeutic process itself. A crucial component to achieving treatment success is
anticipating treatment obstacles and challenges to implementing the plan for
treatment. Predicting these challenges and obstacles is the test of an effective case
conceptualization. When effectively conceptualized, these can predict obstacles
such as resistance, ambivalence, transference, and issues which may impede the
maintenance of successful effects or treatment termination (Sperry, 2010a).

Explanatory and Predictive Power of a Case

Conceptualization
There are two criteria that evaluate the adequacy and precision of a case con-
ceptualization. These criteria are explanatory power and predictive power. High
levels of explanatory power and predictive power are the characteristics of highly
effective case conceptualizations.

 Explanatory power: The value of a case conceptualization is contingent on the

degree to which it explains, accurately and compellingly, the client’s maladap-
tive pattern, which is referred to as its “explanatory power” (Sperry & Sperry,
2012). Case conceptualizations have variable gradations of explanatory power,
ranging from low to very high. When trainees are asked at case conferences:
“How compelling is this case conceptualization toward answering the ‘Why?’
question?” and the response is “Not very compelling,” it usually suggests that
predisposing factors, risk and protective factors, or contextual elements might
need revision in order to raise explanatory power. In my experience as a clin-
ical supervisor and case consultant, I’ve found that increasing the accuracy of
the maladaptive pattern factors often boosts explanatory power.
 Predictive power: Treatment outcomes are likely to increase when a compelling
explanation provides a focused and tailored treatment plan to inform the
process of therapy for the individual client. The supreme test of an effective
case conceptualization is its utility in predicting obstacles and facilitators
throughout the span of the therapy, which is referred to as its “predictive
 Pattern 37

power” (Sperry & Sperry, 2012). Highly predictive case conceptualizations

allow the therapist to more suitably anticipate treatment obstacles. Addi-
tionally, highly predictive case conceptualizations increase the accuracy of the
client’s prognosis for treatment. A prognosis is an estimation of how long the
therapeutic outcomes and duration of treatment will be, which are tailored
to the client and context.

Developing Clinically Useful Case Conceptualizations

Initially, developing an effective and clinically useful case conceptualization may
seem like a forbidding and drawn-out process. However, this is not necessarily the
case. The following sections will present a straightforward method for identifying
the key elements and structure of effective case conceptualizations. The compo-
nents will seamlessly fall into place once the structure is evident.
This method of case conceptualization centers on patterns (Sperry & Sperry,
2012). As previously emphasized, the ability to identify patterns with high levels
of precision is essential to the process of case conceptualization. Not surprisingly,
master therapists are experts in identifying patterns effortlessly and expeditiously.
A useful way to think about the case conceptualization process is as a bridge between
assessment and treatment. The process of case conceptualization begins with identifying
and assessing the maladaptive pattern(s). The adaptive pattern is derivative, and typically
the inverse of the maladaptive pattern. Then, from the adaptive pattern, the therapist
derives the goals and focus of the treatment, which informs the tailored treatment
interventions to be implemented. Consistently throughout this book, treatment goals
are demarcated between first-order and second-order change goals. The final compo-
nent is identifying foreseeable challenges and obstacles to implementing the desired
change. That, in essence, comprises the structure of case conceptualization. In discuss-
ing or observing the work of master therapists, this structure surfaced as the implicit
manner in their deliberation about client issues and conceptualization of cases.
This structure also serves as the basic outline for writing case conceptualization
statements. Case conceptualizations that boast high explanatory and predictive
power can be the result of answering each of eight questions. This statement can be
reduced to eight sentences, one for each of the eight answers, resulting in a sig-
nificantly brief process. However, it can also be considerably longer as therapists
may choose to elaborate on certain features.
Throughout my experience in training programs and seminars, if therapists and
therapists in training are encouraged to address and answer the following eight ques-
tions, they can immediately see progress in developing useful case conceptualizations
and develop their confidence in their ability to do so. In the following section,
the questions will be provided and illustrated using the case of Aimee.
38 Pattern

1 What is the client’s presentation and what precipitates it? This question seeks to
derive the “presentation” and “precipitant” elements. The beginning of the pro-
cess involves seeking information in order to satisfy both, as well as the link
between the two. For example, Aimee presents with depression, fatigue,
insomnia, anger at her mother, and worries about her children and ex-husband.
The precipitants for this case include demands to care for others as well as the
anticipatory anxiety due to her ex-husband’s imminent release from prison.
2 What is the client’s basic movement and what is its purpose? The movement
describes the individual’s overarching interpersonal strategy (i.e., how they
relate to others). The three basic types of movement are: (a) moving toward
others; (b) moving away from others; and (c) moving against others. A
fourth type is a combination of simultaneous movements, referred to as
ambivalent (e.g., toward and against, toward and away). For example, Aimee’s
movement was toward others for the purpose of meeting others’ needs,
which was consistent with her personality structure (dependent personality
style). However, as therapy progressed, a secondary movement surfaced and
became increasingly evident. Aimee also moved against others and herself to
satisfy needs of perfection. Aimee followed a pattern of meeting others’
needs and behaving in a pleasing manner, and it was also important to her to
do her best and thereafter criticize herself if she did not achieve perfection.
3 What is the maladaptive pattern, based on the individual’s movement and purpose? This
question addresses the “pattern-maladaptive” element of the case conceptualization
and it is derivative of the movement and purpose. For example, Aimee’s mala-
daptive pattern is that she focuses on meeting others’ needs while ignoring her
own needs. This pattern is also supported by a secondary perfectionistic pattern.
4 What is the origin of the maladaptive pattern? This question seeks to answer
the element “predisposition” or “predisposing factors.” As previously
emphasized, a thorough and complete “predisposition” element supports
and expands the explanatory power of the case conceptualization. For
Aimee, the value of pleasing others and meeting their needs is that she will
feel meaningful and worthy. This pattern is likely rooted in her upbringing,
as her parents were self-centered, critical, overly demanding, and emo-
tionally neglectful; she also has skills deficits in assertiveness and self-care,
which also inform the pattern. Additionally, Aimee has beliefs about herself
as nice but deficient, and she views the world as demanding, conditional,
and critical. These dynamics influenced the development of her pleasing
and perfectionistic pattern.
5 What is a clinically appropriate adaptive pattern? The appropriate adaptive pat-
tern is the “treatment pattern” element of the case conceptualization, which
is derived from the maladaptive pattern element. The adaptive pattern is
 Pattern 39

essentially the mirror opposite of the maladaptive version. For example, the
opposite of Aimee’s meeting others’ needs while ignoring her own, is to meet
others’ needs while maintaining adequate care and consideration for her own
needs. In addition, the next part of her maladaptive pattern is over-con-
scientiousness, for which the mirror opposite is reasonable conscientiousness.
A combination of the two results in a statement such as: meets others’ needs
and also meets her own needs in a reasonably conscientious manner.
6 What needs to happen to shift from the maladaptive pattern to the adaptive pattern? To
adequately answer this question, structural factors need to be considered, beyond
common therapeutic factors, such as empathic responding and support. The client’s
personality and contextual dynamics must be considered. In the case of Aimee, the
structural factors that must be modified are her core beliefs and schemas, as well as
addressing skill deficits. Essentially, her improvement necessitates a shift toward
becoming more empowered, confident, assertive, and less perfectionistic. She must
behave in ways that allow engagement of self-care without guilt.
7 What are clinically appropriate first-order change and second-order change goals?
The “treatment goals” and “treatment focus” elements of the case con-
ceptualization are addressed with this question. These questions expand upon
the structural components defined in the preceding question. They oper-
ationalize targets, the “treatment intervention” element of case con-
ceptualization, made up of tailored goals. For Aimee, first-order goals include
decreasing symptoms, such as depression, fatigue, and insomnia. Second-
order goals are to increase her self-efficacy and empowerment by shifting
core beliefs as well as increasing assertiveness. Also, the decrease of her
perfectionistic striving falls into her second-order goals.
8 What obstacles and facilitators are likely to be encountered in attempting to achieve these
goals? This question addresses the “treatment obstacles and outcomes” element of
the case conceptualization. As previously noted, the supreme test of a case con-
ceptualization is whether it can accurately predict therapeutic obstacles and out-
comes. In the case of Aimee, due to her highly critical and demanding patterns, the
therapist must be mindful of making comments that could potentially activate
transference if misinterpreted as demanding or disparaging. It also makes it
increasingly possible that the client will cling and make for a difficult termination of
therapy, given her dependent personality style. Table 2.4 lists likely obstacles and
challenges for several personality styles (Sperry & Carlson, 2014). This is a non-
exhaustive list of examples of challenges or obstacles to the therapeutic process in
this case. On the other hand, given that she previously had confronted her abusive
husband, the therapist may note that the client has the ability to be assertive and
can confront her mother, accordingly. These denote some of the potential facil-
itators for this case.
Table 2.4 Anticipated treatment challenges
Treatment pattern Treatment challenge
Avoidant Personality
Engagement Premature termination; “testing” behavior, e.g., canceling
appointments; fear of being criticized; difficulty with self-
disclosure
Transference Testing; overdependence
Countertransference Frustration and helplessness; unrealistic treatment expectations
Pattern triggers Close relationships and public appearance
Maintenance Homework avoidance
Termination Anxiety and ambivalence about termination
Borderline Personality
Engagement Client’s difficulty viewing therapist as helpful/collaborative
Transference Dependency, merger fantasy
Countertransference Anger, rescue fantasies
Pattern triggers Personal goals, close relations
Maintenance Focus on feeling good vs. changing
Termination Abandonment fears, relapse proneness
Dependent Personality
Engagement Silent demand for therapist to make decisions and solve their
problems; comply rather than collaborate
Transference Clinging resistance; multiple requests; idealize therapist
Countertransference Rescue fantasies; directive role; failure to confront limited
progress
Pattern triggers Demands for self-reliance and/or being alone
Maintenance Resist increasing independence, assertiveness
Termination Fear of termination/abandonment with paradoxical worsening
of progress
Narcissistic Personality
Engagement Demanding mirroring; easily narcissistically wounded
Transference Idealizing to devaluating; projective identification
Countertransference Not recognizing one’s own narcissistic needs; boredom; feeling
controlled, angry, hurt, impotent
Pattern trigger Evaluation of self
Maintenance Difficulty relinquishing specialness, entitlement
Termination Premature termination
Histrionic Personality
Engagement Quickly develops therapeutic alliance; believes therapist can
understand them intuitively
Transference Fantasy of being rescued; erotic or eroticized transference
 Pattern 41

Table 2.4 (Cont.)

Treatment pattern Treatment challenge
Countertransference Messiah/rescue role; aloofness, anxiety; exploitation
Pattern triggers Opposite sex relationships
Maintenance Resist being ordinary
Termination Fantasies of a continuing relationship; fear of termination
Obsessive Compulsive
Personality
Engagement Appears eager to comply in and between sessions
Transference Obsessive rambling and lists; discounting therapist
Countertransference Disengagement; isolated affect; anger; collude with client’s
defenses
Pattern triggers Authority issues; unstructured situations; close relationships
Maintenance Resists getting in touch with “soft” feelings
Termination Ambivalence about termination

Very Brief Case Conceptualizations

Therapists can greatly benefit from formulating a very brief, albeit provisional,
case conceptualization. In contrast to a full-scale case conceptualization, a very
brief, pattern-based case conceptualization can emerge in the first 10 minutes of
the first meeting with a client.
The necessary components of such a brief, pattern-based case conceptualiza-
tion are the client’s presenting problem, the precipitant for the presenting pro-
blem, the client’s pattern, psychological predisposition, perpetuants, and
treatment plan. For example, David presents with a depressed mood (presenta-
tion) after unfortunate events in his business that resulted in a substantial loss of
capital (precipitant). Throughout his life, David has demonstrated a perfectio-
nistic pattern, holding himself to extremely high standards and beating himself up
for any shortcomings, real or perceived pattern (plan). Background information
and social history revealed that David’s mother suffered from depression (biolo-
gical predisposition). He demonstrates an obsessive-compulsive personality style
and holds the belief that he can only rely on himself (psychological predisposi-
tion). Throughout childhood, David felt that his peers did not understand him
and therefore he spent most of his time alone (social predisposition). He cur-
rently has few friends and maintains extremely high standards for himself and
others, reinforcing his view of others and self (perpetuants). An effective treat-
ment plan for David would indicate behavioral activation interventions and a
decrease in his perfectionistic pattern.
42 Pattern

Conclusion
Pattern is both a critical component of assessment and the heart of the case
conceptualization, particularly in Pattern Focused Therapy. This chapter described
the key components of assessment with an emphasis on pattern identification. It
also detailed the elements of a case conceptualization including the very brief,
pattern-based case conceptualization. Clearly, the takeaway message from this
chapter is that pattern is the central concept in all of Pattern Focused Therapy.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th
ed. Alexandria, VA: American Psychiatric Press.
Beitman, B., & Yue, D. (1999). Learning psychotherapy. New York, NY: Norton.
Bodenheimer, T., & Handley, M. A. (2009). Goal-setting for behavior change in primary care:
An exploration and status report. Patient Education and Counseling, 76(2), 174–180.
Eells, T. (2010). The unfolding case formulation: The interplay of description and inference.
Pragmatic Case Studies in Psychotherapy, 6(4), 225–254.
Frances, A. (2013). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5. New
York, NY: Guilford Press.
GAP Committee on Cultural Psychiatry (2002). Cultural assessment in clinical psychiatry.
Washington, DC: American Psychiatric Press.
Hays, P. A., & Iwamasa, G. Y. (2006). Culturally responsive cognitive-behavioral therapy. Washing-
ton, DC: American Psychological Association.
Hill, C. E. (2005). Therapist techniques, client involvement, and the therapeutic relationship:
Inextricably intertwined in the therapy process. Psychotherapy: Theory, Research, Practice,
Training, 42(4), 431–442.
Kendjelic, E. M., & Eells, T. D. (2007). Generic psychotherapy case formulation training
improves formulation quality. Psychotherapy: Theory, Research, Practice, Training, 44(1), 66.
Lenzen, S. A., van Dongen, J. J., Daniels, R., van Bokhoven, M. A., van der Weijden, T., &
Beurskens, A. (2016). What does it take to set goals for self-management in primary care? A
qualitative study. Family Practice, 33(6), 698–703.
Livesley, W. J. (2003). Practical management of personality disorder. New York, NY: Guilford Press.
Masten, A. S., & Garmezy, N. (1985). Risk, vulnerability, and protective factors in develop-
mental psychopathology. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psy-
chology (pp. 1–52). New York, NY: Plenum Press.
McCullough, M. E., & Snyder, C. R. (2000). Classical sources of human strength: Revisiting an
old home and building a new one. Journal of Social and Clinical Psychology, 19(1), 1–10.
Meier, S. T. (2015). Incorporating progress monitoring and outcome assessment into counseling and
psychotherapy: A primer. New York, NY: Oxford University Press.
Persons, J. B., & Mikami, A. Y. (2002). Strategies for handling treatment failure successfully.
Psychotherapy: Theory/Research/Practice/Training, 39, 139–151.
Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of
Orthopsychiatry, 57(3), 316–331.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
 Pattern 43

Sperry, L. (1989). Integrative case formulations: What they are and how to write them. Indivi-
dual Psychology, 45(4), 500–508.
Sperry, L. (2005). Case conceptualization: A strategy for incorporating individual, couple, and
family dynamics in the treatment process. American Journal of Family Therapy, 33, 353–364.
Sperry, L. (2006). Cognitive behavior therapy of DSM-IV-TR personality disorders, 2nd ed. New
York, NY: Routledge.
Sperry, L. (2010a). Highly effective therapy: Developing essential clinical competencies in counseling
and psychotherapy. New York, NY: Routledge.
Sperry, L. (2010b). Core competencies in counseling and psychotherapy: Becoming a highly competent
and effective therapist. New York, NY: Routledge.
Sperry, L. (2014). Behavioral health: Integrating individual and family interventions in the treatment of
medical conditions. New York, NY: Routledge.
Sperry, L., & Binensztok, V. (2019a). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Sperry, L., & Binensztok, V. (2019b). Learning and practicing Adlerian therapy. San Diego, CA:
Cognella.
Sperry, L., Blackwell, B., Gudeman, J., & Faulkner, L. (1992). Psychiatric case formulations.
Washington, DC: American Psychiatric Press.
Sperry, L., Brill, P., Howard, K., & Grissom, G. (1996). Treatment outcomes in psychotherapy and
psychiatric interventions. New York, NY: Brunner/Mazel.
Sperry, L., & Carlson, J. (2014). How master therapists work: Effecting change from the first through
the last session and beyond. New York, NY: Routledge.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and
confidence. New York, NY: Routledge.
Sperry, L., & Sperry, J. (2020). Case conceptualization: Mastering this competency with ease and
confidence. 2nd ed. New York, NY: Routledge.
Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A
critique and reformulation. American Psychologist, 42(1), 37–45.
Tang, N. K., & Crane, C. (2006, May). Suicidality in chronic pain: A review of the prevalence,
risk factors, and psychological links. Psychological Medicine, 36(5), 575–586.
Wu, E., & Mak, W. (2012). Acculturation process and distress: Mediating roles of sociocultural
adaptation and acculturative stress. Counseling Psychologist, 40, 66–92.
Chapter 3

Practicing Pattern Focused

Therapy

So far, the case has been made for the clinical value of this third-wave Cognitive
Behavioral Therapy (CBT) approach in Chapter 1 and the centrality of pattern.
The importance of a full and integrative assessment and case conceptualization in
Pattern Focused Therapy were highlighted in Chapter 2. This chapter describes
the origins, premises, and components of Pattern Focused Therapy. Next, its core
therapeutic strategy is discussed. This is followed by a description of the most
common interventions and techniques of Pattern Focused Therapy. Then, the
characteristic structure to therapeutic process as well as protocol for a typical
session is described. Finally, a case example illustrates the above discussion.

Origins and Premises of Pattern Focused Therapy

This section describes the origins, premises, and components of Pattern Focused
Therapy.

Origins
Pattern-Focused Therapy was developed by Len Sperry (Sperry, 2016). It is derived
from four sources: (1) the pattern focus in Biopsychosocial Therapy; (2) the proces-
sing format of Cognitive Behavioral Analysis System of Psychotherapy (CBASP); (3)
specific questions from Motivational Interviewing; and (4) outcomes research and
progress monitoring. Biopsychosocial Therapy is an integrative approach that incor-
porates biological, psychological, and socio-cultural factors in planning and imple-
menting psychological treatment. It was developed to assist individuals, couples, and
families with mental health and health care concerns. It emphasizes pattern identifi-
cation, pattern change, and pattern maintenance (Sperry, 1988; 2000; 2006),
The Cognitive Behavioral Analysis System of Psychotherapy is a psychotherapy
approach that focuses on identifying and changing hurtful thoughts and behaviors
into more helpful ones (McCullough, 2000; McCullough, Schramm, & Penberthy,
 Practicing Pattern Focused Therapy 45

2014). CBASP is designated as an empirically supported treatment by the Society

of Clinical Psychology of the American Psychological Association.
Motivational Interviewing (MI) is a therapeutic strategy for helping individuals
discover and resolve their ambivalence to change (Miller & Rollnick, 2002). While
there are a number of specific interventions to increase a client’s readiness for
change, the basic premise of this approach and method is to invite the client’s input
and involvement. The specific contribution of MI is regularly asking permission of
clients to proceed in the treatment process and to identify the importance of a
specific change effort in their life and the confidence they have to achieve it.
Psychotherapy outcomes research assesses and evaluates the effectiveness of
therapy and the mechanisms of change associated with treatments. It also involves
monitoring the treatment progress and the therapeutic over the course of therapy
(Sperry, Brill, Howard, & Grissom, 1996; Sperry 2010; Meier, 2015). Outcomes
research is an integral part of identifying the evidence base for an approach, and I
have been engaged in outcomes research throughout my professional career.

Premises
Pattern Focused Therapy is based on five premises. The first premise is that individuals
unwittingly develop a self-perpetuating, maladaptive pattern of functioning and relating
to others. Subsequently, this pattern underlies a client’s presenting issues. The second
premise is that pattern change, i.e., replacement or shifting to a more adaptive pattern,
is a necessary component of evidence-based practice. The third premise is that effective
treatment involves a change process in which the client and therapist collaborate to
identify the maladaptive pattern, break it, and replace it with a more adaptive pattern.
At least two outcomes have been observed to result from this change process:
increased wellbeing as well as the resolution of the client’s presenting issue (Sperry &
Sperry, 2012). The fourth premise is that the process of replacing non-productive
thinking and behaviors with more adaptive or productive ones can more quickly lead
to effective therapeutic change. This contrasts with therapeutic approaches that
attempt to directly restructure or challenge cognitions, i.e., Cognitive Therapy, or to
directly modify behavior, i.e., Behavior Therapy. Finally, the fifth premise is that ther-
apy that incorporates the clients’ clinically relevant strengths and protective factors can
result in both a positive therapeutic alliance and positive treatment outcomes.

Components of Pattern Focused Therapy

Components refers to the core elements and active ingredients of a therapeutic
approach that can effect change. Pattern Focused Therapy involves four such
components:
46 Practicing Pattern Focused Therapy

1 Pattern focused case conceptualization

2 Query Sequence
3 Brief therapeutic interventions
4 Outcomes assessment, progress monitoring, and incorporation of feedback

1. Pattern-Focused Case Conceptualization

Case conceptualization is the first component of Pattern Focused Therapy. As
previously stated, a Pattern Focused case conceptualization is the clinical strategy
for obtaining and organizing client information, identifying maladaptive patterns,
focusing treatment, and anticipating challenges and roadblocks throughout treat-
ment, as well as preparing for termination (Sperry, 2010). It is, without question,
the most important competency in psychotherapy and particularly in Pattern
Focused Therapy. As previously noted, identifying and then shifting or replacing a
maladaptive pattern with a more adaptive one is the heart of Pattern Focused
Therapy. An important element of such conceptualizations is that they are atten-
tive to clients’ strengths and protective factors.
The process for developing a Pattern Focused case conceptualization was described
in Chapter 2. As already stated, pattern is the heart of such a case conceptualization.
This is not simply a slogan, but a practical clinical reality, because, once identified, this
pattern serves as the therapeutic focus and drives treatment decisions. While such a
written case conceptualization statement may be 200–300 or more words, the few
words that specify the pattern become like a mantra or touchstone for the course of
therapy. For example, if a client’s maladaptive pattern is stated concisely as “avoid and
be safe,” these four words or even two words, “avoidance pattern,” guide the therapy
process as both client and therapist collaborate to replace or shift from the mala-
daptive pattern to a more adaptive one. This point will be repeatedly made and illu-
strated throughout this book.

Pattern Identification
Accurate identification is essential to effecting therapeutic change in Pattern Focused
Therapy. It is critical to note that a maladaptive pattern and an adaptive pattern
rather consistently reflect an individual’s core personality dynamics (Sperry, 2010).
Accordingly, it can be helpful for therapist to identify an individual’s basic personality
style or personality disorder. Then, the therapist can develop hypotheses about cor-
responding maladaptive patterns. It is important to specify a corresponding adaptive
pattern since this will be reflected in the second-order treatment goal. Table 2.2 in
Chapter 2 is a useful guide to pattern identification. It summarizes the most common
maladaptive and adaptive patterns based on personality dynamics.
 Practicing Pattern Focused Therapy 47

Pattern Shifting
Pattern shifting by means of the Query Sequence is the core therapeutic strategy
in Pattern Focused Therapy. Shifting from a maladaptive to a more adaptive pat-
tern indicates that second-order change has occurred (Sperry & Binensztok,
2019). Other CBT approaches which focus primarily on symptoms are not likely
to achieve pattern shifting or personality change. Instead, they can achieve symp-
toms resolution, or personal or relationship stabilization, which are first-order
change goals (Fraser & Solovey, 2007).

2. Query Sequence
The Query Sequence is the second component of Pattern Focused Therapy. It
reflects the core therapeutic strategy of replacement in Pattern Focused Therapy. It
is the unique change intervention of Pattern Focused Therapy. This questioning
sequence was adapted from the Cognitive Behavioral Analysis System of Psy-
chotherapy. Recognized as an evidence-based or empirically supported treatment by
the American Psychological Association (APA, 2018), CBASP was developed by
James P. McCullough for the treatment of chronic depression (McCullough, 2000).
The core therapeutic strategy of CBASP is also replacement. As such, it focuses
on identifying and replacing hurtful thoughts and behaviors with more helpful
ones. It consists of two phases: the situation analysis phase with six steps, and the
remediation phase with two additional steps (McCullough, Schramm, & Pem-
berthy, 2014). The genius of this approach is that it is relatively easy to learn and
apply to a wide variety of difficult client presentations. In the process of analyzing
a specific situation together with their therapist, clients can “replace” problematic
and hurtful thoughts and behaviors with more helpful ones. This often occurs
more quickly than if the therapeutic core strategy was to cognitively restructure
problematic thoughts or to modify problematic behaviors. As the expectation and
demand for therapy become shorter and time-limited, there is considerable value
in replacement approaches like CBASP.
To increase its teachability and clinical utility, the CBASP therapeutic process
was refashioned to a standardized nine steps of a questioning sequence which I
first published in 2005 (Sperry, 2005) and became a key component of Pattern
Focused Therapy. Later, in order to optimize outcomes and clinical success, a
tenth step was added. The questioning sequence includes two key questions for
rating and scaling therapeutic progress (Sperry, 2016; Sperry, & Binensztok,
2018). The first assesses the “importance” of a making a specific change, while
the second assesses the client’s degree of “importance” and “confidence” in
achieving that change. Both are derived from Motivational Interviewing (Miller
& Rollnick, 2013).
48 Practicing Pattern Focused Therapy

What makes the Query Sequence unique from CBASP is the singular focus on
pattern and pattern shifting. In fact, the entire purpose of therapeutically pro-
cessing any concern or issue that arises in therapy is the influence of the client’s
maladaptive pattern. This is designated as Query-P in which the therapist brings
that maladaptive pattern into play for both client and therapist to process.

Query Sequence in Action

Table 3.1 presents the ten-plus queries in the Query Sequence. It focuses on
analyzing and processing problematic situations. Invariably these situations reflect
the client’s maladaptive pattern.
Since the Query Sequence is the main therapeutic strategy for shifting from a
maladaptive to an adaptive pattern, it is the main intervention for achieving
second-order change (Fraser & Solovey, 2007). In this therapeutic processing,
clients achieve their desired or expected outcomes because they replace a hurtful
thought or behavior with a more helpful one. At the same time they incrementally
replace their maladaptive pattern with a more adaptive one. As therapy pro-
gresses, clients come to understand how their thoughts and behaviors reflect their
maladaptive pattern and underlie their presenting problem. This is what the first
premise of Pattern Focused Therapy means. The second premise is that as pat-
terns shift to more healthy ones, the presenting problem recedes.

3. Brief Therapeutic Interventions

The third component of Pattern Focused Therapy is brief therapeutic interven-
tions. While the Query Sequence is the main therapeutic strategy for achieving
second-order change, the use of brief therapeutic interventions, most with CBT
roots, are the primary strategy for achieving symptom reduction or first-order
change (Fraser & Solovey, 2007). Chapter 4 describes 12 ultra-brief interventions
that are short enough to be introduced, learned, and practiced easily within a 30-
minute session and then assigned as homework to be practiced between sessions.

4. Outcome Assessment, Progress Monitoring, and Incorporation of

Feedback
The fourth component of Pattern Focused Therapy is the use of outcomes
assessment measures to continuously monitor progress and incorporate client
feedback into the therapy process throughout therapy. The most common of these
measures are the Patient Health Questionnaire-9 (PHQ-9), the Outcomes Ques-
tionnaire (OQ-45), the Outcome Rating Scale (ORS), and the Session Rating
 Practicing Pattern Focused Therapy 49

Table 3.1 Query Sequence in Pattern Focused Therapy

Query P We’ve been talking about your _______ pattern and the need to shift to a more adaptive
one. This pattern is likely reflected in daily situations. Can we talk about one of those
situations?
Query 1 Please describe what happened. [elicit the situation, making sure the client’s narrative
of the situation has a coherent beginning, middle, and ending]
Query 2 What was your interpretation [your thoughts] of the situation?
Query 3 What were your behaviors? [what did you say? what did you do?]
Query 4 What did you want to get out of the situation? [Desired Outcome]
Query 5 What actually happened [Actual Outcome]
Query 6 Did you get the outcome you wanted?
Query 7 Would you like to look at this situation together with me to review what happened and
how it might have turned out differently?
Query 8 Did your first [second, etc.] interpretation help or hurt you in getting what you wanted?
THEN: What alternative interpretation would have helped you get what you wanted?
[then follow up with] So, how will that new interpretation get what you want?
Query 9 How did your first [second, etc.] behavior help or hurt you in getting what you wanted?
THEN: What alternative behavior [interpretation] would have helped you get what you
wanted? [then follow up with] So, how will that new behavior get what you want?
AND/OR: Were your expectations [desired outcome] realistic?
AND/OR: How can your expectations [desired outcome] be modified to be more
realistic?
Query How important is it for you to ________change your maladaptive pattern)? On a
10–1 scale from 0–10, where 0 is not at all important, and 10 is extremely important, where
would you say you are?
Query How confident are you that if you decided to ______, you could do it? On that 0–10
10–2 scale (not confident to extremely confident) where would you say you are?

Scale (SRS). Client progress is also monitored using any of these. These and other
self-report measures are used in the case of Jerrod described in Chapter 6,
Chapter 7, and Chapter 8. Chapter 5 provides an extended discussion of the
necessity and clinical value of this form of assessment and monitoring. It also
details 15 commonly used measures.

Practicing Pattern Focused Therapy

Pattern Focused Therapy begins with establishing a collaborative relationship and
educating the client in the basic premises of this approach. Central to the
assessment and case conceptualization process is the identification of the mala-
daptive pattern, and then planning treatment that focuses on pattern shifting or
change. Other key factors considered in planning treatment are severity, skill
50 Practicing Pattern Focused Therapy

deficits, motivation and readiness for change, and strengths and protective factors.
A basic therapeutic strategy in the change process is to analyze problematic
situations reported by clients in terms of their maladaptive pattern. Inevitably,
clients report that their thoughts and behaviors were hurtful to them and that
they did not achieve their expected outcome. However, as a result of shifting to a
more adaptive pattern, they can now achieve their expected outcome.
A hallmark of third-wave approaches is sensitivity to the therapeutic relation-
ship. Pattern Focused Therapy places a high value on the development and main-
tenance of an effective and growing therapeutic relationship. Accordingly, near the
end of each session in this approach, the client rates the therapeutic relationship
on the Session Rating Scale (SRS). The results are shared, compared to previous
session ratings, and counselor and client discuss how their working together might
be improved (Sperry, 2016).
The therapy process and sequence can be summarized as:

1 The identification of presentation, precipitant, and predisposition, which

include individual dynamics, family or system dynamics, values, strengths, and
protective factors.
2 A functional assessment and pattern identification.
3 A Pattern Focused case conceptualization that emphasizes and incorporates
pattern and protective factors and strengths.
4 With the Query Sequence and brief therapeutic interventions, a more
adaptive pattern emerges, and symptoms are reduced and eliminated.
5 Outcomes are assessed and monitored, and feedback incorporated into the
therapy process.
6 Finally, as clients continue to make and maintain treatment gains, they are
encouraged to become their own therapists, i.e., third order change (Fraser
& Solovey, 2007) and preparation for termination ensues.

A Typical Session in Pattern Focused Therapy

Here is a four-step preview of how the Pattern Focused Therapy process typically
develops and proceeds. The four steps are:

1 For every session, but particularly in the early meetings, a strong therapeutic
relationship is established and maintained, utilizing various relationship-
enhancing strategies common among third-wave approaches, including
“seeking client permission” and related MI questions.
2 Simultaneously, each session—after the first one—begins with a brief review
of progress on treatment goals since the last session with the Session Rating
 Practicing Pattern Focused Therapy 51

Scale (SRS). Client’s ratings are discussed in relation to the client’s maladaptive
pattern and the goal of shifting to a more adaptive pattern.
3 The Query Sequence is used to analyze the client’s behaviors and inter-
pretations in a specific problematic situation, in terms of whether they help
or hurt the clients in achieving his/her desired outcome. Typically, in a 30-
minute session, one problematic situation can be processed whereas two
might be processed in a 45-minute session. Brief therapeutic interventions
are incorporated that target symptoms for reduction.
4 Near the end of the session, mutually agreed upon between-session activ-
ities (homework) are set. Then, the MI “importance” and “confidence”
questions and answers are processed. The effectiveness of the therapeutic
relationship in that session is assessed with the Session Rating Scale (SRS),
and processed for how the counselor could be more responsive.

Evidence-Based Practices and Pattern Focused Therapy

Evidence-based practice and evidence-based approaches are increasingly impacting
psychotherapy practice. Not so long ago, it was common for therapists to make
treatment decisions based on the therapeutic orientation they espoused and their
experience. Less often, their decisions were based on scientific evidence that the
treatment they provided would be safe, effective, and ethical. Today, because of
the increasing requirement for accountability, there has been a shift to the con-
cept of evidence-based practice. As described, evidence-based practice is a process
of inquiry to help therapists and their clients make key decisions about treatment.
It is a strategy for deciding which interventions to provide, based on the following
factors: research evidence, clinician experience and expertise, client preferences
and values, plus professional ethics, situational circumstances, and the availability
of resources (Sackett, et al., 1996).
Evidence-based practice differs from an evidence-based approach or intervention,
which is also known as “empirically supported treatment” (APA Presidential Task
Force on Evidence-Based Practice, 2006; American Psychological Association, 2018).
That means that one can provide an empirically supported treatment without con-
sidering the factors of client values and clinician expertise. Another way of saying
this is that engaging in evidence-based practice is more encompassing and demand-
ing than simply employing an evidence-based approach or intervention. More spe-
cifically, it means that a therapist may engage in evidence-based practice with or
without employing an evidence-based approach or intervention.
Pattern Focused Therapy is not yet listed by Division 12 of the American Psy-
chological Association (2018) as one of its 80 empirically supported treatments.
However, a key component of Pattern Focused Therapy, CBASP, is recognized as
52 Practicing Pattern Focused Therapy

an empirically supported treatment by the American Psychological Association.

Accordingly, Pattern Focused Therapy can be considered an evidence-informed
therapy approach because it incorporates this key component.
Finally, a therapist or trainee can confidently engage in the evidence-based prac-
tice of Pattern Focused Therapy, assuming that the therapist has sufficient expertise
to provide a treatment approach which is supported by sufficient research evidence.
At this point in time, and because a key component of it is empirically supported,
Pattern Focused Therapy appears to have more value in evidence-based practice
than many conventional therapy approaches.

Case Illustration: Pattern Focused Therapy Session

This case illustrates the practice of Pattern Focused Therapy. Specifically, it shows
how the four components of this approach are easily and seamlessly incorporated
in the fourth session of a relatively brief six-session treatment.

Background Information
Eliana is a 21-year-old, single, Hispanic female who sought therapy at her uni-
versity counseling center which had a policy of initially offering up to six sessions
of individual therapy that could be extended if indicated.
Eliana presented as mildly to moderately depressed and socially isolative during the
initial assessment. Symptoms included low mood, difficulty falling asleep and staying
asleep, fatigue, and difficulty concentrating. As a result, she took a brief leave of absence
from coursework midway through the second semester of her junior year and moved
out of her dorm and back to her parents’ home. Because she misses the DSM-5
diagnosis of Major Depressive Disorder by one criterion, a diagnosis of Other
Specified Depressive Disorder with mild anxious distress is given. Similarly,
because she was one criterion short of the diagnosis of Avoidant Personality
Disorder, Avoidant Personality Style was noted. Her PHQ-9 score at the time of
this evaluation was 10, which is on the border of mild and moderate depression.

Case Conceptualization
Eliana reports a lifelong history of social isolation, and she appears to move away
from others to be safe and avoid rejection and criticism. This avoidant pattern can
be understand in light of deficits in relational and coping skills and her history of
being teased by her older brother and kids in her neighborhood and school. She
views herself as vulnerable and inadequate, while viewing others as critical,
demanding, hurtful, and distrustful. As a result, she avoids close relationships and so
 Practicing Pattern Focused Therapy 53

reduces her vulnerability to rejection. She also has some notable protective factors
and strengths: she has described a secure attachment to her grandmother, and she is
intelligent, insightful, articulate, consistently maintained an A average in college
courses until the semester she dropped out and is reasonably motivated to change.
She identifies as Mexican American and is highly acculturated with no indi-
cation of acculturative stress. She believes that the root of her issues is because
of her inability to use relational skills in interpersonal relationships and her
limited healthy coping skills. Both personality and cultural factors appear to be
operative and cultural dynamics are not likely to negatively impact the ther-
apeutic relationship, given that the therapist is a supportive female. Treatment
progress does not appear to be dependent on cultural factors, nor are culturally
sensitive interventions indicated at this time.
Given her relatively high level of functioning and, at her request, there was
mutual agreement on a six-session course of psychotherapy with the provision of
additional sessions if indicated. The first-order change goal is to decrease her mild-
moderate depressive symptoms. The second-order change goal is to shift her mala-
daptive pattern to a more adaptive one. Pattern Focused Therapy will focus on
replacing or shifting her maladaptive pattern and related thoughts and behaviors so
that she can feel safer connecting with others who are reasonably trustworthy.
Treatment obstacles may include “testing” behavior; difficulties with self-disclosure;
and fear of being criticized and negatively evaluated by the therapist. Given her pro-
tective factors and strengths, treatment prognosis appears to be relatively good.

Course of Treatment
Eliana has completed three sessions of the planned six-session therapy. A good
working therapeutic alliance began in the initial session and Eliana has become
increasingly comfortable with her female therapist and the pattern focused therapy
process. She has responded well to three ultra-brief CBT interventions: behavioral
activation for depressive symptoms in the first session, breath retraining for her
anxiety symptoms, and assertive communication for increasing assertiveness in the
second. She also responded well to the Query Sequence which was implemented in
the second session. Routine monitoring of progress involves the PHQ-9, the Mood
Scale, the ORS, the SRS, and she continues with improvements noted over the first
three sessions.

Plan for Session 4

This is the fourth of six sessions with reasonable progress made on both first-order
and second-order treatment goals. It begins by reviewing the mutually agreed upon
54 Practicing Pattern Focused Therapy

homework in the last session to find an opportunity to communicate more assertively

with her parents. Also her scores on the PHQ-9, the Mood Scale, the ORS, and the
SRS will be reviewed. The Query Sequence will be used to process a recent trouble-
some situation in light of her avoidance pattern. Mutual agreement on relevant
homework activity between now and the next session will be reached.

Transcription: Session 4
THERAPIST: Can we start the session by discussing your PHQ-9 and ORS scores?
(Sure). I see that your PHQ-9 is now 7. That’s great! I also see that your
ratings for behavioral activation activities are really good also. (Progress
monitoring––PHQ-9; homework: behavioral activation)
ELIANA: Yeah, I’m have a bit more energy and my mood is up more. (Pause) I
think I’ll continue with the same behavioral activation activity. I’m up to
walking two miles a day. I’m feeling better, finally.
THERAPIST: Great! It also looks like there are positive changes in your overall ORS
scores from our last session. In particular, your scores for individual well-
being (5 to 6) and interpersonal wellbeing being (4 to 6) are higher. What
has changed from our last meeting that contributes to your higher wellbeing
scores? (Progress monitoring—ORS)
ELIANA: My relationship with my parents has been getting better because I have
been communicating my feelings more. I’ve also signed up to start some
classes this fall so I can resume my plan to finish my degree. I’ve been trying
some relaxation techniques that we spoke about too, to help me relax more,
like the breathing exercises.
THERAPIST: That’s excellent. Sounds like your assertive communication practice
efforts are working well and you’ve become more effective in communicating
with your parents. (Pause) Glad to hear that you recognize how your prac-
tice of breath retraining is paying off. (Pause) And, it’s wonderful that you
are starting school again too because I know how important this was to you.
(Review homework: assertive communication and breath retraining)
ELIANA: Yeah, it is so good that these interventions are making a difference. I
guess it was worth all the hard work and having to stretch myself and taking
the risk to be more assertive and communicative with my parents.
THERAPIST: This means that your pattern is shifting to be more adaptive. Con-
gratulations on your hard work. It’s paying off! (Pause). Might there be anything
else that has contributed to your higher scores on the ORS this week?
ELIANA: Um, no, that’s pretty much it. Um … I have been trying to be more social
with others. To network a bit too. I know it can help shift my pattern to be
less avoidant, but I still feel a little hesitant to socialize with others.
 Practicing Pattern Focused Therapy 55

THERAPIST: I agree. Shifting from an avoidant pattern to a more adaptive one is a

process. We can continue to work together on you being more at ease
around others. Is that okay with you? (Query-Pattern)
ELIANA: Yeah, it’s becoming clearer that I need to work more on reducing and
replacing my avoidant pattern.
THERAPIST: Great! Let’s start with your homework from last session in which you
agreed to increase socializing with one of your friends. How did that go?
ELIANA: Last week my best friend, Jackie, invited me to a mixer to socialize and
network with others. I’m trying to change my ways of avoiding others and
agreed to go and see how it turns out. Otherwise, normally I would have
declined the offer to go out and just stay home and be a homebody.
THERAPIST: Okay, so you agreed to go to a mixer with your friend and how did it
turn out for you?
ELIANA: So, it was a mixer at a restaurant downtown and there were a lot of
people there. It seemed to be a good turnout for the restaurant because a lot
of people attended the event there. Jackie and I got a table and we ordered
dinner at the restaurant. She had other people there that she knew and
called them over to our table and she introduced them to me and vice versa.
But I noticed that when they sat down and joined us it was like I had
nothing to say to them. I ended up not saying too much to them and when
they asked me questions to try and talk to me or, I guess, just include me
into the conversation, I had short responses with them to end the con-
versation quick. I didn’t even really notice I was doing that until my friend
told me how I was acting at the mixer afterwards. I guess it comes natural
for me to just sit back and be behind the scenes and quiet. It’s just … I don’t
know … it’s hard for me to trust people like that. I kind of just keep my
business to myself.
THERAPIST: Yes, I remember in the past when we discussed your difficulties in
socializing at events because it is hard for you to trust others. How did you
feel about not being able to socialize the way you want to at that mixer?
ELIANA: I definitely felt frustrated. It’s like I know that I want to be able to get
better at doing this by now but it’s hard sometimes. I find myself isolating
myself all over again when I try to socialize with people at events. I don’t
know why it’s that way. It took a lot just to get me there.
THERAPIST: Well, let’s look at it this way, you definitely made some progress
because you actually attended the event with your friend whereas before you
would have just stayed home instead.
ELIANA: Yeah, you’re right. Before that’s exactly what I would’ve done.
THERAPIST: Did anything else happen that night? Or was it specific to that situa-
tion at the table with your friend and her associates? (Query-1)
56 Practicing Pattern Focused Therapy

ELIANA: Well, a guy approached me and tried to talk to me, but I kind of just did
the same thing and kind of pushed him away too. It’s like I want to talk to
guys too and get to know someone, but there I go again avoiding interactions
with people. I was anxious and it was difficult to continue the conversation
with him so once again I just kept it real short until the conversation kind of
just trailed off and came to an end and he walked away.
THERAPIST: What were you thinking in both situations with the friend’s associates
and the guy that approached you for conversation? (Query-2)
ELIANA: Well, when my friend’s associates came over to the table and sat down to
chat, I was thinking, “Yeah, this is awkward.” And when the guy approached
me, I was thinking, “Okay, I have nothing to say to this guy.” Both situations
were really out of my element because I’d rather just stay home and catch
something on TV or just do something else at home.
THERAPIST: In both situations, it seems like you were trying to avoid interacting
with new people.
ELIANA: Yeah. I mean, just like we spoke about before, I am trying to change that,
but I still need to work on that.
THERAPIST: Yeah, I agree that it’s a gradual process. We can discuss ways in which
you can do things to help you become better at socializing with new people
and not have to feel anxious and mistrustful of others.
ELIANA: Yeah, that’s true. I have a hard time seeing the positives sometimes.
THERAPIST: What were your behaviors in the situation, such as what did you say or
do when you were at the event? (Query-3)
ELIANA: Um, I, kind of, was short with people when they were trying to talk to
me, and I guess my facial expression didn’t show enthusiasm to socialize with
them at the restaurant.
THERAPIST: Okay, so to avoid interactions with others at the restaurant you were
very brief in your responses and your facial expression did not indicate that
you were pleased to continue socializing with others.
ELIANA: Yeah, that’s pretty much it, that’s all I did.
THERAPIST: What did you want to get out of that situation at the restaurant?
(Query-4)
ELIANA: Well, I just wanted to be able to socialize with people without being distant
and anxious about interacting with them.
THERAPIST: Okay, so you want to be able to be more confident and less anxious
about interacting with people that you do not know well. Is that correct?
ELIANA: Yes, I just want to be able to do this without having such a hard time
doing it, you know, like socializing with new people.
THERAPIST: What actually happened at the restaurant? (Query-5)
 Practicing Pattern Focused Therapy 57

ELIANA: I just ended up not interacting the way that I want to learn how to
interact with others. I was brief with people and I didn’t show that I wanted
to socialize with people. I was more comfortable with my best friend only
because I’ve known her for many years, but when it comes to meeting new
people, I’m not as comfortable.
THERAPIST: It sounds like you didn’t get the outcome that you wanted. What do
you think? (Query-6)
ELIANA: Yeah, I agree that it didn’t turn out the way that I wanted it to. I wish
that I could have just spoken to the people without being like that. I kind of
feel bad too because I didn’t want my friend to think that I was being rude
to her friends. I don’t know what they were thinking about the way I was
acting, but it probably wasn’t good.
THERAPIST: Did you let your friend know about how you felt and that you didn’t
mean to come off that way to her friends?
ELIANA: Yes. When she brought it to my attention about how I interacted with
them, I let her know that. She said she understood, but still I kind of felt bad
for doing that around her friends, you know?
THERAPIST: Don’t beat yourself up about it because you did explain to your friend
why you were behaving that way and you said that she understood as well.
ELIANA: Yeah, that’s true, it didn’t turn out bad because Jackie did say it was okay.
I guess maybe I just feel bad that I can’t socialize like everyone else does.
THERAPIST: Well, you’re trying to do something about it and that’s what counts.
You may not be able to socialize and network the way you want now, but it’s
just a matter of not being able to do it yet. I have confidence in you that
you’ll gradually learn how to be more social in situations that require inter-
action with others you may not know well.
ELIANA: Thanks. I appreciate you saying that.
THERAPIST: We can look at this situation and review your thoughts and behaviors
and see if it could have turned out differently that night and possibly for
future events as well. OK? (Query-7)
ELIANA: Yeah, let’s do that. I definitely need to learn how to change that.
THERAPIST: Your first thought was “This is awkward.” Did it help or hurt you in
getting what you wanted out of the interactions at the restaurant? (Query-8)
ELIANA: It definitely hurt me because I already put it in my head that it was going
to be awkward and look what happened, it ended up being awkward.
THERAPIST: Yes, this is true when you put negative thoughts in your head. In a
sense you’re already expect the situation to turn out negatively. It seems that
you fulfilled what you were thinking of the situation.
ELIANA: Yeah, you’re right, that’s exactly what happened. I do that a lot too. I
think negative about something and expect things to go wrong too. And I
58 Practicing Pattern Focused Therapy

really want to change that too. I know that it’s not good to think that way,
but sometimes I can’t help it.
THERAPIST: Okay, so what thought could you have had instead of thinking that
interacting with them will be awkward that would helped you get the out-
come that you wanted?
ELIANA: I mean, I guess I could have just thought that it would not be awkward to
talk to them … yeah, I could have just thought that the interaction with her
friends will turn out to go well instead of thinking that it is awkward.
THERAPIST: Yeah, that could definitely work in this situation with her friends and
other situations where you are interacting with new people by thinking that
the interactions are going to be positive.
ELIANA: Also, I could think that this will be a good opportunity to network with
other people.
THERAPIST: Right, that would be a good opportunity to network with people for
opportunities that may be beneficial to you.
ELIANA: Yeah, I need to start networking with people more because there may be
opportunities that I’m missing out on.
THERAPIST: That’s true, you never know who you might meet as far as opportunities
go. You may meet the right person who can help you pursue your goals further.
ELIANA: Yeah, exactly.
THERAPIST: Let’s move on to your second thought which was that you had nothing
to say when the guy approached you. Did that help or hurt you in getting
what you want out of the situation? (Query-8)
ELIANA: It hurt me because I ended up looking standoffish and, I mean, it possibly
could have led to something else by getting to know each other, maybe possibly
being able to date someone. You know, I wouldn’t like to start dating but I
have to work on being able to keep the conversation going and feeling more
relaxed. I guess I just always have my guard up when it comes to trying to let
people in. That just seems to be the way that it always goes.
THERAPIST: Yes, if you were trying to get to know someone to possibly date, then
I could see how this hurt you in this situation. Do you think that you would
be able to let your guard down just a bit to get to know other people?
ELIANA: Uh, maybe I could, but I mean I’d have to practice that though, because
I’ve been hurt in the past and that’s why I keep that guard up against other
people because I don’t want that to happen again.
THERAPIST: It seems that we can’t control others hurting us, but is being hurt
worth putting up a strong guard to prevent you from forming relationships
with people?
ELIANA: Well, I guess, no, it’s not worth it because then I won’t meet someone new.
 Practicing Pattern Focused Therapy 59

THERAPIST: Right, avoiding interactions with others will not lead to a new rela-
tionship with a guy because it will create distance.
ELIANA: Yeah, that’s true. And I do that often too, distancing myself.
THERAPIST: So, what could you have thought instead of thinking that you have
nothing to say to this guy, to get what you wanted out of the situation?
ELIANA: I guess I could have just thought, okay, well, I do have something to say
with people instead of thinking I don’t.
THERAPIST: By thinking that you do have something to say, how would you have
used that in the situation with that guy?
ELIANA: I mean, I guess I could have found some common ground between us to
keep the conversation going. I guess I wasn’t really paying attention to what
we had in common because I was anxious and wanted the conversation to be
over quickly.
THERAPIST: Okay, that’s great. Next time when you interact with others you can
find common ground to make the conversation flow easier.
ELIANA: True. I can definitely do that in the future.
THERAPIST: So, let’s review the alternative thoughts that you came up with. Your
first alternative thought was to think that interactions with others will be
positive and that it could be an opportunity to network with others. Your
second one was that you could think that you do have something to say when
you interact with others. Do you feel that you can see yourself using these
thoughts in future interactions with others?
ELIANA: Yeah, I can see myself doing it and I know it will require some practice
though, but it can be done.
THERAPIST: Right, and it is okay that from time to time you may have negative
thoughts, but to realize when you have them and how they impact the way
you interact with others.
ELIANA: I’m seeing that more clearly now.
THERAPIST: Let’s move on to the behaviors. Did your first behavior which was to
be brief or short in conversation with others, did that help or hurt you in
getting what you wanted in that situation? (Query-9)
ELIANA: That ended up hurting me.
THERAPIST: And how did this hurt you?
ELIANA: Well, I guess because being short with them didn’t necessarily help keep the
conversation going to socialize with others and have a good time at the event.
THERAPIST: So, what might you have done differently to get to interact well with
others in that situation?
ELIANA: I could have not been so short with her friends when I was trying to
interact with them.
60 Practicing Pattern Focused Therapy

THERAPIST: Right, right, you could have continued the conversation instead of
being short with her friends and that way you could have gotten to know
them better and possibly hang out with her and her friends in the future.
ELIANA: Yeah, I definitely need to be more social to have fun at these events.
THERAPIST: Your second behavior which was having a facial expression that did not
seem enthusiastic to interact with others, did that help or hurt you in getting
what you wanted in that situation? (Query-9)
ELIANA: I could have just had a positive expression on my face when I was talking
to her friends.
THERAPIST: Right, and a more positive expression would let them know that you
are interested in engaging in conversation with them and they would be
equally pleased to continue the conversation with you.
ELIANA: Yeah, that’s true. I need to gage my facial expressions to know when I’m
looking standoffish versus looking happy or more pleasant.
THERAPIST: Do you see yourself doing that in future conversations by not being
short with people and paying attention to your facial expressions?
ELIANA: Yeah, I think I can do this if I practice doing them.
THERAPIST: Great. Can you see yourself practicing this more adaptive pattern in
interactions between now and when we meet next? We can review your
experiences then. Would that be OK?
ELIANA: Yes, I do.
THERAPIST: So, how important is it for you to make those changes in your adaptive
pattern? On a scale from 0–10, where 0 is not at all important, and 10 is
extremely important, where would you say you are? (Query-10–1)
ELIANA: I’d say 9 or 10.
THERAPIST: And on that 10-point scale, how confident are you that you will make
some changes in it this week? (Query-10–2)
ELIANA: That’d be a 6.
THERAPIST: Can you see yourself practicing this more adaptive pattern in interac-
tions between now and when we meet next? (Yes) We can review your
experiences then. Would that be OK?
ELIANA: Yeah, I can do that till we see each other next time. I definitely need to
practice them. That’s for sure.
THERAPIST: Okay, so let’s take a few moments to complete the SRS so that I may
gage how the session was today. (Progress monitoring––SRS) Eliana fills out
form and hands it back.
THERAPIST: Okay, well, I see that the scores (38) are pretty consistent with last
week’s (38), which are pretty high. Is there anything that you’d like to see
differently in our sessions?
 Practicing Pattern Focused Therapy 61

ELIANA: No, I think you covered everything that we need to talk about during
sessions. And, I do feel heard by you; and it is becoming easier to trust you.
THERAPIST: So glad to hear that. Thanks. (Pause) Do you have any questions or
concerns about this session and the technique we used?
ELIANA: No.
THERAPIST: Okay. So, when we meet next, we can discuss your use of the new
alternatives you learned in this session when you interact with others. Does
that make sense, and do you agree that would be a reasonable homework
activity? (Homework)
ELIANA: Yes, it makes sense, and I’m ready to do it. (Pause) It means I’m going to
have to stretch myself and move out of my comfort zone.

Commentary
This transcription represents a fairly typical session of Pattern Focused Therapy
and demonstrates how the four components of this approach are incorporated. It
began with a review of scores on screeners and outcome measures, and the agreed
upon homework assignment. This allowed the therapist to assess the effectiveness
of the ultra-brief interventions introduced in previous sessions. Of note is that
Eliana is quite engaged in the therapeutic process, has reduced her depressive
symptoms (PHQ-9 = 7), reports being more assertive with her parents, and
experiences some shift to a more adaptive pattern. Her scores on the two MI
questions suggest that shifting to a more adaptive pattern is very important to her
(score of 10) while her confidence in making this change (score of 6) is moving in
the right direction. Subsequent sessions presumably will focus on her level of
confidence.

Conclusion
The practice of Pattern Focused Therapy appears to have considerable appeal for the
everyday practice of therapy today. This focused approach is easily learned and effec-
tively practiced by both novice and experienced therapists. Since 2012, this approach
has been fully implemented in a graduate psychotherapy training program (Sperry,
2016; Sperry & Sperry, 2018), and initial data shows it to be effective and successful in
achieving treatment goals in clients. Furthermore, because it incorporates a key com-
ponent of a recognized empirically supported (evidence-based) treatment, Pattern
Focused Therapy can be considered an evidence-informed therapy approach.
62 Practicing Pattern Focused Therapy

References
American Psychological Association (2018). Psychological treatments. Washington, DC: American
Psychological Association. Retrieved from www.div12.org/treatments/
APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in
psychology. The American Psychologist, 61(4), 271–285.
Fraser, J. S., & Solovey, A. D. (2007). Second-order change in psychotherapy: The golden thread that
unifies effective treatments. Washington, DC: American Psychological Association.
McCullough, J. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of
psychotherapy. New York, NY: Guilford Press.
McCullough, J., Schramm, E., & Penberthy, K. (2014). CBASP as a distinctive treatment for
persistent depressive disorder: Distinctive features. New York, NY: Routledge.
Meier, S. (2015). Incorporating progress monitoring and outcome assessment into counseling psy-
chotherapy: A primer. New York, NY: Oxford University Press.
Miller, W., & Rollnick, S. (2013). Motivational interviewing: Helping people change, 3rd ed. New
York, NY: Guilford Press.
Sackett, D., Richardson, W., Rosenberg, W., Haynes, R., & Brian, S. (1996). Evidence based
medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72.
Sperry, L. (1988). Biopsychosocial therapy: An integrative approach for tailoring treatment.
Journal of Individual Psychology, 44, 225–235.
Sperry, L. (2000). Biopsychosocial therapy: Essential strategies and tactics. In J. Carlson & L.
Sperry (Eds.). Brief therapy with individuals and couples. Phoenix, AZ: Zeig, Tucker & Theisen.
Sperry, L. (2005). A therapeutic interviewing strategy for effective counseling practice: Appli-
cation to health and medical issues in individual and couples therapy. The Family Journal, 13
(4), 477–481.
Sperry, L. (2006). Psychological treatment of chronic illness: The biopsychosocial therapy approach.
New York, NY: Brunner/Mazel.
Sperry, L. (2010). Highly effective therapy: Developing essential clinical competencies in counseling and
psychotherapy. New York, NY: Routledge.
Sperry, L. (2016). Pattern-focused psychotherapy. In L. Sperry (Ed.). Mental health and mental
disorders: An encyclopedia of conditions, treatments, and well-being. 3 vols. (pp. 816–818). Santa
Barbara, CA: Greenwood.
Sperry, L., & Binensztok, V. (2019). Ultra-brief cognitive behavioral interventions: A new practice
model for mental health and integrated care. New York, NY: Routledge.
Sperry, L., Brill, P., Howard, K., & Grissom, G. (1996). Treatment outcomes in psychotherapy and
psychiatric interventions. New York, NY: Brunner/Mazel.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and
confidence. New York, NY: Routledge.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
Chapter 4

Ultra-Brief Therapeutic
Interventions

As already noted, Pattern Focused Therapy is characterized by a unique core

therapeutic strategy and the incorporation of an ultra-brief intervention. Its core
therapeutic strategy is the Query Sequence which focuses primarily on second-
order change, particularly shifting from a maladaptive pattern to a more adaptive
one. Ultra-brief interventions focus primarily on first-order change goals, such as
symptom reduction, self-management, or relational improvement. The Pattern
and Query Sequence are described in detail in Chapter 3.
This chapter describes 12 of the most commonly used brief therapeutic inter-
ventions that I have found to be both very useful and essential in everyday clinical
practice, particularly in the context of short-term therapy.
Each of these interventions is designed to produce changes in behaviors and
presenting symptoms in a short time frame. Because many of them can be quickly
introduced and implemented in a session, these focused interventions are quite
compatible with the trend toward short-term therapy practiced in mental health
and integrated case settings. Furthermore, these interventions can easily be
incorporated into therapists’ “therapeutic arsenal,” irrespective of their theoretical
orientation. Each of these interventions is defined and described, including their
indications and how they can be incorporated into the therapeutic process. The
chapter begins with a description of brief interventions.

Brief Interventions and Brief Intervention Protocols

The term “brief therapeutic intervention” has yet to be clearly defined in terms
of a specific time frame. However, the term “ultra-brief therapeutic interven-
tion” has been defined as “specific cognitive behavioral methods that can be
utilized in very brief, i.e., ultra-brief time frame of 10 to 20 minutes” (Sperry &
Binensztok, 2019, p. 18). Typically, such interventions are implemented within a
single treatment session.
64 Ultra-Brief Therapeutic Interventions

A related designation, “ultra-brief treatment protocols” (Otto & Hofmann, 2010)

refers to the number of sessions of treatment; typically five sessions as compared to
the customary delivery of psychotherapies which range from 12–20 sessions (Otto,
Tolin, Nations, Utschig, Rothbaum, Hofmann, & Smits, 2012). In primary care set-
tings, short-term therapy is often delivered in 6–8 individual or group sessions,
instead of 16–18 individual or group sessions in conventional mental health settings.
Not surprisingly, the reason why session durations can be short (20–30 minutes) is
because ultra-brief interventions are used to achieve a specific therapeutic outcome in
a given session. Table 4.1 lists these interventions. Near the end of the chapter is a
section entitled “Key Resources.” It includes valuable resources that therapists may
find invaluable in learning more about these interventions.

Assertive Communication
Assertive communication is a behavioral intervention to teach individuals to express
emotions, opinions, and needs more clearly and appropriately (Sperry & Binensztok,
2019). Its aim is to increase an individual’s ability to express thoughts, feelings, and
beliefs in a direct, honest, and appropriate manner without violating the rights of
others. Specifically, it involves the ability to say “no,” to make requests, to express
positive and negative feelings, and to initiate, continue, and terminate conversations
(Alberti, 2008). Lack of assertive behavior is usually related to specific skills deficits
but may also be related to interfering emotional reactions and thoughts. A variant of
assertive communication is compassionate assertiveness which is a way to express
needs and deal with conflict while keeping a kind heart, i.e., being compassionate. In
short, mindfulness is a key component of this form of assertive communication,

Table 4.1 Ultra-brief therapeutic interventions

 Assertive Communication
 Behavioral Activation
 Behavioral Rehearsal
 Breath Retraining
 Cognitive Defusion
 Cognitive Disputation
 Habit Reversal
 Limit Setting
 Mindfulness
 Relapse Prevention
 Stimulus Control
 Thought Stopping
 Ultra-Brief Therapeutic Interventions 65

(Vavrichek, 2012). Assertive communications training can occur in individual ses-

sions, group therapy, as well as in other small contexts, such as support groups.
Used alone or as an adjunct to other interventions, assertive communication is
useful for clients presenting with stress, bullying, anxiety, depression, eating dis-
orders, substance abuse, and autism spectrum disorders. It is also useful in
increasing self-esteem in sexual abuse survivors and improving interpersonal skills
in clients with disabilities. It is not recommended for clients whose difficulty in
communicating arises from chronic depression, in which case, the depression
should be treated first (Segal, Williams, & Teasdale, 2013). Providers should also
be aware of views of assertiveness in non-Western cultures.
Here is how this intervention can be incorporated into the therapeutic process.
Initially, the therapist performs a careful assessment to identify the following: situations
of concern to the individual; current assertiveness skills; personal and environmental
obstacles that need to be addressed, such as difficult significant others or limited social
contexts; and personal and environmental resources that can be drawn on. Next, the
therapist formulates an intervention plan. If appropriate behaviors are available but not
performed because of anxiety, the focus may be on enhancing anxiety management
skills. Discrimination training is required when skills are available but are not performed
at appropriate times. If skills deficits are present, skills training is indicated. Then, the
intervention is introduced. For skills training, the therapist teaches the individual spe-
cific skills via modeling, behavioral rehearsal, feedback, and homework. Modeling
effective behavior in specific situations is accomplished by using one or more of the
following methods: in vivo demonstration of the behavior by the therapist, written
scripts, videotapes, audiotapes, or films. In behavior rehearsal, the individual is provided
opportunities to practice the given skill in the clinical setting. After that, the therapist
provides positive feedback following each rehearsal in which effective verbal and non-
verbal reactions are noted and specific changes that could be made to enhance perfor-
mance are identified. Homework assignments involve tasks that the individual agrees to
carry out in real-life contexts. Finally, the length of assertion training depends on the
domain of social behaviors that must be developed and on the severity of countervailing
personal and environmental obstacles. If the response repertoire is narrow, such as
refusing requests, and the obstacles minor, only a few sessions may be required. If the
behavior deficits are extensive, additional time may be required even though only one or
two kinds of social situations are focused on during the intervention.

Behavioral Activation
Behavioral activation is a behavioral intervention to help individuals break cycles of
inactivity and avoidance by substituting more activating behaviors (Sperry &
Sperry, 2018). This technique aims to break the self-perpetuating cycle of
66 Ultra-Brief Therapeutic Interventions

inactivity often accompanying depression and avoidance conditions. As individuals

reduce pleasurable activities, they receive less positive reinforcement, leading to
worsened depression and further reduction of activities. Similarly, individuals who
avoid necessary tasks may be left with a sense of defeat that worsens their mood
symptoms. Behavioral activation emphasizes the role of environmental factors over
internal causes in depression and avoidance conditions. The focus is on increasing
activity, rather than analyzing cognitions. By scheduling both pleasant and neces-
sary activities weekly, the individual increases pleasure, motivation, and self-effi-
cacy. Small changes reinforce the individual and help lead to increasingly
challenging activities.
Behavioral activation was initially used with depressive disorder. More recently, it
has been utilized with various avoidance conditions such as Avoidant Personality
Disorder, Social Anxiety Disorder, and other anxiety disorders.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist teaches the client about cycles of inactivity and explains how
the client’s avoidant behavior reinforces his or her symptoms. Then the therapist
and client discuss how the client’s current inactivity and avoidant behavior have
been contributing to his or her symptoms. The intervention and its rationale are
then explained. Next, the therapist helps the client make three lists—one of the
activities the client currently engages in, one of the necessary tasks the client
needs to perform but has been avoiding, and one of pleasurable activities the
client can potentially engage in. The therapist may give the client a handout of
possible activities to choose from.
During the first week, the client chooses one or two activities that take no
longer than 15–20 minutes each to complete. It is important that the client
begins by setting small goals and not taking on too much at once. The chosen
activities should include both pleasurable and necessary tasks. When beginning,
the client should choose easier activities. This can also be achieved by breaking
down a larger task into several small tasks. Next, the therapist helps the client
schedule the activities for the week, choosing a specific day and time for each.
Back-up activities should also be identified to increase the likelihood that activities
will be completed. The therapist gives the client a handout to track the comple-
tion of tasks. The client is asked to rate each activity on a scale from 0–10 for
level of completion and amount of pleasure derived. Then, the client brings the
activity log to the next session, in which the activities are reviewed. Each activity
is reviewed separately, and the client is asked to explain his or her ratings for
completion and pleasure. The therapist asks what was good and what was not
good about each activity. Finally, over the next few sessions, the client increases
the number of activities completed each week, as well as the duration and com-
plexity of activities.
 Ultra-Brief Therapeutic Interventions 67

Behavioral Rehearsal
Behavioral rehearsal is a behavioral intervention to help individuals identify and
practice behaviors that are more useful and appropriate in social settings (Sperry
& Binensztok, 2019). Behavioral rehearsal helps individuals build appropriate
social skills through modeling, practice, and feedback. The individual identifies
social skill deficits and the therapist helps generate behaviors that would be more
effective in social settings. The therapist models appropriate verbal and nonverbal
behaviors for the client to learn. The client is encouraged to be an active parti-
cipant, giving the therapist feedback and suggestions. The therapist then role-plays
a situation, allowing the client to practice the new social skills. Skills should be
easy to learn and implement. The therapist uses praise and constructive feedback
to help the client improve the new skills.
Behavioral rehearsal can be used with clients of various ages and developmental
levels. It is useful as an adjunct technique to help clients practice the new tech-
niques and skills they learn in therapy before implementing them in real-world
settings. Therapists should take cultural and contextual factors into account before
teaching and modeling targeted behaviors.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist helps the client identify the social skill deficit to be targeted.
The client may identify a specific situation in which he or she is unsure of beha-
viors to implement. Next, the therapist explains the process and benefits of
behavioral rehearsal and elicits the client’s permission to engage in the interven-
tion. The therapist describes and then models appropriate social skills for the
targeted situation. Next, the therapist asks the client for feedback and suggestions
and modifies the modeling accordingly. Then, the therapist role-plays the situation
with the client, allowing the client to practice the new skills. After the role-play,
the therapist praises the client for his or her efforts and provides constructive
feedback. Finally, the role-play may be repeated, incorporating this feedback.

Breath Retraining
Breath retraining, also known as controlled breathing, is a behavioral intervention
used to slow an individual’s breathing and restore regulated breathing rhythms,
resulting in reduced stress-related symptoms (Sperry & Binensztok, 2019). Breath
retraining is used to train individuals to regulate their breathing rate. Shallow or
rapid breathing patterns can increase stress and panic, while regulated deeper
breathing patterns can lead to a more relaxed state by calming the para-
sympathetic nervous system response. Purposely engaging in controlled breathing
can also interrupt negative thought patterns and give an individual a sense of
control over symptoms. Diaphragmatic breathing is the primary method of
68 Ultra-Brief Therapeutic Interventions

teaching individuals how to take slow, deep inhales and exhales from the abdominal area,
rather than the chest. Diaphragmatic breathing should slow respiration to about half of
the typical rate—about six to eight breaths per minute. The individual may place a hand
on their stomach in order to gain feedback on the depth of the breaths. Paced respiration
is another technique for controlling breathing. With this method, the individual inhales
and exhales at a paced rate, often by counting or by using a pacing instrument like a
metronome. The individual may be instructed to position his or her lips in a way that
facilitates slowed breathing, i.e. pretending to blow on a spoonful of soup.
This technique can be used with individuals suffering from symptoms associated
with panic, stress, anxiety, chronic pain, insomnia, and headaches, among other
concerns. It is useful for children, adolescents, and adults. Breath retraining is
often combined with other techniques like progressive muscle relaxation, guided
imagery, or cognitive restructuring.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist asks the client to breathe normally and observes the client’s normal
breathing pattern. Next, the therapist then explains the role of breathing in the cli-
ent’s presenting symptoms, and also explains how controlled breathing can help alle-
viate symptoms. Then the therapist teaches the client to take slow, smooth, deep
breaths that originate in the abdomen. The therapist may model the diaphragmatic
breath for the client. The therapist can instruct the client to position his or her lips in
such a way that breathing is slower and smoother. The therapist can use examples
like, “Imagine you are blowing bubbles or blowing on a spoonful of hot soup.” The
therapist instructs the client to take six to eight breaths per minute. Inhales and
exhales can be paced by counting. Finally, the therapist instructs the client to practice
the breathing technique between sessions and when symptoms arise.

Cognitive Defusion
Cognitive defusion is a mindfulness-based method for distancing oneself from trouble-
some thoughts, rather than disputing, restructuring, or replacing them (Sperry &
Binensztok, 2019). Cognitive defusion is a core technique in Acceptance and Commit-
ment Therapy. It is based on the premise that individuals “fuse” with negative thoughts
and judgments, leading to distressing feelings. Cognitive defusion is used to help the
client accept distressing thoughts instead of disputing them, which may serve to reinforce
these thoughts. This technique teaches individuals to treat thoughts as just thoughts and
not attach feelings or judgments to the thoughts. The individual is encouraged to see
himself or herself as not comprised of his or her thoughts but that thoughts are a sepa-
rate entity from the person. The individual is also encouraged to change the language
used to address the thoughts. Language can be used to separate oneself from the dis-
tressing thoughts. For example, the person can say, “I am having an anxious thought,”
 Ultra-Brief Therapeutic Interventions 69

rather than, “I am anxious,” or “I can’t stand it.” The individual can repeat distressing
thoughts over and over again until they lose their meaning, thus changing the person’s
perspective on the thoughts. One or more of these methods can be used with the goal of
the individual not fusing with the thoughts, thus weakening their hold on the individual.
Cognitive defusion can be used to treat depression, anxiety, substance abuse, eating dis-
orders, and impulse control disorders.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist helps the client identify a problematic situation and the client’s
thoughts associated with the problem. Then, the therapist helps the client
understand the nature of thoughts and how they tend to come and go and do not
comprise who the person is. It can be helpful for the therapist to explains how
language influences thoughts and the way the individual defines his or her
experiences accordingly. The therapist can use metaphors to explain this. The
therapist explains how language reinforces thoughts and behaviors. Next, the
therapist helps the client defuse from thoughts by teaching the client to notice
them without judgment and label them differently. Finally, the client is asked to
practice cognitive defusion by labeling thoughts without judgment and interaction.

Cognitive Disputation
Cognitive disputation is a cognitive-behavioral intervention that uses logic to assist
individuals in identifying the irrationality of their maladaptive thoughts (Sperry &
Sperry, 2018). Cognitive disputation is based on the understanding that cognitions
lead to feelings and behaviors and it focuses on challenging individuals’ maladaptive
beliefs. The therapist disputes the client’s irrational beliefs by using logic, with the aim
of teaching the client to challenge his or her own thoughts without the help of a
therapist. Thoughts can be disputed using Socratic questioning, an approach based on
Aaron T. Beck’s cognitive therapy, focusing on logical errors or cognitive distortions, i.
e. catastrophizing, all-or-nothing thinking. The therapist can also directly dispute the
thoughts, an approach based on Albert Ellis’ Rational Emotive Behavior Therapy,
focusing on one’s beliefs that things “should” or “must” be a certain way for situations
to be bearable. Both approaches encourage the client to test their thoughts against
reality, with Beck’s method encouraging clients to view their thoughts as testable
hypotheses rather than facts. Clients learn to become aware of their thoughts by
recording them, as well as events that may later help dispute irrational thoughts.
Cognitive disputation is useful for treating depression, anxiety, eating disorders,
substance abuse, and marital distress. It is contraindicated for individuals who have
limited cognitive capacity, including those with intellectual disability, borderline
intellectual functioning, dementia, psychosis, or who engage primarily in pre-
operational or emotional thinking.
70 Ultra-Brief Therapeutic Interventions

Here is how this intervention can be incorporated in the therapeutic process. First,
the therapist helps the client identify maladaptive thoughts, and explains that
thoughts may be specific to a situation or more generalized. Next, the client is asked
to document thoughts as homework. Then, the therapist explains the rationale for
cognitive disputation and explains how thoughts influence feelings and behaviors. The
therapist then illustrates how this intervention works by disputing the client’s mala-
daptive thoughts, using logic to demonstrate how the thoughts are irrational. Either
Socratic questioning or disputation is used to convince the client that the thoughts are
irrational. The therapist may ask the client to view the thought as a hypothesis and
test it against reality. Then, the client is asked how much he or she believes the
thought on a scale from 0–10 where 0 is not at all and 10 means totally. After gath-
ering evidence for and against the belief, the therapist asks the client to again rate
how much he or she believes the thought on the same scale. Finally, the client is given
homework to continue to identify maladaptive thoughts as they arise. The therapist
asks the client to journal the daily occurrences to provide a basis for disputing other
beliefs and then practices disputing his or her own thoughts between sessions.

Habit Reversal
Habit reversal is a behavioral intervention used to reduce tics, stuttering, hair-pull-
ing, and skin-picking by engaging in a competing response which then suppresses
the unwanted behavior (Sperry & Sperry, 2018). Habit reversal is intended to
reduce the occurrence of compulsive behaviors, such as hair-pulling, by replacing
those behaviors with inconspicuous, opposing behaviors. Instead of breaking or
stopping a negative habit, it substitutes it with a better or incompatible one (Sperry,
2011). Habit reversal therapy is comprised of four stages: (1) building awareness;
(2) developing a competing response; (3) increasing motivation; and (4) skill gen-
eralization. In the awareness stage, the client increases awareness of the behavior by
describing it or performing it in a mirror, as well as identifying situations in which
the behavior frequently occurs. In the competing response stage, the client learns a
behavior that is incompatible with the unwanted behavior. The competing response
should be the opposite of the unwanted behavior and inconspicuously performed in
social situations. The competing behavior should also induce isometric tension of the
muscles involved in the unwanted behavior and be practiced for several minutes at a
time. In the motivation stage, the client explores reasons to discontinue the
unwanted behavior, including times when the behavior has proved embarrassing or
inconvenient. The client’s friends and family are asked to encourage the client’s
reduction of the unwanted behavior and the client controls the unwanted behavior
in front of trusted people. Finally, in the generalization phase, the client rehearses
the competing behavior in other situations.
 Ultra-Brief Therapeutic Interventions 71

Habit reversal is useful in treating tic disorders, hair-pulling disorder, skin-

picking disorder, stuttering, and other habits like nail biting, teeth grinding,
scratching, and oral-digital habits. It can be used with children, adolescents, and
adults. Habit reversal is not indicated for clients with borderline intellectual
functioning or intellectual disability.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist helps the client become aware of the unwanted behaviors. The
client either describes the behavior in detail or observes himself/herself performing
the behavior while looking in a mirror. Then, the therapist can also point out when the
behavior occurs during sessions until the client becomes more aware of the behavior.
Next, the therapist helps the client identify warning signs for the oncoming behavior,
such as urges, physical sensations, or thoughts. Situations in which the behavior is most
likely to occur are also identified. Similarly, the therapist helps the client identify a
competing behavior that is the opposite of the unwanted behavior and is inconspicuous
in public. For example, the behavior may involve putting one’s hands in one’s pockets or
pinching one’s forearm. Next, the client practices the competing behavior for several
minutes at a time. Then, the therapist works with the client to write a list of problems,
inconveniences, and embarrassments caused by the unwanted behavior. Outside the
session, the client enlists family and friends for support and demonstrates suppression
of the unwanted behavior in front of them. These individuals are enlisted to praise the
person for control of the behavior. Next, the therapist helps the client symbolically
rehearse performing the competing behavior in different areas of the client’s life.
Finally, the client practices the competing behavior in different contexts.

Limit Setting
Limit setting is a behavioral intervention to establish the boundaries of positive and
acceptable client behavior. The aim of limit setting is to foster therapy-enhancing
behaviors that facilitate the achievement of first- and second-order change goals while
limiting treatment-interfering behaviors. Typical treatment-interfering behaviors
include: (1) coming late for sessions, missing a session, unnecessarily delaying or fail-
ing to make payment; (2) harmful behavior to self or others, including parasuicidal
behaviors; inappropriate verbal behavior, such as abusive language; (3) dominating
treatment by excessive or rambling speech; (4) efforts to communicate with the
therapist outside the treatment context (i.e., unnecessary phone calls); inappropriate
actions such as hitting or unwanted touching, breaking or stealing items; or (5) failure
to complete assigned therapeutic tasks or homework. In short, limit setting exists in
therapy to protect and enhance the therapeutic experience.
Limit setting is a common intervention with personality-disordered clients who
have difficulty maintaining boundaries, as well as appreciating and anticipating the
72 Ultra-Brief Therapeutic Interventions

consequences, especially the negative consequences, of their actions (Sperry,

2016). Setting limits and setting boundaries are considered a life skill in Dialec-
tical Behavior Therapy which has developed specific guidelines for limit setting
(Linehan, 2015). Furthermore, limit setting is a therapeutic intervention that is
quite useful in outside treatment settings as well.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist observes or anticipates the treatment-interfering behaviors. Next,
the therapist begins implementing limit setting by setting the limit. The limit is spe-
cified in “if __ then __ ” language. It is crucial that the therapist states the limit in a
neutral, non-critical tone and non-judgmental language. Then, the therapist explains
the rationale for the limit. After that, the therapist specifies or negotiates with the
individual the consequences for breaching the limit. Finally, the therapist responds to
any breaches of the limit setting. Because individuals can and do test limits—whether
for conscious or unconscious reasons—more commonly in the early phase of treat-
ment, limit testing should be expected. The therapist should be prepared to respond
by confronting and/or interpreting it; enforcing the consequences, and discussing the
impact of the breach on treatment; or predicting that such testing may reoccur.

Mindfulness
Mindfulness is an intervention which helps individuals to focus on the present without
judgment (Sperry & Sperry, 2018). The result is that it can reduce stress, anxiety,
mood symptoms, and mindless action. Mindfulness originated in the Buddhist tradi-
tion and is used to mediate physical, emotional, and behavioral symptoms. It can
facilitate individuals to build awareness and observation of thoughts, sensations, and
mood states without active engagement with or judgment of them. The individual
becomes aware of bodily sensations, emotional states, thoughts, and mental images,
while practicing remaining fully present in the moment. Instead of attempting to
escape these sensations, the individual views them as objective facts. For example, one
might observe physical symptoms of anxiety and describe, “My throat feels tight right
now.” Observation of thoughts and feeling states should be non-judgmental and the
participant should bring all attention to the current experience. Individuals are
encouraged to cultivate mindful attention in daily activities. As mindfulness practice
evolves, individuals habituate to unpleasant sensations and thoughts. Mindfulness is
thought to relieve distressing thoughts, improve self-management, and allow indivi-
duals to recognize impending relapse or mood symptoms so they can implement
coping skills to manage these occurrences.
Mindfulness can be used for chronic pain, medical problems, anxiety disorders,
mood disorders, eating disorders, substance abuse, and personality disorders. It has
been reported that the mindfulness exercise of loving kindness is not recommended
 Ultra-Brief Therapeutic Interventions 73

for clients who present with chronic depression (Segal, Williams, & Teasdale,
2013). Mindfulness can be applied as a skills training method, as a meditative
technique, or as a component of other interventions. Though typically taught in a
group setting, mindfulness instruction may take place in a one-on-one format.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist teaches the client to observe his or her thoughts without
labeling or describing them. Next, the therapist assigns homework for the client
to continue observing thoughts, feelings, and sensations. The therapist then tea-
ches the client to observe sensations without judgment through an activity like
mindful eating, in which he/she focuses on the smells, texture, temperature, and
physical sensations during the experience. The client is asked to describe thoughts
and sensations as they arise, i.e. “The tomato is watery,” without making judg-
ments, i.e., “I don’t like it.” After that, the therapist helps the client practice
making a running commentary on events and experiences without judgment.
Finally, the therapist assigns homework for the client to practice giving full
attention to experiences, either in daily meditation or during everyday activities.

Relapse Prevention
Relapse prevention is a behavioral intervention that originally taught individuals to
maintain sobriety while coping with everyday stressors and temptations, but more
recently is used to maintain therapeutic gains with most presentations (Sperry &
Sperry, 2018). After completing treatment for substance use issues, individuals are
tasked with maintaining sobriety while facing stressors and obstacles. Individuals may
find it challenging to avoid relapsing if their judgment is still affected by continued use.
Relapse prevention helps clients develop coping skills and self-efficacy. The approach is
based on the premise that when facing a stressful event, an individual’s coping skills are
the main determining factor between relapse and maintained sobriety. Employing
effective coping mechanisms in the face of distressing events leads to increased self-
efficacy and a decreased risk of relapse. Relapse prevention uses relapse education,
which teaches individuals to identify warning signs and high-risk situations, learn
effective coping skills, challenge irrational beliefs, form more realistic expectations, and
create a toolkit that includes social support, self-care, and avoidance of relapse triggers.
Relapse prevention is useful for individuals in recovery from substance abuse and
other addictive behaviors, such as eating disorders, overeating, smoking, and self-
harm. More recently, it is being used to maintain therapeutic gains with nearly all
mental health conditions in conjunction with most therapeutic approaches. It is a key
intervention in Pattern Focused Therapy.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist assesses the client’s patterns of use or behavior, coping skills, self-
74 Ultra-Brief Therapeutic Interventions

efficacy, expectations, and readiness for change. Then, the therapist educates the
client on relapse and the benefits of a relapse prevention plan. Next, the therapist
helps the client make a list of the client’s high-risk situations, and stressful events that
can potentially trigger the unwanted behavior. After that, the client and therapist
discuss the high-risk situations and how they lead to use. Next, the therapist helps the
client identify and challenge irrational beliefs about use since clients use such irra-
tional beliefs to provide emotional relief in difficult situations. Then, the client and
therapist make an inventory of relapse warning signs, including major stressors as well
as a culmination of small stressors, and the client is taught to address initial small
stressors rather than waiting to reach his or her breaking point. Then, the client is
encouraged to keep a log of warning signs. Similarly, the client and therapist devise a
list of supportive efforts to ensure the plan is maintained. These may include con-
tinued therapy, attending 12-step meetings, a list of supportive people to call, a list of
people and places to avoid, the use of a sponsor, and improved self-care. Finally, the
client commits to a lifestyle change that supports his or her recovery, including caring
for his or her health, exercise, positive social interactions, etc.

Stimulus Control
Stimulus control is a behavioral intervention to identify factors, i.e., stimuli, that
precede a behavior to be changed and then taking steps to alter the factors to
bring about the desired result (Sperry & Binensztok, 2019). Stimulus control
works by using an individual’s ability to associate a stimulus with a consequence.
The stimulus then works to control the individual’s behaviors. A stimulus can be
an object, activity, image, or place. Stimulus control can be achieved when a sti-
mulus is paired with either a pleasant or unpleasant experience, or when a beha-
vior is reinforced or punished in the presence of a stimulus. For example, a person
who gets food poisoning after eating chicken, may then avoid chicken entirely, with
the dish serving as the stimulus and its consumption as the behavior being controlled.
The stimulus then serves as a trigger for a specific behavior or response.
Stimulus control can be used to increase any desired behavior and decrease any
undesired behavior. Originally used as an essential intervention for alcohol use
disorders and other addictions, it is now a mainstay treatment for insomnia and
obesity. Potentially, there are many other conditions in which it could be applied.
In short, it is a simple and easy to implement intervention that is too often
underutilized in clinical practice.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist helps the client identify a targeted behavior that the client would
like to either increase or decrease. Then, the therapist then explains how stimuli
become behavioral triggers and how stimulus control can be used to modify
 Ultra-Brief Therapeutic Interventions 75

behaviors. Next, possible triggers of the targeted behavior are identified as the
therapist asks about contributing thoughts, feelings, behaviors, and environmental
factors, including specific individuals. Then, the client is directed to monitor those
target behaviors and keeps a log of occurrences to identify all possible triggers. When
they meet again, the client and therapist review the triggers and agree on which
triggers will be controlled. Finally, the therapist helps the client devise a plan for
controlling each specific trigger. For example, a client with insomnia may find that she
cannot fall asleep on days when she answers work emails before bed. Once the client
identifies triggers and agrees that she would like to control them, the therapist helps
her identify ways to control each trigger. She identifies having her notebook computer
next to her bed as the main trigger. Her plan is to stop answering work emails before
bedtime by removing the computer from her bed stand, she effectively controls the
stimulus which is the trigger for her difficulty in falling asleep.

Thought Stopping
Thought stopping is a behavioral intervention to block or eliminate ruminative or
intrusive thought patterns that are unproductive or anxiety-producing (Sperry,
2016). It may also have the effect of increasing the individual’s sense of control
and reducing distress. This intervention is usually introduced and demonstrated by
the therapist. It is then practiced and applied by the individual. As a result of
applying this intervention, the individual increases his sense of control.
Thought stopping can be used for obsessive thoughts associated with obsessive-
compulsive disorder, psychotic symptoms, depression, panic, generalized anxiety,
tobacco use, drug and alcohol use, and body dysmorphic disorder. It can be used
as either a stand-alone or auxiliary treatment.
Here is how this intervention can be incorporated into the therapeutic process.
First, the therapist instructs the client on the similarities between normal and
obsessive/intrusive thoughts. An agreement is reached to try to reduce the duration
of the intrusive thoughts, thus making them more “normal” and increasing the client’s
sense of control. Then the therapist and client draw up a list of three obsessional
thoughts and several specific triggering scenes. Next, a list of up to three alternative
thoughts (i.e., interesting or relaxing thoughts) is made. For example, a scene from a
movie, lying on a sandy beach, or taking a walk through the woods. Each obsessional
thought is rated for the discomfort it produces on a scale of 1–10 (1 = lowest, 10 =
highest). Then the therapist demonstrates how to block obsessional thoughts and
substitute an alternative thought. The therapist directs the individual to close his or
her eyes and become relaxed with the instruction to raise a hand when the obsessional
thought is first experienced. For example: “Sit back and relax and let your eyes close.
I’ll mention a specific triggering scene to you, and then describe you experiencing an
76 Ultra-Brief Therapeutic Interventions

obsessional thought. As soon as you begin to think the thought, raise your hand,
even if I’m only describing the scene.” The therapist then describes a typical
triggering scene, and as soon as the individual raises a hand, the therapist says
“Stop!” loudly. The therapist asks the client whether the obsessional thought was
blocked and whether the individual was able to imagine the alternative scene in
some detail. The discomfort arising from that obsessional thought is then rated
on the 1–10 scale. Next, the therapist then leads the client in practicing thought
stopping with different triggering scenes and alternative thoughts, and the dis-
comfort ratings are recorded. Practice continues until the individual can suffi-
ciently block and replace the obsessional thought. After that, the procedure is
modified so that following the therapist’s description of the triggering scene and
obsessive thought, the client says “Stop!” and describes the alternative scene.
Next, the therapist gives an intersession assignment (homework) to the client for
15 minutes of practice a day at times when the client is not distressed by intrusive
thoughts. A log is kept with ratings of 1–10 made of the distress and vividness
evoked by the intrusive thought. Finally, after a week of practice, the therapist
prescribes the intervention to be used to dismiss mild to moderately distressing
thoughts as they occur. The client is instructed that as his or her sense of control
increases, the thoughts, when they occur, will become less distressing (on the 1–
10 scale) until the individual experiences little or no concern about them.

Conclusion
This chapter describes 12 brief interventions that can easily and effectively be
incorporated into Pattern Focused Therapy or other therapy in both mental health
and integrated care settings. Chapter 5, Chapter 6, Chapter 7, and Chapter 10
will illustrate the use of such interventions over the course of successful therapies.
The interested reader will find 20 ultra-brief therapeutic interventions described
with clinical illustrations in the book by Sperry and Binensztok (2019) as well as
other sources of brief interventions (Sperry, 2016; Sperry & Sperry, 2018).

Key Resources

Assertive Communications
Alberti, R. (2008). Your perfect right: Assertiveness and equality in your life and relationships. 9th ed.
San Luis Obispo, CA: Impact Publications.
Segal, Z., Williams, J., & Teasdale, J. (2013). Mindfulness-based cognitive therapy for depression. 2nd
ed. New York, NY: Guilford Press.
Vavrichek, S. (2012). The guide to compassionate assertiveness. Oakland, CA: New Harbinger Press.
 Ultra-Brief Therapeutic Interventions 77

Behavioral Activation
Beck, J. (2011). Cognitive behavior therapy: Basics and beyond. 2nd ed. New York, NY: Guilford Press.
Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided
action. New York, NY: Norton.
Veale, D. (2008). Behavioral activation for depression. Advances in Psychiatric Treatment, 14, 29–36.
http://dx.doi.org/10.1192/apt.bp.107.004051
Veale, D., & Willson, R. (2007). Manage your mood: A self-help guide using behavioural activation.
London: Constable & Robinson.

Behavioral Rehearsal
Wolpe, J. (1990). The practice of behavior therapy. New York, NY: Pergamon Press.
Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy techniques: A guide to the treatment of neuroses.
New York, NY: Pergamon Press.

Breath Retraining
Lehrer, P. M., Woolfolk, R. L., & Sime, W. E. (2007). Principles and practice of stress management.
3rd ed. New York, NY: Guilford Press.
Mirgain, S., Singles, J., & Hampton, A. (n.d.). The power of breath: Diaphragmatic breathing
clinical tool. Retrieved from http://projects.hsl.wisc.edu/SERVICE/modules/12/M12_CT_
The_Power_of_Breath_Diaphragmatic_Breathing.pdf

Cognitive Defusion
Hayes, S., & Smith, S. (2005). Get out of your mind and into your life: The new acceptance and
commitment therapy. Oakland, CA: New Harbinger.

Cognitive Disputation
Beck, J. (2011). Cognitive behavior therapy: Basics and beyond. 2nd ed. New York, NY: Guilford Press.
Ellis, A., & MacLaren, C. (1998). Rational emotive behavior therapy: A therapist’s guide. San Luis
Obispo, CA: Impact.

Habit Reversal
Azrin, N. H., & Peterson, A. L. (1988). Habit reversal for the treatment of Tourette syndrome.
Behaviour Research and Therapy, 26(4), 347–351. doi:10.1016/0005-7967(88)90089-7.
Sperry, L. (2011). Switch and snap techniques: Breaking negative habits and reducing distress.
In H. Rosenthal (Ed.), Favorite counseling and therapy homework assignments (pp. 309–311).
New York, NY: Routledge.
Woods, D. W., & Miltenberger, R. G. (1995). Habit reversal: A review of applications and
variations. Journal of Behavior Therapy and Experimental Psychiatry, 26(2), 123–131.
doi:10.1016/0005-7916(95)00009-0.
78 Ultra-Brief Therapeutic Interventions

Limit Setting
Green, S. (1988). Limit setting in clinical practice. Washington, DC: American Psychiatric Press.
Linehan, M. (2015). Skill training manual for treating borderline personality disorder. 2nd ed. New
York, NY: Guilford Press.
Sharrock, J., & Rickard, N. (2002). Limit setting: A useful strategy in rehabilitation. The Aus-
tralian Journal of Advanced Nursing, 19(4), 21.

Mindfulness
Crane, R. (2009). Mindfulness-based cognitive therapy: Distinctive features. New York, NY:
Routledge.
Forsyth, J. P., & Eifert, G. H. (2007). The mindfulness and acceptance workbook for anxiety. Oakland,
CA: New Harbinger Publications.
Linehan, M. (2015). Skill training manual for treating borderline personality disorder. 2nd ed. New
York, NY: Guilford Press.
Segal, Z., Williams, J., & Teasdale, J. (2013). Mindfulness-based cognitive therapy for depression. 2nd
ed. New York, NY: Guilford Press.

Relapse Prevention
Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for addictive
behaviors: A clinician’s guide. New York, NY: Guilford Press.
Gorski, T., & Miller, M. (1986). Staying sober: A guide for relapse prevention. Aspen, CO: Inde-
pendence Press.
Marlatt, G. A., & Donovan, D. (2005). Relapse prevention: Maintenance strategies in the treatment of
addictive behaviors. 2nd ed. New York, NY: Guilford Press.

Stimulus Control
Bootzin, R. R. (1972). A stimulus control treatment for insomnia. Proceedings of the American
Psychological Association, 7, 395–396.
Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2006). Cognitive behavioral treatment of
insomnia: A session-by-session guide. New York, NY: Springer.

Thought Stopping
McKay, M., Davis, M., & Fanning, P. (2012). Thoughts and feelings: Taking control of your moods
and your life. 4th ed. Oakland, CA: New Harbinger Publications.
Wolpe, J. (1990). The practice of behavior therapy. New York, NY: Pergamon Press.
Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy techniques: A guide to the treatment of neuroses.
New York, NY: Pergamon Press.
Yamagami, T. (1971). The treatment of an obsession by thought-stopping. Journal of Behavior
Therapy and Experimental Psychiatry, 2(2), 133–135. doi:10.1016/0005-7916(71)90028-0.
 Ultra-Brief Therapeutic Interventions 79

References
Alberti, R. (2008). Your perfect right: Assertiveness and equality in your life and relationships. 9th ed.
San Luis Obispo, CA: Impact Publications.
Linehan, M. (2015). Skill training manual for treating borderline personality disorder. 2nd ed. New
York, NY: Guilford Press.
Otto, M., Tolin, D. F., Nations, K. R., Utschig, A. C., Rothbaum, B. O., Hofmann, S. G., &
Smits, J. A. (2012). Five sessions and counting: Considering ultra-brief treatment for panic
disorder. Depression and Anxiety, 29(6), 465–470.
Otto, W., & Hofmann, S. G. (2010). Avoiding treatment failures in the anxiety disorders. New York,
NY: Springer.
Segal, Z., Williams, J., & Teasdale, J. (2013). Mindfulness-based cognitive therapy for depression. 2nd
ed. New York, NY: Guilford Press.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
Sperry, L. (2011). Switch and snap techniques: Breaking negative habits and reducing distress.
In H. Rosenthal (Ed.), Favorite counseling and therapy homework assignments (pp. 309–311).
New York, NY: Routledge.
Sperry, L. (2016). Cognitive behavior therapy of DSM-5 personality disorders. 3rd ed. New York, NY:
Routledge.
Sperry, L., & Binensztok, V. (2019). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Vavrichek, S. (2012). The guide to compassionate assertiveness. Oakland, CA: New Harbinger Press.
Chapter 5

Outcomes Assessment and

Indicators of Successful
Treatment

In the era of accountability, therapists are not only expected to provide successful
treatment but are increasingly expected to demonstrate that their provided treatment
is effective. Two perspectives have surfaced on how to achieve such expectations. The
first is “evidence-based practice,” based on the empirically-demonstrated effects of a
specific treatment intervention with specific psychological indications. The second is
“practice-based evidence,” wherein therapist-client collaboration and feedback are the
focus of clinical effectiveness rather than specific treatment interventions (Sperry,
Brill, Howard, & Grissom, 1996; Rousmaniere, 2017).
From the latter perspective, ongoing assessment throughout the course of
therapy is of crucial importance where therapists monitor the processes and
outcomes of treatment. This chapter emphasizes the latter perspective. The focus
of research, until recently, was on the overall assessment of outcomes in treat-
ment. More recently, it has since shifted to ongoing assessment, i.e., session-by-
session monitoring of the progress of therapy called progress monitoring and
routine outcome monitoring (Rousmaniere, 2017). As already noted, outcomes
assessment and incorporating feedback are the fourth key component of Pattern
Focused Therapy.
The chapter begins with a discussion of outcomes assessment, progress mon-
itoring, and routine outcome monitoring, and their clinical value. It reviews some
key research findings and applications to everyday clinical practice. Then, it
describes several common outcome measures and screeners that are essential to
clinical practice. Finally, it describes seven indicators of what highly effective
therapists do to achieve successful therapeutic outcomes.

Outcomes Assessment, Progress Monitoring, and Routine

Outcome Monitoring
Let’s begin with some technical definitions. Outcomes assessment is the use of
measures to collect clinical data about the amount and type of change clients
 Outcomes Assessment, Successful Treatment 81

experience from the beginning to the end of therapy. Progress monitoring is the
use of outcome measures that produce clinical data to monitor client change or
non-change during the course of therapy (Rousmaniere, 2017). Routine outcome
monitoring adds another element to progress monitoring in that it measures cli-
ents’ progress not simply to evaluate change or non-change but, if necessary, to
adapt treatment (van Sonsbeek, Hutschemaekers, Veerman, & Tiemens, 2014).
Therapists are not especially adept at predicting the strength of their client-
therapist relationship nor predicting treatment outcomes. Instead, research has
suggested that client ratings are more accurate at predicting the client-therapist
alliance and treatment outcomes than those of their therapists (Orlinsky,
Rønnestad, & Willutzki, 2004). The client’s subjective experience of progress in
the early treatment process is also a superior predictor of treatment success than
all other predictors or measures, according to research (Orlinsky, Rønnestad, &
Willutzki, 2004). How, then, can a therapist evaluate or accurately assess a client’s
treatment response? A simple answer is to measure and monitor both the alliance
and outcomes of treatment.
A key premise of psychotherapy outcomes research is that therapists can use
feedback to improve their clinical effectiveness (Sperry, Brill, Howard, & Grissom,
1996). Research has consistently shown that therapists who receive feedback on
their ongoing work with clients outperform those who do not. Their treatment
effectiveness increases significantly, as does the quality of their therapeutic rela-
tionships. In a study by Whipple et al. (2003), therapists who had access to
feedback on their clients’ progress and information about the therapeutic alliance
were able to achieve significant changes with their clients, had fewer results of
treatment dropout, and their clients were less likely to deteriorate. Another study
examined the relationship between clients and therapists that were at risk of
adverse outcomes. Therapists who received formal feedback in the study were
65% more likely to accomplish positive treatment results than those who did not
get feedback (Whipple et al., 2003). A study including in excess of 6,000 clients
reported that therapists who used formal feedback measures on an ongoing basis
had significantly higher rates of retention and doubled the positive effects overall
in comparison to therapists who did not have such feedback (Miller, Duncan,
Brown, Sorrell, & Chalk, 2006). Although it was not a randomized controlled trial
(RCT), the results reported in this study are noteworthy due to its notably large
sample size. Finally, Shimokawa, Lambert, and Smart (2010) examined clients who
were on-track for positive outcomes versus clients who were predicted to be
treatment failures. They reported on the effects of feedback on these clients.
Their review included over 4,000 clients and compared the treatment-as-usual
conditions to feedback-assisted treatments in six RCTs. Results indicated that the
condition in which therapists received feedback was far superior to treatment-as-
82 Outcomes Assessment, Successful Treatment

usual clients, by approximately 20–30% of the clients. The feedback provided an

advantage as it enabled therapists to identify and treat clients differently than in
the treatment-as-usual condition. The results of the feedback also reduced the
rates of deterioration to 5.5%, adding evidence of its substantial benefit.
Three predictions can be made when both the therapist and the client are aware of
how the client rates the therapeutic relationship and the progress of treatment: (1)
the therapeutic relationship is more likely to be effectively developed and maintained;
(2) the client is more likely to stay in treatment; and (3) there are more positive
treatment outcomes. Therefore, the monitoring of treatment outcomes and processes
is absolutely crucial to providing effective therapy. This section will provide a
description of various ways of assessing the therapeutic relationship and ensuring the
ongoing examination of treatment processes and outcomes.

Clinical Value of Progress Monitoring

Inconsistent and limited therapist performance is a major reason for giving feed-
back. A study of over 6,000 clients treated in routine practice found that only
about a third improved or recovered while approximately two-thirds did not
improve or recover (Hansen, Lambert, & Forman, 2002). Some therapists rarely
have a single client who deteriorates, while others experience consistently high
rates. Failures are usually due to therapist failure to identify deterioration or those
who are not improving. Regularly assessing and monitoring outcomes has become
indispensable in identifying clients who are not doing well, and in improving
therapists’ performance by increasing awareness of clients’ progress. Such systems
regularly track progress using measures which clients complete throughout
treatment and which provide immediate feedback to therapists which is then used
to inform treatment decisions (Lambert, Whipple, & Kleinstäuber, 2018).
Two extraordinary studies were published in 2018 that have significant impli-
cations for psychotherapy practice. Both have immediate clinical applications for
therapists wishing to increase their expertise and clinical effectiveness. The first
summarizes the meta‐analytic results and clinical practice implications of fitting or
tailoring treatment to specific client characteristics, such as attachment style,
coping style, culture, gender identity, reactance level, religion and spirituality,
sexual orientation, stages of change, and therapy preferences. These findings are
from the APA Task Force on Evidence‐Based Relationships and Responsiveness
and its 28 recommendations for fitting psychotherapy to an individual client
(Norcross & Wampold, 2018).
The second study is a systematic review and meta-analysis that examines the
impact of measuring, monitoring, and feeding back information on client progress
to therapists while providing psychotherapy. It considers the effects of the two
 Outcomes Assessment, Successful Treatment 83

most frequently studied routine outcome monitoring practices: The Partners for
Change Outcome Management System, i.e., the ORS and SRS, and the Outcome
Questionnaire System, i.e., the OQ-45. All three of these are described in detail in
the following section.
Both attempt to enhance routine care by assisting therapists in recognizing
problematic treatment response and then increasing collaboration between thera-
pist and client to overcome poor treatment response. A total of 24 studies were
analyzed. Two-thirds of the studies found that these two progress monitoring
systems were superior to treatment-as-usual offered by the same therapists. Their
use reduced deterioration rates and nearly doubled clinically significant change
rates in clients who were predicted to have a poor outcome.
The practice implications of using either OQ-45 or ORS/SRS monitoring in rou-
tine practice is made clear by this study. The first is that these feedback systems pro-
vide therapists a most effective means of helping clients improve as well as preventing
deterioration or lack of change among the two-thirds of clients who would otherwise
do poorly. The second implication is that routine outcomes monitoring can further
optimize treatment outcomes in the other third of clients. Across the 24 studies of
both systems, results did not seem to depend on the presenting problem and diagnosis.
There are two questions therapists and trainees are increasingly asking about
tracking client progress. The first is: Does tracking clients’ response to treatment
improve the overall outcome? Based on this meta-analysis, the answer is “yes.” Both
progress monitoring approaches for tracking a client’s mental health vital signs were
found to improve outcomes compared with treatment without such monitoring. The
second is: How does it work? The answer is that these progress monitoring systems
help therapists prevent treatment failure as well as optimize positive outcomes because
therapists using them become more responsive to the client’s needs and difficulties.
Finally, another key article focuses on some practical considerations in incorporat-
ing progress monitoring in everyday psychotherapy. It reviews the benefits, obstacles,
and challenges that can hinder and have hindered implementation of routine outcome
monitoring in clinical practice (Boswell, Kraus, Miller, & Lambert, 2015).

Outcome Measures and Screeners

There are several psychometrically-sound outcomes measures and screeners avail-
able. This section describes 15 such measures. Some are primarily outcome mea-
sures: ORS, SRS, Polaris MH, and the OQ-45 which are described first, while the
others serve both screening and outcomes monitoring functions. Screeners or
screening instruments are “assessment tools that are easily administered, and
scored, and provide useful insight into a client’s presenting problem” (Sperry &
Binensztok, 2019, p. 91).
84 Outcomes Assessment, Successful Treatment

Session Rating Scale (SRS)

The Session Rating Scale (SRS; Duncan et al., 2003), is a 4-item instrument
which measures the therapeutic alliance, that is short and easy to administer. The
client is provided with four horizontal lines (measuring 10 cm long) printed on a
sheet of paper. The first line is used to measure to what extent the client felt
respected and understood. The second line indicates how much the therapist
addressed what the client wanted to talk about. The third line measures the “fit”
of the therapy approach for the client. On the fourth line, the client provides an
indication on the level of satisfaction with the session. The client completes the
scale immediately following the end of the session (Miller et al., 2006). The SRS is
free of charge and available to individual mental health professionals by license
accessible at: www.heartandsoulofchange.com/.

Outcomes Rating Scale (ORS)

The Outcomes Rating Scale (ORS; Miller et al., 2003) is a brief and easy-to-
administer measure that assesses the client’s outcomes. The client is provided a
sheet of paper containing four lines that are 10 cm in length. The client is asked
to indicate on the line how things went based on how they feel; their relation-
ships; ratings of social life and work life; and the overall well-being. This scale is
given to the client to fill out prior to the start of the session. However, it may be
administered after the first meeting (Miller Duncan, Sorrell, & Brown, 2005).
The ORS is free of charge and available to individual mental health professionals
by license accessible at: www.heartandsoulofchange.com/

Polaris MH
Polaris MH is a comprehensive outcomes and diagnostic system. Like its pre-
decessor, COMPASS-OP (Howard, Kopta, Krause, & Orlinsky, 1986; Howard,
Moras, Brill, Martinovich, & Lutz, 1996; Sperry et al., 1996), Polaris MH is a
psychometrically sophisticated, computer-based assessment system. Polaris MH
provides both treatment process and outcomes feedback, in addition to a number
of diagnostic and critical indicators. Like other comprehensive treatment out-
comes measures, Polaris MH provides the following outcomes information and
indicators: suggested treatment focus; treatment progress; client satisfaction with
treatment; and, therapeutic alliance. Polaris MH also provides the following
information and indicators: severity and nature of the patient’s symptoms; the
impact of the patient’s problems upon his/her life functioning; the presence of co-
morbid conditions: chemical dependency, psychosis, and bipolar disorder; presence
of critical conditions (e.g., suicidality, psychosis, violence).
 Outcomes Assessment, Successful Treatment 85

The Polaris-MH measures three domains: Subjective Well-Being, Symptoms,

and Functional Impairment. The Symptoms scale is a composite of sub-scale
scores: depression, anxiety, post-traumatic stress disorder, obsessive-compulsive,
somatization, panic, phobia, and an overall scale of symptomatic distress. The
three sub-scales of Functional Impairment are personal, social, vocational, as
well as a scale of overall functioning. Polaris-MH also assesses for general health
problems, substance abuse, psychosis, and bipolar disorder. In addition, it mea-
sures resilience, meaning, treatment motivation, satisfaction with treatment. and
the therapeutic alliance or bond.
Polaris-MH consists of three measures or questionnaires. The Patient Intake
form provides detailed information for treatment planning. The Patient Update
form provides information concurrently with treatment about the client’s condi-
tion, progress, and satisfaction with treatment. The Brief Patient Update form
provides a global mental health status indicator, and the severity of symptoms of
depression. Polaris-MH also provides Reports that provide information for clinical
decision support, i.e., individual patient reports, and for outcomes assessment, i.e.,
program-level aggregate data (Lueger, 2006).

OQ-45
The OQ-45 (Lambert, Gregersen, & Burlingame, 2004) is probably the most
commonly used commercial treatment outcomes measure today. It is a brief,
45-item, self-report outcome and tracking instrument that is designed for
repeated measurement of client progress through the course of therapy and
following termination. It measures client functioning in three domains: symp-
tom distress; interpersonal functioning; and social role. Functional level and
change over time can be assessed which allows treatment to be modified
based on the changes noted. The OQ-45 also contains risk assessment items
for suicide potential, substance abuse, and potential violence at work. It has
been translated into more than ten languages and is based on normative data
and has adequate validity and reliability. It can be administered and scored in
either electronic or paper format. Access to the OQ-45.2 version is available
at www.agapepsych.com/serfiles/1059203/file/Updated%20Forms%20(01_
2018)/OQ-45_2.pdf.

The Patient Health Questionnaire-9 (PHQ-9)

The Patient Health Questionnaire-9 (PHQ-9) is a 9-item questionnaire that corre-
sponds to the nine DSM-5 criteria for Major Depressive Disorder. Each question is
rated on a 4-point scale from 0–3 where 0 ꞊ not at all, 1 ꞊ several days, 2 ꞊ more than
86 Outcomes Assessment, Successful Treatment

half the days, and 3 ꞊ nearly every day. A tenth question asks how any symptoms the
client rated between 1 and 3 have interfered with the person’s ability to function at
work, at home, and with other people. Clients rate their experiences for the previous
two weeks. The scoring for the PHQ-9 is as follows:

0–4 ꞊ minimal or none

5–9 ꞊ mild
10–14 ꞊ moderate
15–19 ꞊ moderately severe
20–27 ꞊ severe.

The PHQ-9 is useful for screening, diagnosis, treatment planning, and progress
monitoring. The first two questions of the PHQ-9 are referred to as the PHQ-2
and are used for screening since they assess for depressed mood and lack of
pleasure, and at least one of those symptoms must be present for the diagnosis to
be met. The full instrument is required for diagnosis and progress monitoring
(Martin, Rief, Klaiberg, & Braehler, 2006).

The Columbia Suicide Severity Rating Scale (C-SSRS)

The Columbia Suicide Severity Rating Scale (C-SSRS) is a questionnaire used
to assess suicidal ideation and risk. It consists of several forced choice (yes/
no) questions and several multiple choice and free response questions. The C-
SSRS assesses whether clients are having thoughts of suicide, the intensity of
those thoughts, whether clients have taken any steps to create a suicide plan
and prepare for suicide, and whether the client has attempted suicide pre-
viously. There is also a computer-automated version of this measure (Mundt
et al., 2010).

The Mood Scale

The Mood Scale is very brief measure of an individual’s overall experience, in the
moment, of a down mood and depression. Instructions for its use are simple and
straightforward. Ask the client to rate their overall feeling of nervousness and
anxiousness at a particular point in time on a scale of 0–10, where 0 is the worst
mood possible and 10 is the best possible mood (Sperry, 2010).
A mood of 3 or less is considered severe, 4–5 is considered mildly depressed,
6–8 is considered euthymic or normal, and higher is considered happy and
upbeat. The Mood Scale is useful for progress monitoring.
 Outcomes Assessment, Successful Treatment 87

Subjective Units of Distress (SUDS)

The Subjective Units of Distress scale is a useful, informal tool to rate a client’s
level of anxiety or panic. Developed by Joseph Wolpe (1969), clients can be rated
on a 0–10 or a 0–100 scale. This scale is useful for both clients and providers to
assess the intensity of symptoms and the distress and disturbance they cause for
clients. It is also a useful measure to monitor progress through therapy and after
interventions. The instructions are simple: On a 1–100 scale where 1 represents the
most calm and serenity you can imagine and 100 represents the most severe distress
you can imagine, give the number that best indicates how you currently feel (or in a
specific past situation). With a minimum amount of practice in SUDS, clients can
quickly and accurately rate and communicate their distress to a therapist. The
widespread use of this self-rating assessment reflects its clinical utility.

Generalized Anxiety Disorder-7 (GAD-7)

The Generalized Anxiety Disorder-7 (GAD-7) is a 7-item questionnaire that
corresponds to the DSM-5 criteria for Generalized Anxiety Disorder (Lowe et
al., 2008). Each question is rated on a 4-point scale from 0–3 where 0 ꞊ not at
all, 1 ꞊ several days, 2 ꞊ more than half the days, and 3 ꞊ nearly every day. Cli-
ents rate their experiences for the previous two weeks. The scoring for the
GAD-7 is as follows:

0–4 ꞊ minimal or none

5–9 ꞊ mild
10–14 ꞊ moderate
15–21 ꞊ severe.

The first two questions of the GAD-7 are referred to as the GAD-2 and can be
used to screen for anxiety but the full instrument is required for diagnosis and
progress monitoring. The GAD-7 has also been shown to be useful in screening
for Panic Disorder and Social Anxiety (Bardhoshi et al., 2016).

The PCL PTSD Checklist

The PCL PTSD Checklist is a 17-item questionnaire widely used as a PTSD
screening instrument. Respondents are asked about the severity with which a
particular symptom has affected them within the last month. Each question is
rated on a 5-point scale where 1 ꞊ not at all, 2 ꞊ a little bit, 3 ꞊ moderately,
4 ꞊ quite a bit, and 5 ꞊ extremely. The PCL includes subscales for Reexper-
iencing, Avoidance, and Hyperarousal, and is available for civilians (PCL-C)
88 Outcomes Assessment, Successful Treatment

and members of the armed forces (PCL-M). Both instruments are available to
the public and used by the Department of Veterans Affairs (Bardhoshi et al.,
2016).

The Anxiety Scale

The Anxiety Scale is very brief measure of an individual’s overall experience, in
the moment, of anxiety and panic. Instructions for its use are simple and
straightforward. Ask the client to rate their overall feeling of nervousness and
anxiousness at a particular point in time on a 1–10 scale: where 1 ꞊ feeling you
were going to die or have a heart attack or go crazy, and where 10 ꞊ being per-
fectly calm and anxiety-free (Sperry, 2010). The Anxiety Scale is useful for pro-
gress monitoring.

The Insomnia Severity Index

The Insomnia Severity Index (ISI) is a 7-item questionnaire that corresponds to
the DSM-5 criteria for insomnia (Morin, Belleville, Bélanger, & Ivers, 2011).
Each question is rated on a 5-point scale from 0–4 where 0 ꞊ none, 1 ꞊ mild, 2
꞊ moderate, 3 ꞊ severe, and 4 ꞊ very severe. Questions assess difficulty in falling
and staying asleep, as well as implications for mood and daily functioning. The
scoring for the ISI is as follows:

0–7 ꞊ no clinically significant insomnia

8–14 ꞊ subthreshold insomnia
15–21 ꞊ clinical insomnia (moderate severity)
22–28 ꞊ clinical insomnia (severe).

The Drug Abuse Screening Test

The Drug Abuse Screening Test (DAST) is a 28-item forced-choice (yes/no) self-
report questionnaire that assesses problem drug use and its associated consequences.
The DAST enquires about use of prescribed and over-the-counter drugs in excess of
directions and the non-medical use of drugs (Cocco & Carey, 1998).

The PEG Pain Scale

The PEG Pain Scale is a 3-item instrument used to assess pain intensity and
interference. Each question is rated on an 11-point scale from 0–10 where 0 ꞊ no
pain, and 10 ꞊ pain as bad as you can imagine. Clients are asked to rate their
 Outcomes Assessment, Successful Treatment 89

average level of pain in the past week, the extent to which the pain has interfered
in their enjoyment of life in the past week, and the extent to which the pain has
interfered with general activity in the past week (Krebs et al., 2009).

The Current Opioid Misuse Measure (COMM)

The Current Opioid Misuse Measure (COMM) is a 17-item instrument used to
assess a patient’s misuse of medication by determining its effect on social, emotional,
and general functioning. Each question is rated on a 5-point scale from 0–4, where
0 ꞊ never, 1 ꞊ seldom, 2 ꞊ sometimes, 3 ꞊ often, 4 ꞊ very often. This patient self-
report instrument also measures contextual factors such as emotional volatility and
recent history of arguments. These questions are meant to measure the effect of
medication misuse on the client’s functioning, but may not necessarily point to
medication abuse. This screening tool is best paired with an interview about how
the client is using medications (Butler et al., 2007).

Seven Indicators of Successful Therapy

There has yet to be clinical or research consensus on exactly how significant and
enduring client change is effected. Clearly, using feedback to inform therapy makes
a difference. But, there is more to it. Some have speculated it can be used as well
as to provide qualitative and quantitative research to identify the differences
between how highly effective therapists and average therapists function. Dr.
Marvin Goldfried contends that there are four principles of change and distinct
methods that highly effective therapists consistently utilize that average therapists
do not (Goldfried, 1980). Approximately 32 years later, he remains convinced that
these four defining principles define how master therapists work, based on his and
others’ research (Goldfried, 2012). The four indicators are: (1) enhance the
therapeutic alliance; (2) enhance positive expectations and client motivation; (3)
increase client awareness; and (4) facilitate corrective experiences. Based on my
observations of other highly effective therapists, three additional indicators can be
added: (5) identify patterns and focus treatment; (6) facilitate first-, second-, and
third-order change; and (7) increase therapist expertise. Each of these indicators
is described in this section.

1. Enhance the Therapeutic Alliance

The therapeutic alliance refers to both the relationship and bond between the client
and therapist and the agreed-upon goals and methods of therapy. A productive
therapeutic alliance, in which clients can trust the therapist to be competent and
90 Outcomes Assessment, Successful Treatment

concerned about their best interests, is associated with effective therapy. Ther-
apeutic alliances are not consistent from client to client. A therapist may have an
easier time developing a therapeutic alliance with a motivated client and a more
difficult time developing an effective alliance with a defiant one. The latter would
require significant effort and investment on the part of the therapist. The therapist’s
experience and skills in developing the therapeutic alliance are reflected in the
outcomes of therapy, provided that the strong therapeutic alliances are associated
with effective therapy. Enhancing the alliance not only becomes an inviting factor,
creating more involvement on the part of the client, but it may also facilitate will-
ingness to engage in the painful or difficult processes of change (Goldfried, 2012).

2. Enhance Positive Expectations and Client Motivation

For therapy to work, the clients entering the process need a reasonable expectation
it can help them. They also need to have some motivation for change. These two
prerequisites are essential for effecting therapeutic change. Several factors can
influence the prerequisites in a positive or negative way. For instance, seeking
information about panic attacks and discussing the process of change with a friend
or a trusted family member can increase both motivation and expectation. Subse-
quently, this individual may be more motivated to change after experiencing another
panic attack or a related symptom than a teenager who is acting out is sent to
therapy by his or her parents. When motivation or expectations are suboptimal, it
becomes the therapist’s priority to increase these prerequisites, as they are essential
for change (Goldfried, 2012). Unsurprisingly, known master therapists excel at this
task. Whether employing motivational interviewing (MI) or other similar interven-
tions, these therapists increase the credibility of both the clinician and the process
of therapy as they enhance the client’s readiness and motivation for change.

3. Increase Client Awareness

Increasing the client’s awareness is another prerequisite for change. Awareness is
needed in effecting change, irrespective of the therapeutic orientation employed.
However, the degree of awareness and its kind may differ, depending on the pre-
senting problem and the client’s personality:

Some clients may be unaware of how their thinking is influencing their

feelings, others may be unaware of how their emotional reaction results in
behavior, and still others how their behavior negatively impacts on others.
Thus, individuals who are unaware of their anger, and also their tendency to
 Outcomes Assessment, Successful Treatment 91

withdraw when angry are unaware of how this emotion-action link adversely
affects their relationships with others.
(Goldfried, 2012, p. 20)

Therapeutic considerations such as time, frequency, and nature of thoughts, feelings,

and behaviors must be involved in increasing the client’s awareness. The operative
dynamics and determinants of the case can be identified with a clear and accurate case
conceptualization. In effect, such case conceptualization can provide the therapist a
basis for increasing the client’s awareness of factors affecting their life.

4. Facilitate Corrective Experiences

Profound and enduring change necessitates more than marginal insight or simple
behavior change. This type of change can, and often does, require a corrective
experience, in which the individual experiences a relationship or event in an
unexpected way. These are not just ordinarily helpful events in therapy. Instead,
they are significant events that disprove past experiences and have substantial
effects on the individual (Castonguay & Hill, 2012). Corrective experiences are
central to the transformative processes of many psychotherapy approaches and
they represent second-order change. In order for this kind of experience to occur,
the client must “take a risk behaving differently, often in the presence of some
skepticism and apprehension. By experiencing a positive outcome, thinking (e.g.,
expectations that something bad will happen) and emotion (e.g., anxiety) will start
to change as well” (Goldfried, 2012, pp. 20–21). A clear indication of a corrective
experience is noted

when clients report a between-session experience with the tone of surprise

in their voice – either because they behaved in a way that was different for
them or because of the unexpected positive consequences that followed what
they did. At other times, the [corrective experience] may result from an
ongoing interaction with a supportive and affirming therapist.
(Goldfried, 2012, p. 21)

Highly effective therapists are capable of facilitating corrective experiences.

5. Identify Patterns and Focus Treatment

As already noted, pattern is one of the key components of Pattern Focused
Therapy. Not surprisingly, effective therapists can more quickly, accurately, and
effortlessly identify maladaptive patterns than novice therapists and trainees. This
92 Outcomes Assessment, Successful Treatment

capability is predictable given the amount of time and extensive experience

needed to develop the expertise for identifying the complex recognition of pat-
terns (Ericsson, 2006).
For effective therapists, pattern is the heart of case conceptualization. A focused,
accurate, and thorough case conceptualization is required in order to plan, guide, and
effect change (Sperry, 2010). For average therapists, this process can require one or
two sessions and involve eliciting considerable amounts of information on the case.
However, master therapists can typically conceptualize cases in their initial meeting
with the client and base determinations on the recognition of patterns. Thereafter,
they test out the conceptualization and modify accordingly, if necessary. The process
is intuitive and swift for master therapists, whereas for trainees and beginning
therapists, it tends to be much more deliberate and slower (Sperry & Sperry, 2012).
The focus of treatment provides the course for the process and targets in order
to replace a maladaptive pattern with a more adaptive pattern (Sperry, 2010). It
also provides needed stabilization for the process, regularly maintaining the focus
and efforts on change. Positive treatment outcomes are associated with the ability
to track and maintain a treatment focus, which master therapists are unsurpris-
ingly capable of accomplishing. Chapter 9 provides a more in-depth description
and illustration of the process of case conceptualization, including emphasis on the
importance of the treatment focus and pattern recognition.

6. Facilitate First-, Second- and Third-Order Changes

There are a host of strategies that can be utilized in order to manage life concerns.
Some strategies are career counseling, personal counseling, crisis counseling, coaching,
case management, and psychotherapy. Presumably, psychotherapy is a strategy that
primarily aims at effecting profound and enduring change. In order to fully appreciate
the impact of psychotherapy, it can be useful to conceptualize change processes in
terms of orders of change. Good and Beitman (2006) have identified three orders of
change: first, second, and third order. In first-order change, clients endeavor to achieve
stability, reduce symptoms, and manage small changes. Normally, strategies such as case
management, crisis counseling, and career counseling assist in symptom reduction or a
temporary resolution for given life problem. These strategies can effect stability but
not personality or pattern transformation. Second-order change occurs when clients
change or modify a maladaptive pattern to a more adaptive one. This order of change
can be deemed transformative (Fraser & Solovey, 2007). Finally, in third-order change,
clients become their own therapists. That is, they can facilitate change on their own,
without help or guidance. Profound and enduring change is not possible without
second- and third-order change. Whether or not they are acquainted with the change
orders, renowned master therapists are experts in effecting all three orders of change.
 Outcomes Assessment, Successful Treatment 93

7. Increase Therapist’s Expertise

Three questions are central to psychotherapy research as well as psychotherapy
practice. The first question: Is psychotherapy effective? was posed by Hans
Eysenck (1952). It has taken five decades to definitively answer that question.
Today, both the efficacy and effectiveness of psychotherapy have been well
established. But, despite the consistent findings substantiating psychotherapy’s
worth, a second question arose: How does psychotherapy work? Unfortunately,
the question remains unanswered largely because of the ideological feud
between advocates of the common factors (process) position and advocates of
specific factors (evidence-based or empirically supported treatments) position.
Even though a compromise position emerged––integrative approaches where
both common and specific factors are combined––it has not resolved a number
of theoretical and research issues. The hope was that

knowing how psychotherapy works would give rise to a universally accepted

standard of care which, in turn, would yield more effective and efficient
treatment. However, if the outcome of psychotherapy is in the hands of the
person who delivers it, then attempts to reach accord regarding the essential
nature, qualities, or characteristics of the enterprise are much less important
than knowing how to best accomplish what they do.
(Miller, Hubble, Chow, & Seidel, 2013, pp. 90–91)

As it is currently framed, it is not the therapeutic alliance nor a specific inter-

vention that determines whether therapy is effective and successful. Rather, it is
how the therapist expertly develops and maintains the alliance and effectively tai-
lors the intervention to the client that makes the difference. Available research
supports this new perspective. It documents that therapist expertise is probably
the most robust predictor of psychotherapy outcome rather than the therapeutic
alliance (common factors) or a treatment intervention (specific factors). Indeed,
the variance of outcomes attributable to therapists (5–9%) is greater than the
variability among treatments (0–1%), the alliance (5%), and the superiority of an
empirically supported treatment to a placebo treatment (0–4%) (Miller et al.,
2013, p. 90; Wampold, 2005; Lutz et al., 2007; Duncan, 2010).
During this same time frame, a more focused question emerged: Why are some
therapists better than others? Mounting research has already begun to provide an
answer to this third question, but at the same time addresses the second question. The
reality is that therapist expertise and the acquisition of expertise are already changing
psychotherapy research and practice (Barkham, Lutz, Lambert, & Saxon, 2017).
Research on expertise in psychotherapy, also called the therapist effect, is under
way, as are innovative training programs to increase therapist expertise. Seeking
94 Outcomes Assessment, Successful Treatment

client feedback with outcomes instruments to inform therapy and engaging in

deliberate practice are ways of increasing clinical effectiveness and expertise
(Rousmaniere, 2017).
Deliberate practice involves three elements. First, the performance of well-
designed tasks at an appropriate level of difficulty. Second, useful feedback.
Third, opportunities for repetition and correction of errors (Ericsson, 2006). In
leaning new skill sets and competencies, deliberate practice involves engaging in
increasingly difficult elements of the skill or competency. Seeking constant
feedback in various forms is another essential component of deliberate practice.
This includes directly asking clients for feedback as well as using standard out-
come measures to assess and monitor clients’ progress. Then, it requires using
the feedback to alter the course or direction of treatment.

Being open to feedback is part of deliberate practice. Another part of turning

experience into expertise is the use of reflection … There must be a feedback
loop so that the individual can learn from the practice. When therapists are
fully licensed and working alone, they can fall victim to not learning from their
own practitioner experience if there is no deliberate practice feedback system
that includes self-reflection and self-monitoring of oneself as a practitioner.
(Jennings, Skovholt, Goh, & Lian, 2013, p. 241)

In other words, “[d]eliberate practice is essential to developing expertise, it is not

optional” (Sperry & Carlson, 2014, p. 191). Finally, professional training in the near
future will increasingly emphasize the development of evidence-based therapists at
least as much as, if not more than, learning how to perform one or more evidence-
based treatment approaches (Barkham, Lutz, Lambert, & Saxon, 2017).

Conclusion
The first section of this chapter addressed the role of outcomes assessment and
the use of this feedback to inform and improve treatment. The second section
described 15 commonly used outcome measures and screeners. Finally, the third
section addressed seven indicators of successful therapy and suggested that
highly effective therapists differ from less effective therapists and trainees by
using these indicators. Essentially, highly effective therapists foster therapeutic
alliances, foster positive expectations and motivation in their clients, increase
their clients’ awareness, facilitate corrective experiences, quickly identify pat-
terns and maintain the focus of treatment, facilitate first-, second-, and third-
order change, and work to increase their therapeutic expertise, including
deliberate practice. Of course, routine outcomes monitoring is a necessary
 Outcomes Assessment, Successful Treatment 95

element of therapeutic effectiveness, but it is not of itself sufficient. It appears

that being a highly effective therapist assumes routine outcome monitoring and
engaging in these seven indicators.

References
Bardhoshi, G., Erford, B. T., Duncan, K., Dummett, B., Falco, M., Deferio, K., & Kraft, J.
(2016). Choosing assessment instruments for posttraumatic stress disorder screening and
outcome research. Journal of Counseling & Development, 94, 184–194.
Barkham, M., Lutz, W., Lambert, M. J., & Saxon, D. (2017). Therapist effects, effective
therapists, and the law of variability. In L. G. Castonguay & C. E. Hill (Eds.), How and why are
some therapists better than others?: Understanding therapist effects. Washington, DC: American
Psychological Association.
Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions.
In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice
(pp. 13–37). New York, NY: John Wiley & Sons.
Boswell, J. F., Kraus, D. R., Miller, S. D., & Lambert, M. J. (2015). Implementing routine
outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy
Research, 25(1), 6–19.
Butler, S., Budman, S., Fernandez, K., Houle, B., Benoit, C., Katz, N., & Jamison, R. (2007).
Development and validation of the current opioid misuse measure. Pain, 130(1–2),144–156.
Castonguay, L., & Hill. C. (Eds.). (2012). Transformation in psychotherapy: Corrective experiences
across cognitive-behavioral, humanistic, and psychodynamics approaches. Washington, DC:
American Psychological Association.
Cocco, K., & Carey, K. (1998). Psychometric properties of the Drug Abuse Screening Test in
psychiatric outpatients. Psychological Assessment, 10(4), 408–414.
Duncan, B. (2010). On becoming a better therapist. Washington, DC: American Psychological
Association Press.
Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson,
L. D. (2003). The Session Rating Scale: Preliminary psychometric properties of a “working”
alliance measure. Journal of Brief Therapy, 3(1), 3–12.
Ericsson, K. A. (2006). The influence of experience and deliberate practice on the development
of superior expert performance. In K. A. Ericsson (Ed.), Cambridge handbook of expertise and
expert performance (pp. 685–705). New York, NY: Cambridge University Press.
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psy-
chology, 16, 319–324.
Fraser, J., & Solovey, A. (2007). Second-order change in psychotherapy: The golden thread that unifies
effective treatments. Washington, DC: American Psychological Association.
Goldfried, M. (1980). Toward the delineation of therapeutic change principles. American Psy-
chologist, 35(11), 991.
Goldfried, M. (2012). The corrective experiences: A core principle for therapeutic change. In L.
Castonguay & C. Hill (Eds.). Transformation in psychotherapy: Corrective experiences across cogni-
tive-behavioral, humanistic, and psychodynamics approaches (pp. 13–29). Washington, DC:
American Psychological Association.
Good, G., & Beitman, B. (2006). Counseling and psychotherapy essentials: Integrating theories, skills,
and practices. New York, NY: Norton.
96 Outcomes Assessment, Successful Treatment

Hansen, N. B., Lambert, M. J., & Forman, E. V. (2002). The psychotherapy dose-response
effect and its implications for treatment delivery services. Clinical Psychology: Science and
Practice, 9, 329–343.
Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose-effect rela-
tionship in psychotherapy. American Psychologist, 41(2), 159–164.
Howard, K. I., Moras, K., Brill, P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psy-
chotherapy: Efficacy, effectiveness, and patient progress. American Psychologist, 51(10), 1059–1064.
Jennings, L., Skovholt, T. M., Goh, M., & Lian, F. (2013). Master therapists: Explorations of
expertise. In M. H. Rønnestad & T. M. Skovholt (Eds.), The developing practitioner: Growth and
stagnation of therapists and counselors (pp. 213–246). New York, NY: Routledge.
Krebs, E., Lorenz, K., Bair, M., Damush, T., Wu, J., Sutherland, J.., … & Kroenke, K. (2009).
Development and initial validation of the PEG, a three-item scale assessing pain intensity and
interference. Journal of General Internal Medicine, 24(6), 733–738.
Lambert, M. J., Gregersen, A. T., & Burlingame, G. M. (2004). The Outcome Questionnaire-45. In
M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment:
Instruments for adults (pp. 191–234). Mahwah, NJ: Lawrence Erlbaum Associates Publishers.
Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress
feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520–537.
Livesley, W. (2003). Practical management of personality disorder. New York, NY: Guilford Press.
Löwe, B., Decker, O., Müller, S., Brähler, E., Schellberg, D., Herzog, W., & Herzberg, P. Y.
(2008). Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-
7) in the general population. Medical Care, 46(3), 266–274.
Lueger, R. J. (2006). Technology to support the clinical management of psychotherapy cases:
Commentary on the Polaris-MH. Pragmatic Case Studies in Psychotherapy, 2(3), 1–7.
Lutz, W., Leon, S. C., Martinovich, Z., Lyons, J. S., & Stiles, W. B. (2007). Therapist effects in
outpatient psychotherapy: A three-level growth curve approach. Journal of Counseling Psy-
chology, 54, 32–39.
Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief patient health ques-
tionnaire mood scale (PHQ-9) in the general population. General Hospital Psychiatry, 28(1), 71–77.
Meier, S. (2015). Incorporating progress monitoring and outcome assessment into counseling and psy-
chotherapy: A primer. New York, NY: Oxford University Press.
Miller, S. D., Duncan, B. L., Brown, J., Sorrell, R., & Chalk, M. B. (2006). Using formal client
feedback to improve retention and outcome: Making ongoing real-time assessment feasible.
Journal of Brief Therapy, 5,5–22.
Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Claud, D. (2003). The outcome rating
scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog
measure. Journal of Brief Therapy, 2(2), 91–100.
Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The Partners for Change
Outcome Management System. Journal of Clinical Psychology, 61, 199–208.
Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A (2013). The outcome of psychother-
apy: Yesterday, today and tomorrow. Psychotherapy, 50(1), 88–97.
Morin, C. M., Belleville, G., Bélanger, L., & Ivers, H. (2011). The Insomnia Severity Index: Psy-
chometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34(5),
601–608.
Mundt, J., Greist, J., Gelenberg, A., Katzelnick, D., Jefferson, J., & Modell, J. (2010). Feasibility
and validation of a computer-automated Columbia-Suicide Severity Rating Scale using inter-
active voice response technology. Journal of Psychiatric Research, 44(16), 1224–1228.
 Outcomes Assessment, Successful Treatment 97

Norcross, J. C., & Wampold, B. E. (2018). A new therapy for each patient: Evidence‐based
relationships and responsiveness. Journal of Clinical Psychology, 74(11), 1889–1906.
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy pro-
cess-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s
handbook of psychotherapy and behavior change. 5th ed. (pp.307–389). New York, NY: Wiley.
Rousmaniere, T. (2017). Deliberate practice for psychotherapists: A guide to improving clinical effectiveness.
New York, NY: Routledge.
Shimokawa, K., Lambert, M. J., & Smart, D. (2010). Enhancing treatment outcome of patients
at risk of treatment failure: Meta-analytic and mega-analytic review of a psychotherapy
quality assurance system. Journal of Consulting & Clinical Psychology, 78, 298–311.
Sperry, L. (2010). Highly effective therapy: Developing essential clinical competencies in counseling and
psychotherapy. New York, NY: Routledge.
Sperry, L., & Binensztok, V. (2019). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Sperry, L., Brill, P. L., Howard, K. I., & Grissom, G. R. (1996). Treatment outcomes in psychotherapy
and psychiatric interventions. New York, NY: Routledge.
Sperry, L., & Carlson, J. (2014). How master therapists work: Effecting change from the first through
the last session and beyond. New York, NY: Routledge.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and
confidence. New York, NY: Routledge.
Van Sonsbeek, M. A., Hutschemaekers, G. G., Veerman, J. W., & Tiemens, B. B. (2014).
Effective components of feedback from Routine Outcome Monitoring (ROM) in youth
mental health care: Study protocol of a three-arm parallel-group randomized controlled trial.
BMC Psychiatry, 14(1), 3. doi:10.1186/1471-244X-14-3.
Wampold, B. E. (2005). Establishing specificity in psychotherapy scientifically: Design and evi-
dence issues. Clinical Psychology: Science & Practice, 12, 194–197.
Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J.
(2003). Improving the effects of psychotherapy: The use of early identification of treatment failure
and problem-solving strategies in routine practice. Journal of Counseling Psychology, 58, 59–68.
Wolpe, J. (1969). The practice of behavior therapy. New York, NY: Pergamon Press.
Chapter 6

The First Session

During the first session of Pattern Focused Therapy, the client gets a sense of the
therapy experience as well as a map of the process. It is the most critical session
and largely determines both the course and outcome of therapy (Sperry & Carlson,
2014). In my experience, several essential tasks must be accomplished in this session
in order to achieve successful treatment outcomes in short-term therapy in mental
health or integrated care settings (Sperry & Binensztok, 2019a). In the past, these
essential tasks might have been spread out over two or three sessions. But when the
course of therapy is relatively brief––six or fewer sessions––this session tends to be
highly structured in order to quickly and efficiently elicit key clinical information,
establish a treatment focus and goals, and socialize the client to the therapy process,
to name just three of these tasks.
The chapter begins with a description of these essential tasks. Then, the case of
Jerrod is offered to illustrate the initial session in Pattern Focused Therapy. A
transcription of segments and commentary is provided. The remaining sessions of
this completed and successful therapy are presented in Chapter 7 and Chapter 8.

Essential Tasks of the Initial Session

Here is a preview of the eight tasks. Informed consent is the first task. Within this
task, the client is informed about the type of the treatment, as well as his rights and
responsibilities. Then, the clinician begins to establish an effective therapeutic rela-
tionship by joining the client in an atmosphere characterized as safe, mutual, and
nonjudgmental. While it begins in the initial session, establishing and then maintaining
an effective therapeutic alliance continues throughout the course of treatment.
Another key task is assessment. Three crucial components of assessment are required
in the initial session: (1) collecting sufficient data to formulate a diagnosis; (2) com-
pleting a functional assessment; and (3) identifying the client’s pattern. Brief screening
instruments are useful in completing the initial assessment as well as assessing and
monitoring clinical progress. An effective assessment is the basis for identifying the
 The First Session 99

client’s basic pattern and developing an accurate case conceptualization. Accurately

identifying the pattern is essential to developing and maintaining an effective ther-
apeutic alliance and implementing interventions that will achieve treatment goals.
Another task that is important in the initial session is socializing the client to the
treatment context. This includes a thorough explanation of what treatment involves,
its intended effects, and what is expected of both the therapist and the client. This
discussion typically leads to mutual agreement of first- and second-order goals.
Additionally, it is crucial for some change to be facilitated within the first session.
This can take the form of instillation of hope or a reduction of some of the client’s
distress. Finally, the client is assigned homework to complete and present for the
following session. Let us now describe the eight tasks in more detail.

1. Develop and Foster the Therapeutic Alliance

One of the most critical tasks in the first session is to begin to establish the
therapeutic alliance. Increases in treatment compliance, decreases in premature
termination, and the improvement of treatment outcomes have all been linked
to strong therapeutic alliances (Horvath & Luborsky, 1993; Sperry, 2010a).
The term “therapeutic alliance” is used interchangeably with “therapeutic
relationship.” However, this is inaccurate as the alliance is greater and more
inclusive than the relationship. The therapeutic relationship is the bond
between the client and therapist. The alliance, on the other hand, includes the
client-therapist bond, agreement on goals for treatment, and mutual agree-
ment on the methods for treatment (Bordin, 1994). The client must feel
comfortable, understood, and hopeful about therapy in order to form a bond
with the therapist. This influences the client and encourages them not only to
have sensitive conversations, but also to modify their ways of thinking, feeling,
and behaving (Sperry & Carlson, 2014).
The client’s preferred approach and expectations for treatment must also be
identified. While some clients may verbalize their specific hopes and desires for
therapy, others may not. Therefore, structured questions can aid in developing
mutually agreed upon goals. Furthermore, some clients prefer to engage in con-
crete action to control or reduce symptoms, while others show a preference for
mutual exploration. An effective collaboration and assessment of the client’s needs
are part of the therapist’s capacity to form an effective therapeutic alliance.
Even a strong and established therapeutic alliance is susceptible to ruptures
and strains. Therefore, the therapeutic alliance must be monitored throughout.
Ruptures in the therapeutic alliance are considered a factor that interferes
with treatment and can affect treatment outcomes in a negative manner
(Sperry, 2010b).
100 The First Session

The Session Rating Scale (SRS) (Duncan et al., 2003) is administered at the
end of each session in order to monitor and evaluate the therapeutic alliance.
For instance, the SRS may uncover some disappointment on behalf of the
client that a specific topic was not covered within the session. This can lead
to a productive clarification of the client’s needs and inform the therapist
about the expectations of the client, leading to modification in subsequent
sessions. While the therapeutic alliance may be strained or ruptured other-
wise, understanding and agreement facilitated by the use of a monitoring tool
can preserve the therapeutic alliance.

2. Secure Informed Consent

Typically, informed consent involves signing a form that explains confidentiality
and its limits, fees, risks and benefits, the rights of the client to terminate therapy,
and a description of the protocol for treatment. Presumably, the client is provided
the opportunity to asks questions and seek clarification before signing the treat-
ment consent form (Sperry, 2008).
In Pattern Focused Therapy, informed consent is understood as a process not
simply an event, i.e., signing a consent form prior or during the first session. In
fact, it is viewed as an ongoing process of client assent, the client must be pro-
vided a thorough outline of rights and involvement in therapy in a statement. The
statement should explain confidentiality and its limits, fees, risks and benefits, the
rights of the client to terminate therapy, and a description of the protocol for
treatment. The client must be provided with the opportunity to asks questions
and seek clarification before signing the treatment consent form.
In the case of Jerrod that is introduced in this chapter and continues in Chapter
7 and Chapter 8, the client was referred for medication evaluation by his family.
However, he wanted psychotherapy instead. He stated that if psychotherapy was
“not working sufficiently” he would consider adding medication to psychotherapy,
which is called combined treatment. Accordingly, the informed consent needed
inclusion of the consideration of combined treatment. Throughout the discussion of
the terms of treatment, it was mutually agreed upon by both therapist and client
that if his moods did not improve, evaluation for medication treatment would be
scheduled. This became a documented agreement.

3. Begin Assessment
Initial session assessment is focused on identifying possible diagnoses, as well as
presenting problems and concerns, and pattern. Additionally, the precipitants,
predisposing, and perpetuating factors are elicited. One of the main reasons for
 The First Session 101

conducting an initial assessment is to identify the client’s pattern and formulate an

accurate case conceptualization (Sperry, 2010b).
The therapist asks structured questions to rule out comorbid conditions and
pencil in possible diagnoses. Structured and focused questions, as opposed to
open-ended questions, are used purposefully to accomplish an assessment and have
sufficient time remaining to accomplish other first session tasks. Symptom dis-
orders and personality disorders are ruled in or out based on an evaluation of the
severity of symptoms and impairment. Pattern identification is crucial in the first
session. Diagnostically, the therapist must determine whether the client’s pattern
is severe enough to warrant the diagnosis of a personality disorder. As noted in
Chapter 2, with sufficient practice, a full diagnostic assessment can be completed
in as little as 15 minutes.
Functional assessment enhances the diagnostic assessment. This assessment
focuses on the degree to which the client’s presenting problem or concerns
affect his or her daily life. It also distinguishes components that can alleviate or
worsen the problem. These components can be physical, environmental, social,
behavioral, or cognitive in form and make up the focus of the functional
assessment (Sperry & Binensztok, 2019b).
Finally, screening instruments can aid the diagnostic assessment and function as
a monitor for assessing changes over time. The Patient Health Questionnaire
(PHQ-9) (Kroenke & Spitzer, 2002) is one of the most useful and frequently used
screeners in mental health and integrated care settings. It specifically screens and
monitors levels of depression. This 9-item questionnaire, which corresponds to
the nine DSM-5 diagnostic criteria, is rated on a 4-point Likert-type scale. Clients
are asked to rate their experiences for the length of two weeks prior to the ses-
sion. A final tenth question assesses how any of the indicated symptoms that the
client rated between 1 and 3 interfere with the ability of the client to function at
work, at home, and with other people. Depression severity is indicated according
to scores on the PHQ-9 such as: minimal or none (0–4); mild (5–9); moderate
(10–14); moderately severe (15–19); and severe (20–27). The client is asked to
complete the PHQ-9 at the outset of every session on a weekly basis.

4. Identify Pattern
A key outcome of an effective assessment is the identification of pattern, because
pattern is the heart of the case conceptualization and the basis for planning and
implementing effective interventions. It also provides the therapist critical infor-
mation in fostering an effective therapeutic alliance. It also forms the basis for
establishing mutual goals and anticipating potential problems and challenges
throughout the therapy process (Sperry & Sperry, 2012).
102 The First Session

Pattern is also central to establishing and maintaining an effective therapeutic

alliance. It should be noted that agreement on the second and third components
of the alliance, i.e., goals and methods or interventions, requires knowledge of
relevant personality dynamics, particularly the client’s maladaptive pattern in order
to develop an effective case conceptualization and tailored treatment goals and
interventions. Failure to identify the client’s maladaptive pattern in the first ses-
sion and to discuss how it will be central to the treatment process decreases the
value of the therapeutic alliance, in engaging the client in the treatment process,
and effecting change. Chapter 2 elaborates pattern and case conceptualization.

5. Socialize to Treatment
An overview of Pattern Focused Therapy begins with the client in the first session.
Additionally, the therapist explains the main purpose and focus of the therapy as
well as the expectations for the client. The protocol is also explained, and the client
is allowed to ask questions. Then, the therapist prompts the client to determine if
they are willing to proceed with the process that has been laid out. This process
instills a sense of autonomy in the client and fosters clinician credibility as well as
credibility for the indicated approach. If done correctly and successfully, this process
also increases the client’s hopefulness (Sperry, 2010b).

6. Agree on Treatment Goals

The first session offers an adequate context to discuss and establish first-order,
second-order, and third-order goals with the client. The goals established must be
realistic, measurable, and achievable. The client’s agreement to the set treatment
goals is crucial. They must understand the goals, view them as attainable, and
commit to working to achieve them.

 First-order goals. First-order goals are mainly shorter-term goals. They essentially
help the client reduce their symptoms and return to baseline––a previous level
of functioning––and in resolving the presenting problem. For Jerrod, this
includes reducing depressive symptoms, while increasing activity and functioning
in social settings.
 Second-order goals. Second-order goals are longer-term goals. They include
changes in the client’s personality dynamics. In this approach, that is a shift
from a maladaptive to a more adaptive pattern. Therefore, an adaptive pat-
tern must be agreed upon in the first session. The adaptive pattern is com-
monly the reverse of the maladaptive pattern (Sperry & Carlson, 2014). In
the case of Jerrod, for instance, the maladaptive pattern is characterized as
 The First Session 103

over-conscientiousness, to the point of reduced effectiveness. Therefore, it

follows that his adaptive pattern is to be reasonably conscientious while
maintaining effectiveness. Accordingly, he agrees to work toward a second-
order goal of becoming more reasonably conscientious.
 Third-order goals. Third-order change is comprised of pattern change that is
originated and carried out independently by the client. Third-order change evi-
dences that the client has attained the capability of acting as their own therapist.
Therefore, they identify and alter maladaptive responses independently. This
type of goal should be the ultimate goal of therapy as it shows that clients can
respond to internal and external challenges without the aid of a therapist.
Building client awareness is the primary goal toward moving in the direction of
third-order change. As clients become more aware of their patterns, behaviors,
responses, and consequences, they are more likely to respond effectively. Addi-
tionally, clients must increasingly assume responsibility for their responses.
Third-order change is extremely unlikely to happen on its own. Therapists must
purposefully aid clients in gaining awareness and modifying responses (Sperry &
Carlson, 2014). Third-order change is not commonly addressed in the first ses-
sion, but instead is discussed throughout the process of therapy. However, the
two processes of increasing awareness and encouragement do begin in the first
session, and they are important in preparing the client for post-therapy.

7. Effect Initial Change

Effecting some change in the first session helps to build the clinician’s credibility as
well as credibility toward the methods. It also helps the client become more
hopeful about the potential outcomes of therapy. Distressed clients are likely to
return for further sessions if some change is achieved in the first session (Sperry
& Carlson, 2014). Some strategies for achieving this initial change are: offering a
reframe of the client’s problem, emotional first aid, a brief intervention, or even a
novel strategy, such as a paradoxical suggestion.

8. Agree on Homework
Clinicians practicing Pattern Focused Therapy routinely utilize ultra-brief inter-
ventions. These interventions can be introduced in the first session in order to
effect change. They are also utilized as practice or homework between sessions.
Most treatment approaches use homework because they help to supplement and
increase in-session treatment progress. In Pattern Focused Therapy, homework is
not simply between-session activities but also training in third-order change. In
other words, homework becomes the training ground for clients to begin learning
104 The First Session

what it means to be their own therapist. Accordingly, the between-session activ-

ities that make up homework must be agreed upon mutually and not simply
assigned by the therapist (Sperry & Sperry, 2018).

Pattern Focused Therapy: Illustrative Case of Jerrod

The application of Pattern Focused Therapy is demonstrated in the case of Jerrod.
It is a planned, six-session therapy with a male client presenting with moderate
depression. A Student Health Services physician referred Jerrod to the university’s
Counseling and Psychological Services (CAPS) for psychotherapy because Jerrod
expressed concern about the side effects of antidepressant medications. However,
he showed some willingness to consider medications in the case that psychother-
apy alone did not sufficiently alleviate his depressive symptoms.

Background
Jerrod is a 26-year-old biomedical engineering graduate student with low mood, a
reduction in pleasure in activities that he previously found pleasurable, isolation, and
decreased motivation. Jerrod’s symptoms reportedly began three weeks prior to the first
session due to stress and responsibilities. As a result, he began to isolate from his peers.
He also reported feeling fatigue and stated that this was the first time he had felt this
down. He expressed concerns that his current issues may thwart his plans to become a
successful lawyer. Such worries led to undue guilt about his performance and mood
while undertaking school-related tasks. Jerrod has two siblings, each two years apart. He
is the oldest son and described his parents as holding very high standards and routinely
having his siblings compare themselves to him in order to strive for good behavior.

Diagnostic Impression
Jerrod scored a 12 on the Patient Health Questionnaire-9 (PHQ-9) which indicates a
moderate level of depression. However, he did not meet sufficient criteria for the DSM-
5 diagnosis of Major Depressive Disorder. Instead, the diagnosis of Other Specified
Depressive Disorder (311) is given (American Psychiatric Association, 2013). Jerrod
also exhibits an obsessive-compulsive personality style as the evaluation found him to be
one criterion short for the diagnosis of Obsessive-Compulsive Personality Disorder.

Case Conceptualization
Jerrod comes to treatment presenting with low moods, reduced pleasure, guilt
about school performance, and decreased motivation. He meets the criteria for
 The First Session 105

Other Specified Depressive Disorder. The described symptoms have resulted in

decreased social and school function and isolation from friends and peers, due
to the precipitating factor which has been an extreme and debilitating focus on
academic studies. Over-conscientiousness and perfectionism comprise his mala-
daptive pattern, to the point of impairment and ineffectiveness. His predisposi-
tion is likely explained by the following factors: biologically, he may be
genetically predisposed to depression, given a paternal uncle who also suffers
from depression. Psychologically, obsessive-compulsive personality features make
up his personality pattern and style. He holds self-other schemas such as “I
cannot possibly make mistakes because I am responsible for getting things right;”
and a world-view of “Life is unjust and stressful. I have to keep an eye on everything
to make sure nothing goes wrong.” His life strategy seems to be: “I have to be
perfect, so I have to work extremely hard and keep up with my parents’ expecta-
tions.” Skills deficits such as limited coping skills and poor time management have
also been identified. Socially, Jerrod’s history has been riddled with extremely high
parental expectations, social isolation, and struggles with socializing with his siblings
due to perceived parental pressures. Social isolation, unreasonable expectations for
himself, and highly demanding coursework at college make up his perpetuating
factors. Culturally, Jerrod identifies as middle-class Caucasian of Euro-American
background. His cultural explanation is that he is under significant stress and that
he wants to be treated without medications.
First-order treatment goals include increasing social connectedness and redu-
cing symptoms of depression. Second-order treatment goals will include shifting
to a more reasonably conscientious and effective interpersonal style that will
comprise a more adaptive pattern. Keeping in mind his obsessive-compulsive
pattern, Jerrod is likely to resist getting in touch with “soft” feelings, and instead
strive to talk and explain his way through his presenting problems. He may also
present with significant ambivalence at the point of termination. However, given
his low moderate level of depression and motivation for treatment, his prognosis
is good, and it is reasonably likely that he can achieve symptom remission.
Accordingly, he is an appropriate client candidate for six sessions of individual
therapy at CAPS with the provision for two more sessions if indicated.

Session Plan
The general plan for this session is to accomplish the eight therapeutic tasks.
More specifically, background information will be elicited as well as completion of
a brief diagnostic evaluation Scores on a number of screening and monitoring
measures will also be gathered. The client’s maladaptive pattern will be identified
and shared and first- and second-order change goals will be mutually agreed upon.
106 The First Session

Transcription
THERAPIST: Hi, Jerrod. Welcome. Nice to meet you. (smiles and shakes hands
with client)
JERROD: Hi, very nice meeting you as well.
THERAPIST: I want to tell you a bit about our first therapy session––it’s going to be
a bit different from the rest. Today I’m going to be asking you a number of
questions. I want to get a better understanding of what you’ve been going
through and how you’ve been feeling. Does that sound alright?

Commentary
Both verbal and nonverbal communication are used in the initial interaction to
develop rapport. The therapist requests the client’s permission to continue to
instill a sense of autonomy and collaboration, thus beginning to build the
therapeutic alliance. Asking Jerrod for permission to continue also fosters an
egalitarian relationship that de-emphasizes some of the power of the therapist
in the therapist-client dynamic.

JERROD: Sure. That sounds okay.

THERAPIST: Great. Can you tell me a bit more about why you’re seeking therapy?
JERROD: Yeah. (Pause) I haven’t been feeling like myself lately. School has been
really hectic and stressful. I feel like I’m overwhelmed and tired all the time.
The other day I missed a deadline for a project which is very not like me. I
was disappointed, but I was too exhausted to get things in on time.
THERAPIST: Sounds like you’ve had a rough go at it in the recent past. I’m sorry to
hear that. Can you tell me a bit about your mood lately?
JERROD: Uh, it’s been pretty low. I’m down all the time. I feel like I’m dragging
through my days.
THERAPIST: And how often have you felt that way?
JERROD: Every day, basically. Sometimes a bit better, but in general pretty low.
THERAPIST: What about things you typically find pleasant? Are you still doing those?
JERROD: Not really. I haven’t been going to the gym. I have no energy for it. I get so
busy with school that I’m not seeing my friends. I don’t feel like doing anything.
THERAPIST: So, you’re not finding as much pleasure in those things anymore?
JERROD: Yeah. I haven’t really liked or wanted to do anything lately. Everything is gray.
I wasn’t even into it the last time I forced myself to go out with my friends. I was
supposed to do something with them this weekend, but I didn’t go.
THERAPIST: So, you’ve mentioned that you feel exhausted a lot of the time. Can
you tell me more?
 The First Session 107

JERROD: About feeling tired? Yeah, I’m tired all the time. I sleep in sometimes and
I still wake up feeling tired and dragging. It’s hard to focus on things so I’ve
been putting a lot off in the things I have to do.
THERAPIST: So, you feel tired a lot of the time and have been struggling with
concentration.
JERROD: Exactly.
THERAPIST: How about your sleep? How has that been?
JERROD: Well, I’m oversleeping a lot in the past few weeks. If I’m feeling tired in
the morning, I just go back to sleep. I’ve slept through my alarm a couple of
times and the other day when I woke up it was 11 o’clock and I had missed
my morning class. And I was still tired!
THERAPIST: It must be really frustrating to feel tired all of the time with so many
responsibilities.
JERROD: It is. It’s been hard.
THERAPIST: And how long has this been going on?
JERROD: Like three weeks. It feels like much longer though. It’s been rough.
THERAPIST: And have you ever gone through a rough patch like this before?
JERROD: Not really. This is the first time.
THERAPIST: Have you ever been to a psychotherapist or psychiatrist before in your
life?
JERROD: No.
THERAPIST: Have you ever had any psychiatric medications prescribed?
JERROD: No. I’ve never been prescribed or taken anything.
THERAPIST: I see. And how has your everyday life been affected by these
symptoms?
JERROD: Like I said, I don’t do anything I like. I’m in bed all the time. I don’t go
out with my friends. I’m missing study group and classes, which are impor-
tant to me. I’ve been really worried about my grades. I’m pre-law so my
courses are really difficult right now. Law school is going to weigh heavily on
these courses, and I feel like I’m failing. I’m going to mess up my career. I
haven’t even told my parents though because I don’t want them to find out
I’m struggling in class.
THERAPIST: I see. So, you have been isolating, missing important classes and events,
and struggling to keep up with schoolwork. You’re worried that this all will
affect your career and your prospects of getting into law school.
JERROD: Exactly. I feel really guilty about slacking off. I mean, I’m still doing what
I can to keep my grades up, but I know I could do better. I’m down about it
all the time.
THERAPIST: Okay. You’re also feeling guilty even though you have been keeping up
and managing.
108 The First Session

JERROD: Yes, absolutely.

THERAPIST: It seems like this has been a very difficult experience for you. I
appreciate you answering these questions. I’d like to ask you a few more, if
that’s okay.
JERROD: Sure. Go ahead.
THERAPIST: Thanks. You said that you’ve been through some changes recently and
your energy and sleep patterns have been off. Have you had any weight loss
or weight gain recently?
JERROD: No, not really any change.
THERAPIST: So, no weight changes. Have you ever felt like you had extra bouts of
energy and you didn’t need to sleep as much?
JERROD: No. It’s the other way around. I have no energy most of the time. I had a
lot of energy before.
THERAPIST: How about any mood swings? Sometimes going up and sometimes
down?
JERROD: Not really. I wouldn’t say mood swings. Some things get me frustrated,
but never up and down like that.
THERAPIST: Okay. How about any major changes in your life? Like breakups or loss
in your family?
JERROD: No. I’ve been here for more than a year. Nothing big has happened
THERAPIST: Any events that might have made you feel scared or out of control?
JERROD: No.
THERAPIST: Would you also describe yourself as a nervous person?
JERROD: Um, well, sometimes I get a bit worried about missing deadlines and
things like that. I wouldn’t really say I’m a nervous person, though.
THERAPIST: So, schoolwork is your most typical worry. Are there any other things
you worry about?
JERROD: No. Not really.
THERAPIST: You said that you had been staying away from social situations and
other people. Have you ever struggled in social situations, like speaking in
public for a presentation?
JERROD: No, I’m actually good at presentations. I enjoy it. I’ve just been stressed
out and busy. I’ve been too tired and didn’t really care about being with
other people recently.
THERAPIST: Okay, I see. Can you tell me if there are any places, you’re afraid to go
or things you’re afraid of doing?
JERROD: No. I don’t really have anything like that.
THERAPIST: How about any specific fears, like flying or heights?
JERROD: Not really. I really don’t like frogs, but it’s not like a phobia or anything.
 The First Session 109

THERAPIST: Okay. Have you ever been in a situation in which you thought you
might die, stop breathing, or have a heart attack?
JERROD: No. Never.

Commentary
The therapist and Jerrod continued to work through the diagnostic evaluation. The
DSM-5 diagnosis of Major Depressive Disorder was ruled in, while anxiety and
stress-related disorders were ruled out (American Psychiatric Association, 2013). The
therapist exhibited warmth and active listening, regularly reflecting Jerrod’s thoughts
and feelings. This allowed the therapist to develop and enhance the therapeutic alli-
ance. The session continues as other diagnostic conditions are ruled out.

THERAPIST: Have you had any repetitive thoughts of something bad happening, or
any repetitive behaviors that you feel you need to do?
JERROD: No. I’m organized and some of my friends have joked that I’m kind of
predictable because I stick to my routines, but not so much lately. I don’t
have any rituals or anything like that.
THERAPIST: So, with your routines––do you find it hard to break those routines if
something comes up spontaneously?
JERROD: It’s hard, but I can do it. Like if I had thought about organizing my work, I can
head out with my friends for a bit and then get to it later. But it is a struggle.
THERAPIST: So, you have struggled with flexibility at times?
JERROD: Yes, that’s pretty much it.
THERAPIST: I just have a few more questions. Have you ever experienced anything
strange or unusual?
JERROD: I can’t think of anything. No.
THERAPIST: Okay, have you ever felt like you lost touch with reality, heard voices,
or thought that people were trying to hurt you?
JERROD: No.
THERAPIST: Has anyone ever told you that you had strange ideas?
JERROD: No.
THERAPIST: Have you ever felt like your mind was playing tricks on you?
JERROD: Um, what?
THERAPIST: Like any experiences where you felt like you were outside of your
body? Or having a period from your life that you can’t recall?
JERROD: No. That sounds terrible. Definitely not.
THERAPIST: And how has your memory been lately?
JERROD: It’s been fine. I mean I’ve had a hard time focusing like I mentioned but I
don’t think my memory has suffered too much.
THERAPIST: So, no memory decline?
110 The First Session

JERROD: No. Not at all.

THERAPIST: I see. You’ve told me that there hasn’t been any weight fluctuation.
Have you ever had any issues with food, like overeating or eating too little?
Has that ever been a problem?
JERROD: No. I try to eat healthy but I’m not too strict with it. I also don’t starve
or anything like that.
THERAPIST: Have you ever felt like you didn’t have control of how much you were
eating? Eating too much in one sitting?
JERROD: No, never.
THERAPIST: Have you ever restricted your food intake?
JERROD: No, I haven’t.
THERAPIST: How about any behaviors like throwing up what you ate or using
laxatives?
JERROD: No way.
THERAPIST: You mentioned that you liked going to the gym. Any issues with
over-exercising?
JERROD: No.
THERAPIST: Okay. Any drug or alcohol use?
JERROD: I don’t really drink much––only once in a while with my friends. I don’t
like it all that much. I don’t enjoy the feeling. And I’ve never used drugs.
Some of my friends in the past have offered me ADHD drugs to help me
study but I stayed away from it. That stuff is not for me.
THERAPIST: Okay. So, there’s no chance that what’s been going on with you
recently has anything to do with any substance?
JERROD: No. No chance.
THERAPIST: Any prescription or medications over the counter?
JERROD: I don’t take any medications. I mean, like Advil every once in a while, if I have
a headache. I take some allergy medicine sometimes––the non-drowsy kind.
THERAPIST: Have you been diagnosed with any physical or medical conditions?
JERROD: No, I’m healthy. I had a physical recently. The doc said everything was fine.
THERAPIST: It’s good to hear that. Given that you’ve been struggling quite a bit
lately, have you had any thoughts of harming yourself or thought that you
didn’t want to live anymore?
JERROD: No, absolutely not. Nothing like that.
THERAPIST: Okay, how about hurting someone else?
JERROD: No way. Never.
THERAPIST: And how would you describe yourself as a person, Jerrod?
JERROD: Um, I guess I’d say I’m focused. I’m organized and I like to focus on
school and my work. I like to be active and play softball.
 The First Session 111

THERAPIST: And you had mentioned that some people have complained about your
routines. Is that pretty common for you?
JERROD: Yeah, I guess. I mean my friends get on my back about it––if they want
to go someplace but it’s the day I typically clean up around the house, they
tease me about it, “Lame!” and stuff like that. But I don’t think it’s that bad. I
can usually reschedule if I have to.
THERAPIST: So, do you ever find yourself so narrowly focused on organizing, making
a list, or attending to the details that you lose track of your original intent?
JERROD: Oh, for sure! Yes! That sounds just like me. In my first year here, I was
so focused on some of the details of one of my assignments that I did the
thing wrong and ended up with a B minus. It was terrible. I overdid it on
one detail, and I missed the entire point of the assignment.
THERAPIST: Okay, so it sounds like you overcomplicated one portion of it and you
completed the assignment incorrectly?
JERROD: Yeah.
THERAPIST: Then, it sounds like you can get in your own way. This could be called
a pattern of conscientious perfectionism. There’s also an element of pleasing
others. Does this sound right? (maladaptive pattern is shared)
JERROD: (Pause) Well, I’ve never really thought about it like that, but yeah. That
happens. I’m very organized and get annoyed when people are sloppy. People
just don’t care about the details, or maybe I just care too much. I’ve been
called a perfectionist before. I can see that. I also want others to think well
of me and so I guess I do try to please them too.
THERAPIST: I see. And it sounds like being organized and paying close attention has
worked for you in the past––they’re useful traits! Do you think it could be
even more helpful if you could find a balance between being conscientious
and perfectionistic while still maintaining some flexibility and being effective?
(second-order change goal)
JERROD: Yes. Absolutely. That would be awesome. I’ve gotten pretty frustrated in
the past. I’d do something and think “Why did I do that? What’s wrong with
me?” I should have been able to realize that getting focused on one small
detail wasn’t helping anything.
THERAPIST: Right. And it might’ve saved you some time and trouble.
JERROD: Yeah. I want to be more efficient.
THERAPIST: Is it also a pattern for you to avoid social situations or things that you
find pleasurable because you’re focused on your work?
JERROD: Well, yeah. I started doing that when I got overwhelmed and falling
behind. But it hasn’t been a problem for me before. Typically, I can schedule
stuff in and have fun with people.
112 The First Session

THERAPIST: It’s good to hear that. Do you ever find yourself hanging on to things that
you wanted to throw out? Even if those things have no value or are worn out?
JERROD: No. I throw things out all the time. I like things clean and I don’t keep
junk around.
THERAPIST: Right. And you mentioned that you get frustrated with other people if
they’re not as organized as you. Has this ever become an obstacle in working
with others? For instance, if you have to delegate tasks, do you think that
others might not do it as well?
JERROD: Um, yeah that’s hard for me. People have told me that I nitpick a lot. I
like group work, especially if I know the people in the group, but sometimes
that is a struggle. Yes.
THERAPIST: How about handling money? Are you a big spender? Or do you tend to
save your money?
JERROD: Well, I don’t have much to spend right now. My parents help me out. But
I do plan and save a lot. I also like going shopping and going to the movies.
THERAPIST: Okay, so you have a pretty good balance between saving and spending?
JERROD: Yeah.

Commentary
Additional DSM-5 diagnoses were ruled out throughout the screening. Jerrod’s
responses are indicative of obsessive-compulsive personality style. The Major
Depressive Disorder diagnosis was made earlier in the evaluation. The mala-
daptive pattern of over-conscientiousness and perfectionism to the point of
decreased effectiveness became more pronounced. Obsessive-compulsive per-
sonality disorder was ruled out, as Jerrod did not meet full criteria. Jerrod’s
decreased social interest and increased sense of discouragement can be explained
by his maladaptive pattern. There are several rigidly self-imposed rules and cri-
ticism about high achievement expectations. This reduces the ability to remain
flexible and engage with others, exacerbating symptoms of depression. The core
beliefs seem to be that perfection is of the utmost importance in order to be
worthwhile.

THERAPIST: Can you tell me a bit about your family? What was it like growing up
in your home?
JERROD: Sure. I’m the oldest of three. I have a little brother and younger sister.
My sister is four years younger than me and my brother is two years
younger. My childhood was fine. We always had what we needed. I had violin
lessons. I was in many sports. But there was a lot of pressure because I
always did well, and my brother and sister were told to look up to me. My
 The First Session 113

parents expected me to do very well in school because I had to be a good

example for them.
THERAPIST: Okay. So, your parents provided for you well, but also placed a lot of
expectations on you from a very young age.
JERROD: Yeah.
THERAPIST: And how would you describe their relationship? Your parents?
JERROD: Oh, they get along fine. They have a good relationship. You know, some
fights here and there but for the most part good.
THERAPIST: Okay, and who made the big decisions in your family?
JERROD: I think my parents did a good job sharing those responsibilities. My dad
was the breadwinner and my mom worked part-time for some time. She
stayed at home for a few years.
THERAPIST: And how did they work out their problems or conflicts?
JERROD: Um, like I said––some arguments––but for the most part they worked
things out well. Some things seemed like they never worked out though. My
mom complained a lot that my dad worked too much. My dad typically
complained that my mom made him late for things because she took so long
getting ready. He says she’s terrible with time management.
THERAPIST: Do you think there was an expectation that you would take on any
career when you grew up?
JERROD: Yeah. Law, medicine, or business. My parents told me early on. They said
that liberal arts majors are typically unemployed right out of college. I mean,
I don’t mind it because I was on the debate team in high school. I wanted to
go to law school either way.

Commentary
Closed-ended questions were used to assess family dynamics. Although there
were not as many instances of reflective statements, the therapist remained
nonjudgmental and warm throughout which led Jerrod to feel comfortable dis-
closing information and deepening the developing alliance between Jerrod and
the therapist.

THERAPIST: Very good, Jerrod. I appreciate you answering my questions. This pro-
cess has helped me obtain a better understanding of your symptoms and con-
cerns. Also, I think I have a better idea of how these issues have been affecting
your daily life, what it was like for you growing up, and your current career
goals. I’d like to formally discuss the informed consent agreement and a bit
about what your hopes are for our work together in the coming weeks.
114 The First Session

Subsequently, the therapist and Jerrod discussed the informed consent. The
therapist informed Jerrod that informed consent spans more than just signing the
form. It is also a process of “permission seeking” that could emerge in further
sessions if the focus of the treatment changes.

Commentary
Jerrod showcased good cooperation, responding with early recollections and
family constellation. Jerrod’s emotions and experiences were reflected, validated,
and restated throughout. The therapist showed appreciation for Jerrod’s will-
ingness to share and explained the rationale for the processes thus far and how
they helped the therapeutic process. Then, the therapist requested permission to
proceed with the therapeutic goals, which enhanced the therapeutic alliance and
clinician credibility. It also served to preserve the relationship and avoid triggers
for Jerrod’s maladaptive pattern. Jerrod and the therapist set goals collaboratively
and informed consent was discussed. One final consideration was the inclusion of
medication combined with therapy if therapy alone did not alleviate the symp-
toms. Then, Jerrod signed the informed consent form.

JERROD: I’d like to shake off this mood. I’d like to feel better and be motivated to
actually do my work. I also want to get back to playing softball and doing
other things I like.
THERAPIST: I agree that we should focus on your depressive symptoms as well as
increasing your level of energy. This is so that you can get back to enjoying
things you used to like, like playing softball. (first-order change goal)
JERROD: Yeah, I’d like that. I hope that’s possible but I’m worried that I’m going to
keep feeling this way. I also hope that therapy will work because I only want
to use medication as a last resort.
THERAPIST: I hear you. And I think there’s a good chance that we can achieve your
goals working together.
JERROD: It’s good to hear that.
THERAPIST: Before, we talked about a pattern of perfectionism and narrow focus
on details. This was happening to the point where it was getting in the way
of you being effective. Is that also something you’d like to work on in here?
JERROD: (Pause) Yes, I really would. I like that I’m organized and like you said, that’s
worked for me well so far, but I want to be effective and not let it get in my way.
THERAPIST: Right. Well, I think these goals we’ve set are achievable. We can ded-
icate the next few weeks to helping you achieve them and start feeling
better, becoming more flexible and getting more accomplished. Does that
sound alright?
 The First Session 115

JERROD: Yeah. That sounds awesome. I like that there’s a plan in place. It makes
me feel a bit better.
THERAPIST: I’m happy to hear that. So, what do you say we spend a few minutes
discussing your energy levels and motivation?
JERROD: Yeah. We can do that.
THERAPIST: Great. You know, sometimes when people feel like you have been
feeling, they tend to stop doing the things that they find enjoyable. This can
result in inactivity cycles. So, the less they do, the less energy they have to
get involved with things.
JERROD: Interesting. Yeah, I can see that.
THERAPIST: You mentioned that you were active before. The technique I’d like to
suggest is called behavioral activation. That means that by intentionally being
active, you begin to activate more energy and feel less depressed. You can
start feeling positive feelings by starting your physiology. A different way of
saying this is acting “as if” you were motivated or energetic. This way, you
feel a surge of energy and feel more motivated. Does that make sense?
JERROD: Yeah. Sure, but does that actually work?
THERAPIST: Actually, yes. (Pause) Why don’t we schedule some gradual activities?
It’s best to start small. You don’t want to plan something you’re not actually
going to do. Even something small like taking a walk for 10 minutes can start
to snowball into bigger effects.
JERROD: Yeah, like with exercising, it’s not good to take on too much all at the
same time.
THERAPIST: Exactly. So, what would be two activities that you could complete in
15–20 minutes this week? Something that you typically like to do.
JERROD: Well, I like taking saunas. But I haven’t been doing much of either lately
even though it usually makes me feel really good.
THERAPIST: That sounds great. Do taking saunas have a soothing effect on you?
JERROD: Yeah, it also seems to invigorate me.
THERAPIST: Getting both results sounds like it would help with your symptoms. It’s
very encouraging that you have things that you can do that are enjoyable.
Have a look at this list of some other things that people find enjoyable.
(Hands list) This typically gives people some ideas. Can you tell me if any-
thing stands out for you?
JERROD: This is quite a list. And, yeah, things like taking walk to the park stand
out, and reading a novel. I also like collecting coins. I’ve been collecting since
I was a kid.
THERAPIST: Oh, that sounds very interesting. Have you been to one of those coins
shows they hold at the Coliseum?
116 The First Session

JERROD: Yes. I actually went last year and got some new ones, but I’ve been putting
it off. I don’t actually know why. Probably because I’m so busy. (Pause) But if I
had to choose, I’d go for a sauna at the university fitness center.
THERAPIST: Well, great! Is that something that you would consider doing for 20
minutes this coming week?
JERROD: Yes, I can totally do that for 20 minutes
THERAPIST: And when will you do that this week?
JERROD: I can do it on Thursday. I have a little time then.
THERAPIST: Ok, great. Can you think of a backup plan in case something comes up
and you can’t get to that?
JERROD: Well, I like to read and there’s this book on my nightstand. I can read for
15–20 minutes.
THERAPIST: That sounds great. And how about that second activity?
JERROD: I can go through my coin collection and make a list of what I might add to it.
THERAPIST: Ok, sounds good. Would that take you about 15–20 minutes?
JERROD: Yeah.
THERAPIST: And when do you want to plan on doing that?
JERROD: I’d say Friday.
THERAPIST: Good. What about a backup for that activity?
JERROD: Well, I think my backup for that would be to take a walk to the mall and
back. It’s about 2 miles each way.
THERAPIST: Good. So, your first activity is to take a sauna at the fitness center on
Thursday. Then, on Friday, you’ll take a bath for about 15–20 minutes using
your new products. That sounds great. Feel free to keep this list and take a
look at it if needed. Also, I’d encourage you to give yourself permission to try
other things throughout the week if the thought comes up. If not, the plan-
ned activities should be a good start.
JERROD: Ok. Yeah. I can do that.
THERAPIST: It’s also important for us to track your progress. I’m going to give you this
log. Give each activity two ratings, on a scale from 0–10. The first rating will
address the extent to which you completed the activity––all, some, or not at all.
Then, rate how much enjoyment you got from it, 0 would be none at all, and 10
would be the most possible enjoyment. Does that sound doable?
JERROD: Yeah. Seems pretty simple.
THERAPIST: OK, great. I really think you’re going to get some positive results.
JERROD: You know, I think I will get positive results.
THERAPIST: Okay. Now, would you mind filling out the SRS form? This is so that
we can keep an eye on if you’re getting what you want from our sessions.
JERROD: Sure. (Pause while he fills it out)
THERAPIST: Okay. I see you noted that you’re satisfied with what we talked about.
 The First Session 117

JERROD: Yeah. I think this was good for me. I feel better now than when we
started.
THERAPIST: I’m happy to hear that and I look forward to our work together.

Commentary
Jerrod seemed receptive to the behavioral activation intervention His statement:
“You know, I think I will get positive results” and that he feels better than at the
start of the session suggest that Jerrod is feeling a sense of hopefulness, and are
both indications that the task of effecting a small change in the session was met.

THERAPIST: Before we wrap up, can you rate on a scale from 0 to 10, 0 being not
at all and 10 being the most, how important it is for you to attain the goals
we discussed? (Query-Pattern & Query-10–1)
JERROD: A 10. I don’t like how I’ve been feeling, and I want to get back to my old self.
THERAPIST: I see. So, it’s very important for you. Good. And on that same scale,
can you rate your level of confidence? (Query Pattern & Query-10–2)
JERROD: Well, for that I’d say about a 6. It’s hard for me to see it happening.
THERAPIST: . Before we end, I’d like to give you something to do between now and
our next session. Would that be alright?
JERROD: Yeah. That sounds fine.
THERAPIST: This is a daily mood rating sheet. It’s divided into two hours chunks on
the left column. Please write in the dates of the week on top. During this
upcoming week, pay close attention to how you feel––your moods specifi-
cally––and jot it down every two hours. You can write in as much as you
want to describe how you’re feeling. Does that sound okay?
JERROD: Yeah. I think I can do that.
THERAPIST: And, finally, please fill out the Session Review Scale. It’s four items that
review our session today. It looks to assess if you were able to get what you
came here for. Is that okay?
JERROD: Yes. Sure. (Pause while form is filled out)
THERAPIST: (After reviewing the SRS and scoring it as 38 out of 40) So, here you
have indicated that you were satisfied with our session and that we talked
about what you wanted to talk about.
JERROD: Yeah, we did. (Pause) I thought I was going to be much more nervous
and that this was going to be a more painful process, but I got over my
nerves easy. It was easy to talk to you.
THERAPIST: I’m so happy to hear that. (Pause) I also think you did really well, and
I look forward to working with you. Do you have any other questions before
we close?
118 The First Session

JERROD: No, not really.

THERAPIST: Okay, then have a great rest of your week and I’ll look forward to
seeing you next week.
JERROD: Thanks, you too. I’ll see you then.

Commentary
Jerrod’s responses on the importance and confidence rating were surprisingly high in
this first session, especially given his depressive presentation. Presumably, these
responses reflect increases in hope and trust in the therapeutic process. Additionally,
relatively high SRS scores are suggestive of his approval of the alliance with the
therapist, not just the bond, but goals and methods. Given this indication of rela-
tively strong alliance, there is a high likelihood that he will return for the follow-up
session and therefore there was no need for an ultra-brief intervention.
It is important to note that the therapist did not trigger––wittingly or unwit-
tingly––Jerrod’s maladaptive pattern in the session. This might have surfaced if the
therapist had commented in a way that was perceived as critical or demanding
and resulted in a strain or rupture to the alliance. If that had occurred, it would
be the therapist’s responsibility to repair the alliance or risk having the client feel
insufficiently safe or confident to return for the second session (Sperry, 2010a).

Chart Note
The client presents with depressive symptoms and PHQ-9 score of 12, which
suggests moderate depression. He merits the DSM-5 diagnosis of Other Specified
Depressive Disorder (311) and exhibits an obsessive-compulsive personality style.
A maladaptive pattern of conscientious perfectionism and pleasing was identified
and discussed. It was mutually agreed that our therapy would focus on reduction
of depressive symptoms and shifting to a more adaptive pattern. Behavioral acti-
vation and monitoring were agreed upon as homework. Consent form was signed
and therapeutic alliance appears positive and appropriate for a first session and
reflects his confidence in achieving therapeutic change.

Conclusion
In Pattern Focused Therapy, the eight essential tasks described above are the focus
of the first session. These tasks were illustrated using the case of Jerrod. This case
showcases how the therapeutic alliance was fostered and also highlighted that his
maladaptive pattern was identified. and first- and second-order change goals were
mutually established. The other five essential tasks were also accomplished, including
 The First Session 119

effecting some initial change in the first therapeutic encounter. In my experience,

when all the tasks are achieved in the first session, it is highly predictive of the
client engaging in therapy, and specifically returning for the second session.
As noted at the beginning of this chapter, the case of Jerrod will continue in
Chapter 7 and Chapter 8, from the second session through termination in the
sixth session.

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th
ed. Arlington, VA: American Psychiatric Association.
Bordin, E. S. (1994). Theory and research on the therapeutic working alliance: New directions.
In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice
(pp. 13–37). New York, NY: John Wiley & Sons.
Duncan, B., Miller, S., Parks, L., Claud, D., Reynolds, L., Brown, J., & Johnson, L. (2003). The
Session Rating Scale: Preliminary properties of a “working” alliance measure. Journal of
Affective Disorders, 49, 59–72.
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy.
Journal of Consulting and Clinical Psychology, 61, 561–573.
Kroenke, K. & Spitzer, R. L. (2002). The PHQ-9: A new depression and diagnostic severity
measure. Psychiatric Annals, 32, 509–521.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
Sperry, L. (2008). The dictionary of ethical and legal terms and issues: The essential guide for mental
health professionals. New York, NY: Routledge.
Sperry, L. (2010a). Highly effective therapy: Developing essential clinical competencies in counseling
and psychotherapy. New York, NY: Routledge.
Sperry, L. (2010b). Core competencies in counseling and psychotherapy: Becoming a highly competent
and effective therapist. New York, NY: Routledge.
Sperry, L., & Binensztok, V. (2019a). Learning and practicing Adlerian therapy. San Diego, CA:
Cognella.
Sperry, L., & Binensztok, V. (2019b). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Sperry, L., & Carlson, J. (2014). How master therapists work: Effecting change from the first through
the last session and beyond. New York, NY: Routledge.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and
confidence. New York, NY: Routledge.
Chapter 7

The Middle Sessions

The middle sessions in Pattern Focused Therapy are directed at effecting major
change in the client. These sessions implement the treatment plan developed in the
initial session for both first-order change goals and second-order change goals. Spe-
cifically, these sessions target reduction of symptoms (first-order change) and shifting
to a more adaptive pattern (second-order change). While not the primary focus of
these sessions, third-order change is a secondary target. Depending on the practice
setting, the number of middle sessions may be as short as two or three sessions or
considerably longer. In the case of Jerrod, the usual practice policy for therapy was for
six sessions. This included an initial and two ending sessions ,leaving three middle
sessions. This chapter analyzes the middle phase of Jerrod’s therapy: sessions 2, 3, and
4. It provides transcription selections from these three sessions along with commen-
tary. Since Pattern Focused Therapy is focused and intentional, a “session plan” with a
given structure is specified prior to the session.

Session 2

Session Plan
The plan included getting a current PHQ-9 score and as well as reviewing the Mood
Scale rating chart, the ORS, and the behavioral activation assignment. Then, a recent
situation is processed with the Query Sequence to assist in shifting Jerrod’s mala-
daptive pattern to a more adaptive one. If another ultra-brief intervention is indi-
cated, it is introduced. Finally, additional behavioral activation activities and others are
assigned. Continued monitoring with the PHQ-9, the Mood Rating Scale, the Out-
comes Rating Scale, and the Session Rating Scale is done in order to more effectively
tailor the treatment process. Here is the transcription of all of session 2.

THERAPIST: Hi, Jerrod. It is nice to see you again.

JERROD: Thanks. Nice to see you too.
 The Middle Sessions 121

THERAPIST: I see that your PHQ-9 is 10, an improvement since the first time we met.
Very good. What was it like doing your Mood Rating Chart this past week?
JERROD: All right. I was able to fill it in each day. There were a couple of hours where
I forgot but I was able to go back and fill it in. Basically, I was able to keep track.
THERAPIST: Looking at it, I see you wrote “annoyed” and “tired” a lot. Can you say
more about that?
JERROD: Well, yeah––that’s why I came here to start with. I was feeling tired all
the time and didn’t have any motivation. I didn’t realize I wrote “annoyed” so
much though. That’s surprising.
THERAPIS: t: When do you feel annoyed? In what kind of situations?
JERROD: Typically, when I’m feeling a lot of pressure. For example, when I have an
assignment due and my friends are going on about stupid stuff.
THERAPIST: So, you feel annoyed when you’re already overwhelmed or stressed
about things you have to do and your friends are demanding of you? Or
they’re wanting to discuss something trivial?
JERROD: Yes, exactly.
THERAPIST: Would it be okay to add another component to your mood chart
between now and your next session? I’d like you to jot down the kind of
situation you’re in when you’re recording your mood.
JERROD: Yeah––okay. That’s fine.

Commentary
Jerrod’s notations on his mood chart reflect his perfectionistic pattern. Although
he completed the assignment, he admitted there were some days he missed filling
in the Mood Rating Scale log, so he later went back to fill in the blanks. Such
“pleasing” behavior is congruent with his maladaptive pattern. Accordingly, the
therapist praised Jerrod’s efforts and highlighted how the pattern emerges when
Jerrod feels demands are being made of him, as they were in the take home
assignment. It is possible that his ambivalent motivation was triggered by the
therapist’s “demands” that he complete the assignment.

THERAPIST: How would you rate yourself right now on the Mood Rating Scale
from 1–10?
JERROD: I would rate myself between 4 and 5.
THERAPIST: Alright. Looking over the ORS you just filled out, I see the areas
needing the most improvement were individually and socially. Can you tell
me more about that?
JERROD: I haven’t been doing too hot individually. I’m still sad and low. Really
tired too.
122 The Middle Sessions

THERAPIST: That sounds tough. What about socially?

JERROD: Well, I haven’t been seeing other people and I’ve been having a hard time
in school. But that was still my highest score.
THERAPIST: So, socially you marked as the highest, but things were still pretty low
overall. Can you say more?
JERROD: Yeah––I was just tired all the time. I felt like I was dragging, and I felt
guilty about it. I didn’t really get my work done––well, barely. I go to study
group on Tuesdays, typically. I didn’t even go the last week––and I usually
get a lot out of it.
THERAPIST: I understand. I’m sorry to hear you didn’t feel up to going, even
though you usually enjoy the group. The symptoms you described also match
today’s PHQ-9 score.

Commentary
These markers of mood and functioning are useful and necessary. However, Jerrod’s
response to engaging in the assigned therapeutic intervention will be particularly
telling. Accordingly, the therapist with Jerrod will review the behavioral activation
assignment from last session.

THERAPIST: Could we review your behavior activation log?

JERROD: Yeah, sure.
THERAPIST: You had scheduled activities such as taking a walk and sorting through
your collection. You rated your first activity as a 10! Great!
JERROD: Yes, I did that one.
THERAPIST: And how did you rate it as far as the pleasure that you got from it?
JERROD: Like a 7. I felt very relaxed.
THERAPIST: Seven sounds very good. And what was your score on your second
activity, which was to sort out your coin collection?
JERROD: To be honest, that one was only about a 6. I got really busy and I’ve had
this collection since I was a kid. I couldn’t really do it for 20 minutes.
THERAPIST: Well, a 6 is still pretty good. How did you enjoy doing that?
JERROD: I gave it a 6 as well. It took me back to my childhood and I liked that.
THERAPIST: Would you be willing to tell me what you found good about the activity?
JERROD: Sure. I mean, to hold the coins was really good because it took me back.
My uncle gave me some of those and I liked remembering him. He’s actually
the one that started me in collecting.
THERAPIST: That sounds awesome. And what else did you enjoy about it?
JERROD: I kind of felt a sense of peace. Like I was meditating while I was sorting it
through.
 The Middle Sessions 123

THERAPIST: Good. That sounds very reassuring. And what were some of the not so
good things about the activity?
JERROD: I was disappointed because I didn’t get to the rest of it. I had to stop with
barely having completed any of it. I was frustrated.
THERAPIST: I can see how that could be frustrating for you.
JERROD: Yeah. I was upset.
THERAPIST: And has this ever happened before?
JERROD: All the time. I typically get caught up on the little things and miss the big
picture. Or sometimes I don’t get something right and I put it off forever,
like on my assignments.
THERAPIST: I see. Sometimes you get caught up on the details and that takes you
away from completing the work.
JERROD: Yes. Or even if I do finish, I’m obsessing about the one thing that I didn’t
do or do right.
THERAPIST: I see. And what do you think happens that takes your focus into those
small details even if you find that not to be very productive?
JERROD: I just want things to be done right. I don’t want to be a slob or have my
things turn out sloppy.
THERAPIST: You want to do things the right way. That’s admirable.
JERROD: Thanks.
THERAPIST: But maybe it doesn’t always work out how you want it to?
JERROD: No, definitely not.
THERAPIST: So, do you think that there’s a pattern here of conscientious perfectionism
and pleasing? And this pattern gets in the way of being effective and completing
your tasks? (Query-Pattern)
JERROD: Yeah––that sounds about right. (Pause) Just this last week there was
another example of that.
THERAPIST: Yeah? Would you be willing to tell me more? (Query-1)
JERROD: The best possible outcome would be for my professor to let me turn my
paper in without any penalty.
THERAPIST: Ah, yes. That sounds like a pretty ideal outcome. Is that something
that you can control?
JERROD: Um, no. I see.
THERAPIST: Yes. I agree with you there. What might’ve been a best possible outcome
in your control in this given situation?
JERROD: Maybe just turning in the paper on time? It was a small mistake and if I had
turned it in, I wouldn’t have worried about it anymore. I would’ve just been done.
THERAPIST: Okay––so you wanted to get it in on time regardless of that small
mistake. Then that would be a weight off. Right?
JERROD: Yeah. I would’ve wanted that.
124 The Middle Sessions

Commentary
The Query Sequence continued with elicitation of his thought and interpretations.
His desired outcome (Query-4) was to turn his paper in on time and be done with it.

THERAPIST: I see. And what actually happened? (Query-5)

JERROD: Well, instead, I stressed about it and turned it in late.
THERAPIST: You wanted to turn your paper in on time, but instead you went home
to fix it and turned it in late.
JERROD: Yeah.
THERAPIST: Did you get what you wanted out of this situation? (Query-6)
JERROD: No. In fact, I ended up even more stressed out about it.
THERAPIST: It must have been really stressful to have to turn the paper in late after
putting in all the work.
JERROD: Yes, I was really disappointed.
THERAPIST: So, would you be okay with reviewing this situation and seeing how it
might’ve turned out otherwise? (Query-7)
JERROD: Yeah––that’s fine.
THERAPIST: I think we should review your thoughts and behaviors and see if they
follow your maladaptive pattern. Your first thought, for instance, was “I’m
going to fail if this is how I turn in the paper.” Was that thought helpful or
hurtful in getting your desired outcome? (Query-8)
JERROD: Uhm––hurtful.
THERAPIST: It was hurtful––how was it hurtful?
JERROD: I felt like I couldn’t recover. Like everything was already messed up.
THERAPIST: So, it sounds like it affected your confidence.
JERROD: Yeah.
THERAPIST: Does it seem like that’s related to your pattern of perfectionism?
JERROD: Yeah. I mean, that happens a lot. I struggle with letting things go and I
work on them nonstop.
THERAPIST: Right. And this is an obstacle to being effective––like in this example,
getting the paper in on time?
JERROD: Yes, that’s it. Also, when I was sorting through my collection.
THERAPIST: So, it makes sense that your pattern is related to these unhelpful thoughts.
Can you think of an alternative thought that might have been more helpful?
JERROD: I could’ve just thought I did my best or that it wasn’t so big a mistake.
THERAPIST: I see. So, considering that you did your best or that it wasn’t such a grave
mistake––that would certainly fit with a more adaptive pattern that we could
call “reasonably conscientious while maintaining effectiveness.” Make sense?
JERROD: (Pause) Yeah. Makes sense.
 The Middle Sessions 125

THERAPIST: Now, how would that adaptive pattern and thought have been more
helpful to you in getting your paper in on time?
JERROD: I could’ve just been more relaxed about it instead of freaking out.
THERAPIST: So, it might’ve taken the wind out of the sails of catastrophizing the
situation?
JERROD: Yes, that’s a perfect way of saying it. I think everything is the end of the
world when it comes to situations like that.
THERAPIST: I see. And, your second thought was, “This paper is a disaster.” Right?
In getting what you wanted, was that helpful or hurtful?
JERROD: Well, that definitely hurt me as well––it just made me think more and
more how things were completely hopeless.
THERAPIST: And you started to blame yourself?
JERROD: Yeah, I did. That’s where things end up when I think like that.
THERAPIST: Is your mood affected by that at all?
JERROD: (Pause) Of course, I mean, I feel guilty and depressed. Like all I ever do is fail.
THERAPIST: So, you feel like a failure and very guilty about it?
JERROD: Yeah.
THERAPIST: I think it makes sense that these thoughts and feelings are connected,
leading to some feelings of depression. Do you think it might also be related
to your pattern of being overly conscientious and perfectionistic? Especially
when that gets in the way of what you want?
JERROD: Yeah, I see that it stresses me out and I feel guilty and like a failure. I see
how that leads to me feeling depressed.
THERAPIST: Then, it sounds like you’re making a connection between the level of
conscientiousness and the guilt and feelings of depression, is that accurate?
JERROD: Yeah––exactly. I start focusing on a small detail and I feel like I’m going
to fail. It’s all connected, and it affects my mood and makes me feel hopeless.
THERAPIST: So, it also affects your motivation?
JERROD: (Pause) It really does a number on me. It affects my motivation, my
mood, and even the outcome of my work.
THERAPIST: I see. And what’s an alternative thought for “This paper is a disaster”
that might’ve been more helpful?
JERROD: Maybe to consider that only one thing was wrong in my paper and that’s
pretty good?
THERAPIST: Hm. And how would that have been more helpful?
JERROD: It would’ve helped me get over one minor thing.
THERAPIST: Yes, it might’ve emphasized the size of the mistake and let you see all
of the other good work in there.
JERROD: Yes, I worked really hard on that paper and I thought it was pretty good
overall.
126 The Middle Sessions

THERAPIST: Is that a realistic thought? Do you see yourself having a thought

like that?
JERROD: Yeah. I mean, I hadn’t thought about it before. I think this conversation
will help me remember when I’m in another situation like that.
THERAPIST: Sure. Sounds good. Your third thought was “I have to go and change
the paper.” Was that thought helpful or hurtful in getting what you wanted?
JERROD: It was hurtful.
THERAPIST: And how did it hurt?
JERROD: I just got tunnel vision about changing it instead of seeing the big picture.
THERAPIS: t: Right, you had a narrow focus on the thing you didn’t like.
JERROD: Yeah, exactly.
THERAPIST: And what would’ve been a more helpful alternative thought?
JERROD: I could’ve thought “It’s too late now––it’s fine as it is and I can just turn
it in. No time for changes now.”
THERAPIST: Okay, so you might’ve thought that it was too late to change one
small detail.
JERROD: Yeah. I could’ve just turned it in and been done with it. I have other
things I have to get to as well.
THERAPIST: Okay, so this alternative might’ve made it so that you could be more
productive in your other responsibilities?
JERROD: Yes, exactly right.
THERAPIST: That sounds like a good alternative to me. It might’ve saved you a lot
of stress too, it seems like.
JERROD: Very true.
THERAPIST: And it could’ve helped you zoom out and see the big picture as you’re
wanting to work on?
JERROD: Yeah, I don’t want to get stuck on the minutiae all the time.
THERAPIST: I agree with that. Well, moving on to your behaviors––your first
behavior of going over your paper again and again––was that helpful or
hurtful in getting your paper in on time? (Query-9)
JERROD: It definitely hurt.
THERAPIST: So, it was hurtful? How?
JERROD: I started analyzing and overthinking everything. It just snowballed.
THERAPIST: OK, so you found yourself overthinking the task?
JERROD: Yeah.
THERAPIST: And if that was hurtful, what would’ve been a more helpful thing for
you to do?
JERROD: Not looking at it anymore––just turning the thing in.
THERAPIST: Right. So, just going ahead and turning it in?
JERROD: Right.
 The Middle Sessions 127

THERAPIST: How do you think that would’ve been more helpful?

JERROD: I wouldn’t have had a chance to second-guess myself if I’d just let it go. If
I turned it in, that would’ve been it.
THERAPIST: I see. And is that realistic for you to do?
JERROD: Yea, I think. I just need to remember not to stress about it.
THERAPIST: Great. Now, your second behavior of not turning in the paper. Was
that helpful or hurtful in getting it in on time?
JERROD: It was hurtful, obviously.
THERAPIST: Okay. What would have been a more helpful behavior? One that
might’ve been along the lines of “reasonably conscientious while maintaining
effectiveness”?
JERROD: (Pause) I should’ve reminded myself that I did my best and handed it in.
THERAPIST: Okay, so a reminder that you had done your best and committing to
handing it in?
JERROD: Yeah. That would’ve made it, so I didn’t second-guess myself or give me a
chance to overthink it. I could’ve just said “it’s done” and not looked back.
THERAPIST: Sounds like you’re saying that it would be good to trust yourself more
and give yourself fewer opportunities to over-analyze things.
JERROD: Yeah––that’s what gets me in a pickle.
THERAPIST: When you overthink things?
JERROD: Yes.
THERAPIST: When you start overthinking, what happens?
JERROD: I start feeling bad because I get stuck thinking about how things should
be. I feel like a failure.
THERAPIST: And that takes a toll on your mood, huh?
JERROD: (Pause) Yeah. Especially if I’ve worked hard on something, I feel bad
about messing up.
THERAPIST: That must be very frustrating.
JERROD: It really is.
THERAPIST: Your last behavior was that you went back to edit the paper. Did that
help or hurt in this situation?
JERROD: Obviously it hurt.
THERAPIST: I see––you wanted to get the paper in on time. What would have been
an alternative behavior that might have been more helpful?
JERROD: Like I said, just leave it the way it was and turn it in.
THERAPIST: OK, so just go ahead and turn it in as it was?
JERROD: Yeah.
THERAPIST: It seems like that might’ve made a big difference. As we discuss this
pattern of being overly conscientious to the point where it gets in the way of
your effectiveness, on a scale from 0–10, where 0 is not at all important and
128 The Middle Sessions

10 is the highest in terms of importance, how would you rate how important
it is for you to work on changing this pattern? (Query-10-1)
JERROD: About an 8.
THERAPIST: So, an 8 is very important.
JERROD: Yeah. It really gets in the way––I don’t want to change it completely
because it really does work for me sometimes.
THERAPIST: So, you’re saying you’d like to balance out some of its benefits while
maintaining effectiveness?
JERROD: Yes. I want to do good work without overdoing it.
THERAPIST: I see. Now, in terms of confidence, using that same scale, how con-
fident would you rate yourself on being able to become more “reasonably
conscientious while maintaining effectiveness”? (Query-10-2)
JERROD: (Pause) Probably a 6.
THERAPIST: A 6 is very good. You’re more than halfway there! What would need
to happen for you to get to a 7 or an 8?
JERROD: I think if I do it one time. If I just turn the thing in, or if I can
remember to not obsess over things. I’d feel more confident then.
THERAPIST: That makes sense. If you get some practice with it?
JERROD: Yes, that could definitely help.
THERAPIST: Excellent. You had some great ideas about how to come up with
helpful alternatives. How was that for you?
JERROD: It was fine. I felt like I was getting the idea and it can help me overcome
focusing too narrow. I could also see how it affects my mood.
THERAPIST: So, you got a lot of perspective from this. Lots of different ways to
think about it?
JERROD: Yeah, it was good to talk about it and I was able to think about how
much stress it causes.
THERAPIST: It sounds very stressful. I’m also glad you were able to see the links.
Would you be okay if we discussed some of the behavioral activation activ-
ities we can plan for this week?
JERROD: Yeah––let’s do it.
THERAPIST: Great. Any activities in particular that you have in mind for the week?
JERROD: I thought about some things but I’m not really sure. I don’t know what I
want to do.
THERAPIST: Well, what’s one of your ideas?
JERROD: Well, I was going to see a comedian this week with some of my friends,
but I don’t know if that could count because it’s more than 20 minutes.
THERAPIST: That can definitely count. It sounds like a great idea. Laughter can be
great for wellness. When were you thinking of going?
JERROD: On Saturday––I bought the tickets a while back.
 The Middle Sessions 129

THERAPIST: How about another idea?

JERROD: Maybe just going outside since the weather is changing and it’s been
nice lately.
THERAPIST: Okay. And doing what kind of stuff outside?
JERROD: Like just going for a walk.
THERAPIST: Is that something you think you could enjoy?
JERROD: For sure. I used to take my dog all the time. I’d walk for about 5 minutes
to the park and I like seeing the other dogs.
THERAPIST: You like dogs?
JERROD: Yeah, I really do. I want to get one when I finish school.
THERAPIST: So, you can take a walk to the dog park nearby for about 15–20 minutes?
JERROD: Yeah.
THERAPIST: And you’ll schedule that for what day this week?
JERROD: Wednesday after class could work.
THERAPIST: So, it sounds like you have a pretty good plan for this week. On
Wednesday, you’ll take a walk to the park nearby and see the dogs. Then on
Saturday, you’ll go out with your friends to the comedy show. Are you willing
to keep a log of these activities? Rate them from 0–10 in terms of com-
pleteness and how much pleasure you got from it?
JERROD: Yeah––I can definitely do that.
THERAPIST: Great. Well, before you go, would you mind filling out this form? I’d
like to see if you’re getting what you want out of our time together.
JERROD: Alright. Sure.
THERAPIST: You indicated that you were satisfied and that we talked about the
things you wanted to talk about.
JERROD: Yeah. I wanted to discuss my issues at school and we definitely accom-
plished that. I also feel better about it.
THERAPIST: I’m really happy to hear that, Jerrod. I look forward to our next meeting.

Commentary
Jerrod was quite responsive to the query sequence. His engagement is consistent
with his conscientious perfectionism and pleasing pattern. He was also able to gain
some insight into how his perfectionistic pattern affected not only his behaviors
but also his mood. He also began to understand that engaging in negative self-talk,
related to his perfectionistic standards, decreases his motivation and ability to
focus. The therapist reinforces how the query sequence can help Jerrod become
more aware and in control of his pattern. This is important because it not only
increases credibility in therapy but also provides him the sense of control he
wants. As a result, he can be more productive and effective.
130 The Middle Sessions

Session 3

Session Plan
The plan included taking the PHQ-9 and reviewing the Mood Rating Chart, the
ORS, the SRS, and the behavioral activation assignment. Then, a recent situation is
processed that presumably will assist in shifting Jerrod’s maladaptive pattern to a
more adaptive one. If another ultra-brief intervention is indicated, it is introduced.
Finally, additional behavioral activation activities and continued monitoring with the
mood chart are assigned. As with other middle sessions, this third session reviews
the PHQ-9 scores, the Mood Rating Chart log, the ORS, and the behavioral acti-
vation assignment log. The transcription starts with a troubling situation which
Jerrod wants to therapeutically process.

THERAPIST: Could you describe a recent situation that we can process together?
(Query-1)
JERROD: Yeah. One of my friends from the study group texted me and asked if I was
OK. That was nice, but I also felt embarrassed that I was so unproductive.
THERAPIST: So, you felt embarrassed that you didn’t go?
JERROD: Yes, I could really have used the help studying this week. We are cover-
ing some material that is very challenging. I should have gone. But I just
could not bring myself to get up and go, and I didn’t feel like I had the
energy to get ready and walk all the way over there. So, I just stayed home
and watched TV.
THERAPIST: So, it sounds like you typically enjoy going to the study group and you get
a lot out of it, but this week you were too tired to go and stayed home instead.
Then, you felt guilty because you weren’t as productive. Is that correct?
JERROD: Yes.
THERAPIST: What happened after that?
JERROD: That was it. I stayed home.
THERAPIST: Could this be related to the pattern we’ve talked about? Being per-
fectionistic and overly conscientious?
JERROD: It could be. I’ve been worried a lot that I’m not performing as I should. I
got really discouraged. And I felt hopeless––like either way I wasn’t going to
get what I wanted. What’s the point? You know?
THERAPIST: Ok. So, your first thought was, “What’s the point?” (Query-2)
JERROD: Yeah.
THERAPIST: I see. What’s another thought you had?
JERROD: I thought that my peers were going to know that I’m unprepared. I
thought I was wearing my lack of preparation and usually I’m ready and do
really well. They’d think “What’s wrong with him?”
 The Middle Sessions 131

THERAPIST: You were thinking that they would judge you for your lack of
preparation?
JERROD: Yeah.
THERAPIST: So, you were thinking “They’re totally going to know I’m unprepared
and they’re going to judge me for it.”
JERROD: Yeah. Exactly. I hate that feeling.
THERAPIST: Was there another thought?
JERROD: That I totally messed up. I got frustrated with myself.
THERAPIST: So, your thoughts were “What’s the point?,” “They’re going to judge
me because I’m unprepared,” and “I totally messed up.”
JERROD: Yes, that sums it up.
THERAPIST: I see. And what are some of the things you did? What were your
behaviors? (Query-3)
JERROD: Um, I didn’t get my work ready––it’s more about what I didn’t do.
THERAPIST: You didn’t get ready with your work.
JERROD: Yeah. I didn’t shower either. I didn’t get dressed.
THERAPIST: OK, so you didn’t get ready to go. Was there anything else?
JERROD: Yeah, I stayed in my sweatpants watching TV.
THERAPIST: So, essentially, you were tired, so you didn’t prepare, you didn’t get
ready to go, and you stayed home and watched TV.
JERROD: Yes, pretty terrible, huh?
THERAPIST: Well, I’m not sure yet. What did you want to get out of the situation?
(Query-4)
JERROD: I wanted to go. It would’ve made me feel better and I would’ve gotten a
lot out of it.
THERAPIST: So, you wanted to go and be a part of the study group.
JERROD: Right.
THERAPIST: That sounds very reasonable. It also could’ve made you feel better. I
agree with you there.
JERROD: Yeah. I wish I felt more motivated. I think it might’ve helped to actually
do something.
THERAPIST: OK, so what actually happened? (Query-5)
JERROD: Well, I didn’t go, like I said. I stayed in and watched TV. I didn’t even get
dressed and I felt super-guilty about it.
THERAPIST: You wanted to go to the study group but instead you stayed at home
and watched TV. That ended up making you feel guilty.
JERROD: Yeah. Exactly.
THERAPIST: So, did you get what you wanted? (Query-6)
JERROD: No, obviously not.
132 The Middle Sessions

THERAPIST: It also seems like this situation can be connected with your pattern.
You want to do something the right way and that interferes with doing it at
all. Does that sound accurate?
JERROD: Yeah. That’s what happens. I just put so much pressure on myself that it
makes it impossible to accomplish. It happens a lot.
THERAPIST: So that longing to do things perfectly––no mistakes––eventually just
overwhelms you and gets in the way of you doing the thing you wanted to do?
JERROD: Yes, exactly.
THERAPIST: OK, I see. Would you be willing to go over this situation and perhaps
see about other ways things might’ve turned out? (Query-7)
JERROD: Sounds good. We can go over it.
THERAPIST: Well, your initial thought was, “What’s the point?” Did that thought
help you or hurt you in getting your desired outcome––actually going to the
study group? (Query-8)
JERROD: It hurt me; I think.
THERAPIST: How did it hurt you?
JERROD: I felt discouraged afterwards. I was too focused on the wrong things.
THERAPIST: So, you felt discouraged because you were focused on the things you
had done wrong?
JERROD: Yeah.
THERAPIST: And in this instance, what might’ve been a more helpful thought?
JERROD: Uh, I could’ve thought that I could still get something out of the group
even if I’m not where I want to be with my work.
THERAPIST: Right, so you could’ve thought about still benefitting from the group.
JERROD: Yeah. I mean, that’s the whole reason to go to the group––to get you
prepared.
THERAPIST: It sounds like you didn’t have to be as prepared as you thought.
JERROD: No, not exactly.
THERAPIST: How would that new thought have been more helpful?
JERROD: It would’ve made it more likely for me to go to the group––to notice the
good parts and the reason for having group in the first place.
THERAPIST: So, you would’ve focused on the help that you would’ve gotten from
the group?
JERROD: Yes, that would’ve been better.
THERAPIST: Great. Your second thought was people would judge you in the group,
knowing that you were unprepared. Did that hurt you or help you?
JERROD: The thought definitely hurt.
THERAPIST: OK, I see. How did it hurt?
JERROD: I was focusing on all the wrong things, just like with the other thought. I
didn’t think about anything that I did right.
 The Middle Sessions 133

THERAPIST: Just like the first thought, huh?

JERROD: Yeah.
THERAPIST: And what is an alternative thought that might have been more helpful?
JERROD: I might’ve thought that my peers were also not as prepared. I’m usually
more prepared than them, so I’d probably be ahead either way.
THERAPIST: Do you think you gave yourself enough credit then?
JERROD: No. Definitely not. I should definitely do that more. I also shouldn’t
compare myself.
THERAPIST: So, if you didn’t compare yourself and had focused on the fact that
you’re typically more prepared, how would that have helped you actually go
to the group?
JERROD: I wouldn’t have felt so overwhelmed. I’d feel more reassured that I’m
doing well.
THERAPIST: So, it would’ve been more reassuring. That makes sense. It sounds like
it would also have been more accurate.
JERROD: Yeah. I really don’t give myself enough credit.
THERAPIST: And your third thought was about messing up––“I really messed up.”
Did that help you or hurt you in getting to the study group?
JERROD: It hurt.
THERAPIST: How did that thought hurt?
JERROD: Well, it was hard to be motivated because I was beating myself up.
THERAPIST: Okay, so beating yourself up makes it hard to be motivated and do things.
JERROD: Yeah. Exactly. I really don’t even notice when it happens, either.
THERAPIST: Makes sense. This is why processing it in this way can help. Sometimes
we don’t notice our patterns.
JERROD: I can see that.
THERAPIST: What might’ve been an alternative, more helpful, thought?
JERROD: Not focusing on what I did wrong. If I’d thought about doing reasonably
well––I might’ve gone to the group and been more prepared.
THERAPIST: So, to focus on the things that you did well?
JERROD: Yeah.
THERAPIST: How would that have been more helpful?
JERROD: I wouldn’t have been in my head so much. I could have focused on what I
wanted.
THERAPIST: That makes sense. Now, on to your behaviors––your first behavior was
that you didn’t prepare for the work. Was that hurtful or helpful in making
it to the study group? (Query-9)
JERROD: Hurtful.
THERAPIST: How would you say that it was hurtful?
JERROD: I felt sluggish because I started falling behind.
134 The Middle Sessions

THERAPIST: So, you felt sluggish?

JERROD: Yeah.
THERAPIST: And what might’ve been a more helpful behavior?
JERROD: To just grab what I had or prepared to go in advance.
THERAPIST: So, you would have gotten your work together either way?
JERROD: Yes.
THERAPIST: In what way would that have been more helpful?
JERROD: I could have felt more prepared doing that. That would have been one
thing that I did and recognized, instead of falling back into all-or-nothing.
THERAPIST: And it would have helped you go to have felt more prepared?
JERROD: Yeah, like I was already some of the way there.
THERAPIST: Does that sound like your pattern again?
JERROD: Yes. I don’t do things at all if they don’t turn out how I want them to be.
I have to learn to just do my best.
THERAPIST: It sounds like you’re making the connection between your very high
standards and not completing the things you set out to do.
JERROD: Yes, I am getting to see that.
THERAPIST: That’s good insight. Your second behavior was that you didn’t get
ready or dressed. Did that help or hurt in getting your desired outcome?
JERROD: It definitely hurt me because I just felt more tired and lazy.
THERAPIST: So, you felt more tired. It sounds like this also affected your mood and
motivation. Did you feel those things diminish?
JERROD: (Pause) Kind of. I felt kind of defeated. I can see how it’s connected.
THERAPIST: Right. And what might’ve been more helpful for you to do?
JERROD: Maybe picking an outfit I wanted to wear, or just getting ready.
THERAPIST: That sounds good. How would choosing an outfit you wanted to wear
have helped you?
JERROD: I would’ve just felt more ready and actually looking forward to going out.
THERAPIST: So, it might’ve helped in terms of anticipation––actually looking for-
ward to it?
JERROD: Yeah.
THERAPIST: Your third behavior was that you stayed in watching TV. Did that help
or hurt you get what you wanted?
JERROD: It hurt too.
THERAPIST: How did it hurt?
JERROD: I’d given up on going to the group, so I thought I’d just watch TV and
rest, but it backfired. I felt more tired after.
THERAPIST: So, you ended up feeling more tired?
JERROD: Yeah.
THERAPIST: And what might’ve been a more helpful behavior?
 The Middle Sessions 135

JERROD: Maybe just going for a walk or something.

THERAPIST: So, moving around and staying active?
JERROD: Yes.
THERAPIST: I agree with you there. These alternatives are excellent. Do you find
these to be realistic––do you see yourself implementing these?
JERROD: Yes. I do. (Pause) They could’ve definitely turned things around.
THERAPIST: Alright. It also sounds like you’re realizing how much of an effect
these things can have instead of the all-or-nothing rule you used to uphold.
Is that correct?
JERROD: Yeah. I just want to take some small steps. Even if I stayed a bit active. I
think that would be helpful.
THERAPIST: I appreciate you processing this situation with me.
JERROD: Yeah, of course, thank you.

Commentary
The behaviors Jerrod reported during the Query Sequence were all passive
and involved his withdrawing from the situation. These are consistent with a
mild to moderate level of depression, particularly his symptoms of lack of
motivation and social isolation. It is expected that if he can use and inter-
nalize the replacement behaviors that he generated, his future PHQ-9, Mood
Scale ratings, and ORS will reflect this change. Jerrod also gained insight into
how his self-imposed pressure affects him. It reflects his obsessive-compulsive
pattern in which he both moves against others as well as “against himself” by
being self-critical and overly demanding. Toward the end of Query-9, Jerrod
begins to make a case for why he should become more active as well as why
he does not need to strive for perfection. His response indicates a decrease in
symptoms across the duration of the session, indicated by increased motiva-
tion and the beginning of a shift toward a more adaptive pattern.

THERAPIST: Now since we have been talking about this pattern of keeping yourself
from effectively completing your tasks because you are focused on not
making mistakes, on a scale from 0–10, where 0 is not at all and 10 is the
most, how important is it for you to change this pattern? (Query-10-1)
JERROD: I’d say an 8.
THERAPIST: OK, so it’s quite important?
JERROD: Yes, especially now that I see how it holds me back from doing what
I want.
THERAPIST: Good. Now on the same 0–10 scale, how confident would you say you
are that you can change your conscientious perfectionism and pleasing pat-
tern to a more adaptive one? (Query-Pattern & Query-10-2)
136 The Middle Sessions

JERROD: Um, maybe a 6. It can be very hard and I’m not very confident in making
change.
THERAPIST: That is understandable. It can be difficult to change after doing
something for a while. But it is very possible. What do you think it would
take to move that to a 7?
JERROD: I think if I’m able to reassure myself that I’m doing well. Focus on the
positive stuff like we talked about when that comes up again.
THERAPIST: Ok, so practicing some of the thoughts and behaviors we went over
here today?
JERROD: Yes, I think that will be helpful.

Commentary
Jerrod indicates that he is motivated but hesitant to change his pattern. He
reports, however, that he is not very confident he can do it. The therapist is
nonjudgmental and helps Jerrod figure out strategies that can improve his
confidence. Had the therapist taken a more forceful approach here, it might
have triggered Jerrod’s maladaptive pattern. Jerrod’s importance rating was
10 in the first session, compared to 7 now. This probably reflects Jerrod’s
people-pleasing pattern. His ability to report the lower score in this session
indicates the increasing therapeutic alliance, that is, he feels sufficiently
accepted that he can risk not pleasing his therapist by giving an overly high
rating.

THERAPIST: OK, now if you can just fill out the SRS form.
JERROD: OK. (Pause while Jerrod completes the SRS)
THERAPIST: It looks like you were satisfied with our session and that we covered
what you wanted to talk about.
JERROD: Yes, I think it’s going well. I feel a bit better now than when I came in today.
THERAPIST: Glad to hear that and I look forward to hearing about your progress
next time we meet.

Commentary
Jerrod continued to be quite engaged in the Query Sequence and most agreeable
to using the agreed-upon behavioral activation activities. His active role in
understanding the value of behavioral activation and planning activities is reflected
in the symptom improvement that occurred during this session. It is also con-
sistent with his need to please authority figures. Jerrod’s SRS score both reflects
his pattern and confirms his improvement over the session, as he states that he
feels better than when the session began.
 The Middle Sessions 137

Session 4

Session Plan
The plan included taking the PHQ-9 and reviewing the Mood Rating Chart, the
ORS, and the behavioral activation assignment. Then, a recent situation is processed
in terms of Jerrod’s maladaptive pattern. If another ultra-brief intervention is indi-
cated, it is introduced. Finally, additional behavioral activation activities and continued
monitoring with the mood chart are assigned.
The result of the PHQ-9 taken just prior to this session is 6, which is at the
lower end of the mild depression range. Likewise, his ORS score also improved.
Prior to this session, Jerrod reported that he had been able to come up with
alternative thoughts and behaviors. Select sections from this transcription are
presented here.

THERAPIST: Okay. Can we move on to reviewing today’s ORS form?

JERROD: Sure. Let’s do it.
THERAPIST: Your individual functioning rating, here––can you tell me more?
JERROD: Well, yeah––I felt frustrated a lot, but I felt like I did better managing it.
I think it was pretty good.
THERAPIST: So, there were some instances that you felt frustrated. I’m glad to hear
that you managed well. What were some things that helped you manage?
JERROD: Uh, exactly what we had talked about. “What’s happening right now?”
And then noticing that whatever was going on was not the end of the world.
I was able to just chop things down into small tasks and get things done. I
didn’t feel as overwhelmed.
THERAPIST: So, it sounds like you were able to identify and resolve some of that
perfectionistic pattern. When self-criticism surfaced, you helped yourself by
chopping things down and coming up with alternatives?
JERROD: Yes, I felt really good about doing it on my own.

Commentary
Jerrod reports that between sessions he was able to catch himself thinking and
behaving in ways consistent with his maladaptive pattern. Subsequently he successfully
applied alternative thoughts and behaviors on his own. This behavior indicates that
Jerrod engaged in third-order change. This suggests that he can continue to respond
—on his own—in adaptive ways when he has completed therapy. The therapist tied
Jerrod’s behavior back to his pattern. This exchange was validating for Jerrod and
likely increased his level of confidence that he could and would change his maladaptive
pattern.JERROD: Even though things went well at the show, I had a run in with my
138 The Middle Sessions

parents. I forgot to call them, and they were annoyed —so that brought my
rating down a bit. It was the same day of the show. I called them the next
day and they were upset because they had waited for me.
THERAPIST: And how did things end? Was it resolved?
JERROD: I wouldn’t say it was resolved, really. We just talked about other stuff and
they didn’t mention it.
THERAPIST: So, there was some tension with your parents that went unaddressed.
You’ve moved past it?
JERROD: Yeah. I think things are okay. I don’t think they’re going to bring it up
unless it happens again.
THERAPIST: On the mood scale, how would you rate yourself?
JERROD: About a 7, I was stressed about the group project but now I’m doing better.

Commentary
Although Jerrod briefly mentioned the incident involving his parents, the therapist
decided not to pursue it at this time. Even though his family did influence his mala-
daptive pattern, this particular situation with his parents did not trigger Jerrod’s
pattern. Jerrod’s ability to manage this stressful interaction with his parents reflects
his move toward a more adaptive pattern. If Jerrod had been more distressed about
the interaction, or if he were to bring it up again in future sessions, the therapist
might consider processing it. Otherwise, it might be an unnecessary distraction from
the course of therapy. Instead, Jerrod wanted to process a situation with a group
project that was significantly distressing for him.
He reports being a part of a group project with three other students. He ended up
doing most of the work because of lack of faith in the other students. The result was
that this left no time for any relaxation or enjoyable activities. As a result, he was very
stressed. His maladaptive thoughts were: “these students don’t know what they’re
doing,” and “if you want something done right, you have to do it yourself.” His
maladaptive behaviors were to complete portions of other group’s members assign-
ment without consulting with others and working instead of doing leisurely activities
planned. His desired outcome was to “complete my work and save time to relax and
have fun.” The query sequence was employed to process this situation. Up to this
point it included Query-1 to Query-8. The transcript picks up at this point.

THERAPIST: Okay, great. Now, on to your behaviors; your first behavior was that
you took on the part that belonged to the other student. Was that helpful or
hurtful? (Query-9)
JERROD: Um, it was hurtful. I focused on it the whole time and didn’t get to relax.
I was very focused on the details.
 The Middle Sessions 139

THERAPIST: I see. Do you see how that’s related to your patterns again? The
narrow focus?
JERROD: Yes, it crops up when I have to depend on others. Especially in terms of
competence.
THERAPIST: And you find yourself being critical sometimes because of this pattern?
JERROD: Yeah. That happens sometimes.
THERAPIST: And where do things go from there? When you’re critical of others?
JERROD: I focus even more on details and it makes me annoyed and frustrated. It’s
a cycle.
THERAPIST: So, the pattern feeds into itself, then?
JERROD: Yeah. Exactly.
THERAPIST: Right. What would’ve been a more helpful behavior in this instance?
JERROD: I should’ve just done my own part and let the rest of the group worry
about their parts. I would’ve respected my own time and been able to relax if
I’d done that.
THERAPIST: So, working on your parts and leaving the rest for the group might’ve
been respectful of your schedule and time?
JERROD: Right. I undervalue my time sometimes. This process has helped me
reprioritize.
THERAPIST: Okay. So, you’re noticing that you can prioritize your time so that you
take care of yourself and are respectful of yourself, and that in turn will help
you. Good.
JERROD: Yeah. Thanks.

Commentary
While analyzing his behaviors during the Query Sequence, Jerrod connected his
perfectionistic pattern to his tendency to criticize others and recognized the self-
perpetuating nature of his pattern. This is a major indicator of change for Jerrod.
His shift toward a more adaptive pattern helped Jerrod become more aware of
how his maladaptive pattern affected his relationships and increased his motivation
to change this pattern so he could foster better relationships. Finally, Jerrod
recognized some triggers of his pattern and demonstrated the ability to overcome
such triggers without the assistance of the therapist. This, of course, is reflective
of third-order change and will be useful in future relapse prevention planning
which is covered in considerable detail in Chapter 8.

Conclusion
This chapter reviewed the middle sessions of the case of Jerrod. Specifically, it
reviewed sessions 2, 3, and 4 of this successful therapy. Specific selections from
140 The Middle Sessions

transcriptions of these three sessions were analyzed. Behavioral activation is the ultra-
brief intervention that was introduced in the first session. It became a key interven-
tion throughout these middle sessions in targeting Jerrod’s presenting problem of low
mood and loss of interest and pleasure. The Query Sequence was introduced in the
second session with the goal of shifting the client from his maladaptive pattern to a
more adaptive one. As the main therapeutic strategy in Pattern Focused Therapy, the
Query Sequence effected significant change. Not surprisingly, as therapy proceeded,
Jerrod becomes aware that his maladaptive pattern actually engenders his depressive
symptoms. Also noteworthy in these sessions was the value of continuous monitoring
with the PHQ-9, the Mood Rating Scale, the Outcomes Rating Scale, and the Session
Rating Scale in order to more effectively tailor the treatment process. In addition,
Jerrod began demonstrating some third-order change, ensuring that treatment gains
will persist after therapy is complete. In Chapter 8 on the final sessions, third-order
change is further emphasized.
Chapter 8

The Final Sessions

Recall that Jerrod opted for psychotherapy because he did not want to take
medication when it was first proposed by his physician to treat his depression.
In their first meeting, both client and therapist agreed to begin therapy and
later, if indicated, to arrange for medication to be combined with therapy.
Because of Jerrod’s early responsiveness to therapy in the first two sessions,
combined treatment with medication was not needed. This progress continued
in subsequent sessions. This chapter presents the termination phase of effective
Pattern Focused Therapy. These two final sessions focus on critical components
of this therapeutic approach (Sperry & Sperry, 2018). In sessions 5 and 6,
treatment shifts to final assessment and life after therapy. This chapter presents
five guidelines for successful termination, and describes two components: relapse
prevention planning and review of progress.
We return again to the case of Jerrod to illustrate how the process of Pattern
Focused Therapy unfolds over the course of six sessions. As previously noted,
there was a provision for additional sessions if indicated. As it turned out, no
additional sessions were needed. Let’s briefly review this six-session course of
treatment. The first session set the initial phase for the use of Pattern Focused
Therapy. Sessions 2–4 represent the middle phase of treatment. Finally, the ter-
mination phase consists of sessions 5 and 6.

Termination
Concluding therapy with a client is an essential skill of Pattern Focused Therapy
(Sperry & Binensztok, 2019a). This concluding process is commonly known as ter-
mination, and it is a process in which the relationship between client and therapist
changes and the client takes on more responsibility for maintaining treatment gains.
The reactions that clients have during the process of termination largely pivot on their
specific patterns. Not surprisingly, difficulties and challenges in the termination
142 The Final Sessions

process can usually be anticipated based on the client’s personality dynamics and pat-
tern, as reflected in the case conceptualization (Sperry & Carlson, 2014).

Preparing for Termination

Although preparation for termination is indicated toward the final phase of
therapy, some cognitive-behavioral therapy (CBT) approaches consider it
important to address the task much earlier (Beck & Beck, 1995). As previously
noted, the treatment formulation section of a case conceptualization functions
as a guide for specifying treatment interventions and anticipating obstacles in
the therapy. It can also assist the therapist in anticipating specific difficulties that
the client may have with termination. Therefore, it will be no surprise to a
therapist when a particular client with a history of losses or a pattern of
dependent clinging experiences difficulty or begins to act out when approaching
termination (Cucciare & O’Donohue, 2008).

Indicators of Readiness for Termination

The criteria for determining when termination is indicated are theory-specific. On
the other hand, there are general indicators that are common to various approa-
ches. Useful indicators that the client is ready to terminate from treatment
include: (1) the client’s presentation is resolved and/or symptoms are diminished
or relieved; (2) the client has gained insight to sufficiently comprehend both the
problem and the patterns that led to the problem and treatment; (3) the client’s
skills for effectively coping and dealing with life circumstances are sufficient; (4)
the client demonstrates increased capacity for planning and working productively
(Heaton, 1998); and (5) and proactive client efforts. This is called self-therapy in
CBT. The main premise is that clients begin to practice independently to be their
own therapist as problems arise between sessions. This, of course, is third-order
change and prepares clients to address difficulties, setbacks, or relapse following
termination (Beck & Beck, 1995).

The Five Tasks in Effective Terminations

Five main tasks comprise an effective termination: (1) discussing the client’s
thoughts and feelings related to the termination; (2) discussing goals that have
been attained and progress achieved; (3) addressing relapse prevention and for-
mulating a plan; (4) acknowledging client growth and how to maintain it; and (5)
discussing contingencies for future contact, should future sessions prove necessary
(Sperry, 2010; Sperry & Binensztok, 2019a).
 The Final Sessions 143

1. Discussing Termination
In Pattern Focused Therapy, the termination process typically begins in the second
last session. In reviewing therapeutic progress and the therapeutic relationship, it
is essential that the therapist elicits negative as well as positive feedback from the
client. These responses can vary in form and complexity. Clients can respond with
pride as well as apprehension. For instance, they may feel satisfied with their
therapeutic gains while apprehensive about their capacity to sustain growth or
maintain achieved levels of functioning.

2. Review of Progress and Goals

While reviewing progress and goals, the therapist aids the client in examining past
achievements by listing gains within the treatment and comparing them to the goals
that the client and therapist mutually agreed upon. One by one, first- and second-
order goals are addressed. The therapist can use scaling questions (e.g., 1–10 scale)
to prompt the client to assess the extent to which they think they have accom-
plished the set goals. The client can be encouraged to continue to strive to reach
even the goals that were partially accomplished within the therapy. Thereafter, the
clinician can prompt the client to materialize some new goals for them to pursue on
their own (Sperry, 2010).

3. Relapse Prevention Plan

The purpose of a relapse prevention plan is to aid the client in anticipating and
reducing the probability of a return to maladaptive behaviors once treatment has
ended. Relational skills, coping skills, and self-efficacy can be improved by this task
(Marlatt & Gordon, 1985). Planning for relapse prevention starts by identifying
potential triggers of symptoms and behaviors through a collaborative process
(Marlatt & Gordon, 1985). Triggers may occur in intrapersonal, interpersonal,
physical, or contextual environments (i.e., the client’s immediate surroundings). The
acronym HALT (Hungry, Angry, Lonely, Tired) originated in the 12-Steps tradition,
and it can be useful for recognizing triggers. Strategies for avoiding, or coping with,
each potential trigger must be discussed in advance, as many individuals will find
one or more of these to emerge as a stressor (Sperry & Binensztok, 2019b).
Beyond trigger identification, the therapist must help the client identify warn-
ing signs of the return of previous symptoms. Additionally, it is important to
provide tools for the client to anticipate when maladaptive behaviors await on the
horizon. Specific strategies must be acknowledged. Encouragement is also pro-
vided for the client to maintain lifestyle changes, such as exercise and nutrition,
that can help preserve treatment gains and avert relapse (Sperry, 2010).
144 The Final Sessions

4. Maintaining Treatment Gains

Therapy progress almost always consists of a combination of shifting to a more adaptive
pattern, reducing symptoms, achieving more positive thinking, feeling better, and
relating more effectively. However, there are no guarantees that achieved progress will
be sustained in the long term. Regressions often occur in treatment. The client is
challenged with applying the learned skills independently, staying the course, and con-
tinuing to practice them. These efforts are invaluable for sustaining therapeutic change.
Although relapse prevention are skills that are often discussed––and adequately so––in
the beginning and middle of the therapy process, so too are they important to buttress
in the end, while preparing the client for termination. In particular, CBT has been
effective in achieving lasting changes when clients have formulated a plan for maintain-
ing their change through relapse prevention and when they have been motivated to
sustain their growth. Given these factors, treatment effects have been likely to be
maintained or even increased (Gloaguen, Cottraus, Cucharet, & Blackburn, 1998).
Sometimes, clients may want to extend personal growth beyond their original
treatment goals. In these cases, the therapist does well to aid the client in setting new
goals and planning for avenues through which to pursue them. This can include
referrals to a support group or another therapist with a particular expertise. Or, it
may include supporting clients in their own third-order change efforts.

5. Provisions for Future Sessions

Therapist should also discuss the possibility of scheduled future sessions, even if they
are spaced at three- or six-month intervals. There are cases for which follow-on ses-
sions are not necessary. In these cases, the therapist can collaboratively assess with the
client if a follow-up session is needed. The therapist can also inform the client that
returning or calling to set future appointments is welcome (Sperry, 2010).

Session 5

Session Plan
Jerrod’s assessments (PHQ-9, ORS) continue to show increasing improvement. In
the current session, the therapist and Jerrod discuss drafting a relapse prevention
plan in order to prepare Jerrod to terminate therapy. Triggers for both maladap-
tive pattern and depression are identified for Jerrod. He also notes warning signs
indicating a return of his depression and maladaptive pattern, as well as a plan to
address them. Finally, the therapist assesses Jerrod’s motivation to follow through
with the said plan to prevent relapse. Some sections from the transcript of the
session are offered below.
 The Final Sessions 145

THERAPIST: Can you tell me how you would assess your overall functioning right now?
JERROD: I think I’m doing pretty well. Much better than at the start, that’s for
sure. I feel a sense of relief and my mood has changed.
THERAPIST: Your PHQ-9 score is down to 4 which is at the top of the minimal
depression range. (Pause) It’s so good to hear that you have noticed a favor-
able difference in your mood, and you feel relieved; much different from
when you first came in to see me.
JERROD: Yes. A big difference. I was worried that I was going to be depressed
forever.
THERAPIST: And how would you rate yourself interpersonally?
JERROD: Much better as well. I’m getting out and hanging out with friends. My
parents aren’t nagging me as much and our relationship has gotten better
also. Things are going well in that area overall.

Commentary
In this brief discussion, Jerrod mentions his parents for the first time. He repor-
ted an overall improvement in his mood as well as his relationship with his par-
ents. The mitigating factor for his relationship with his parents has been his
increased sense of belonging and social interest.

JERROD: Well, I’m not as irritated anymore, which I took for granted before. I
never really thought about how much control I had over things that bothered
me. My overall rating is good.
THERAPIST: I see. You’ve noticed that you have more control than you had antici-
pated over your mood and how you react to the people you find irritating. It
also seems like you have more control over your pattern.
JERROD: Yes. People don’t really consider how much they can change or how
much responsibility they can take for their lives. I always thought that taking
responsibility for my work was enough, but I’ve learned it’s not. I have to
keep an eye on my mood, so I don’t fall back into my old ways.

Commentary
Jerrod touches on some components that can be helpful for formulating his relapse
prevention plan. He discloses a more sophisticated understanding about his triggers and
pattern. His conscientiousness, which is part of his pattern, increases the likelihood that
he will follow through with alternative behaviors and thoughts of his adaptive pattern,
as he aspires to have increased control over his environment. Therefore, he can exercise
productive and workable control over his responses to relapse triggers and signs. Jerrod’s
outcome measures should reflect a result of this pattern change.
146 The Final Sessions

THERAPIST: That’s very good and important. (Pause) Now that we have reviewed
some of your progress and noticed your significant changes in pattern and
daily functioning, I’d like us to come up with a plan to maintain this progress.
This process is called relapse prevention.
JERROD: OK, sure. I definitely don’t want to relapse.
THERAPIST: OK, great. The first part of the plan is identifying some triggers. This
could be a situation that you find particularly stressful. It could be a place,
person, or event. Can you think of anything that could trigger your mood?
JERROD: Yes. Well, typically I start to get down on myself, being self-critical, or
I’ll focus too much on something that should’ve happened, or I should’ve
done differently
THERAPIST: OK, so self-criticism triggers a low mood. Can you think of any other
triggers?
JERROD: Yes, isolating is terrible for my mood. When I feel depressed, I try to
stay away from others but it’s really the worst thing I can do.
THERAPIST: I agree. (Pause) So moving away from others can be a trigger for low
moods. What about factors or events that can trigger low motivation?
JERROD: Um, mostly when the perfectionism kicks in. Things seem unsurmoun-
table. I start obsessing over little things and then things that I have no con-
trol over when it’s not that big of a deal. Then, I don’t get much done even if
I spend a whole lot of time at it.
THERAPIST: OK, when your pattern of conscientious perfectionism and pleasing
emerges, you feel overwhelmed. Then, focusing on the small details tires you
out and you’re not as effective at accomplishing your goals, which leads to
low motivation and discouragement. Is that accurate?
JERROD: Yes. That’s what right.
THERAPIST: So, what are some things that trigger that pattern of perfectionism and
makes you want to focus on the small details?
JERROD: Well, being evaluated is always stressful for me. If I know I have a big paper
coming up for class or a project that makes up a large percentage of my grade, I
start obsessing over little things. I also struggle with working with other people
because it’s irritating. But I’ve learn how to deal with that in here.
THERAPIST: Good. It seems like evaluation and collaboration with others seem to
trigger the perfectionistic pattern. Is that correct?
JERROD: Yes.
THERAPIST: OK. The next step in our relapse prevention plan is to identify some
early warning signs. What are some indications that you’re beginning to feel a
low mood or depression?
JERROD: Um, I feel apathy or irritability. I feel like I just want to drop everything
because everything gets on my nerves. I just want everyone to leave me alone.
 The Final Sessions 147

THERAPIST: You start to notice feelings of apathy and irritation caused by most things.
JERROD: Yeah.
THERAPIST: And what are some early signs that your pattern is resurfacing?
JERROD: Oh, that’s a hard one. I really start feeling frustrated or annoyed. I guess
when I’m more sensitive to it because I notice it happening with smaller things.
THERAPIST: You notice that there’s a decrease in your irritability threshold––how
much you can take before something makes you irritable––that’s when you’re
noticing your pattern come up?
JERROD: Yes, that sounds right.
THERAPIST: There is an acronym that’s called HALT, which can help us understand
our triggers. It stands for Hungry, Angry, Lonely, and Tired, which are
common triggers. Have you noticed if any of those have ever triggered your
maladaptive pattern?
JERROD: Huh––yes, actually. Interesting. Feeling tired, lonely, or angry have defi-
nitely triggered my pattern. My depression is triggered by loneliness. And I
think my pattern comes out when I’m angry or tired.
THERAPIST: It sounds like you can see how those clearly affect you now––I’m glad you
were able to identify those. Now that we’ve identified triggers and warning signs,
what are some strategies that you can use to prevent things from escalating?
JERROD: (Pause) Well, I’ve been using the Query Sequence between sessions and it
seems to work.
THERAPIST: You’re finding the Query Sequence works between sessions. Great!
(Pause) So you’re replacing maladaptive thoughts and behaviors with more
adaptive ones?
JERROD: Yes. I come up with alternative thoughts and behaviors. Especially with
the thoughts. It has really helped me.
THERAPIST: That’s wonderful! Our goal here is to help you become your own
therapist, and that’s what you’re doing!
JERROD: Yes, it has changed the way I deal with a lot of things. I can also use
affirmations, which is quick and easy.
THERAPIST: Great. Affirmations can be helpful. Can you think of anything else?
JERROD: It has been really helpful for me to exercise. It keeps my mood up. Also
spending time with my friends makes me feel a lot better overall. I like being
out and spending time with people.
THERAPIST: It sounds like this plan could be really helpful. And the more specific,
the better. If you feel something is triggering your mood, is there something
that you can do there and then?
JERROD: Um, I guess reach out to a friend or my mom.
THERAPIST: That’s a really good idea. Do you have someone in mind who you
would reach out to?
148 The Final Sessions

JERROD: My friend Jeff, probably. Or Steve. They’re both very reliable people.
THERAPIST: OK, so you would reach out to Steve or Jeff if you noticed some
warning signs?
JERROD: Yeah.
THERAPIST: What about if you feel that your maladaptive pattern is starting up?
JERROD: I can do some of the things we talked about––exercise or come up with
alternatives. It’s kind of like––I’ve been down that road, you know?
THERAPIST: I do, and it sounds like a great plan. It seems that both exercise and
spending time with friends have been very impactful in your life, and they’ve
helped to reduce your pattern of perfectionism.
JERROD: Yes, it’s been really good.
THERAPIST: On a scale from 0–10, how important is it for you to follow through
with this plan and maintain your progress? (Query-10-1)
JERROD: It’s a 10 for sure. The work we’ve done together has changed my life, so I
want to keep it up.
THERAPIST: OK. Good. You’ve put a lot of effort into this. Now, on the same scale,
what is your level of confidence that you can implement the plan? (Query-10-2)
JERROD: Probably around an 8. I feel confident, but I know that life can still get in
the way. Things tend to get hectic throughout the semester.
THERAPIST: OK, good. How do you think you could get that to 9 or a 10?
JERROD: I think my confidence will grow as I practice it and see that I can do it by
myself. In a couple of weeks––if I’m able to keep it up even when I’m
busy––I’ll feel much more confident about it, especially knowing how it’ll
affect me.
THERAPIST: That’s very good insight.
JERROD: I feel very hopeful about it.
THERAPIST: Great. You know, I’m happy for you (Pause) It sounds as if you can show
yourself that you can maintain the lessons learned, your confidence will go up
about your capacity to sustain these changes for the long term. Is that right?
JERROD: Yes. That’s right.

Commentary
Jerrod was collaboratively involved in creating his relapse prevention plan. He was
agreeable to the process and identified triggers for his decreased motivation,
mood, and surfacing pattern. He also identified early warning signs of his emer-
ging pattern and depressive symptoms. Additionally, strategies to cope with
warning signs and triggers were identified. The therapist made sure to prompt
Jerrod for specific strategies that he could use, rather than general or vague
approaches. Having a specific and carefully defined plan will increase the likelihood
of follow through and can result in his sustaining his gains in treatment.
 The Final Sessions 149

Session 6

Session Plan
This is the final scheduled therapy session. Jerrod’s improvement is reflected by
positive ratings in PHQ-9, the ORS, and the Mood Rating Scale scores. The aim of
this session is to review goals and establish a concrete plan for relapse prevention.
Goals are reviewed and assessed using scaling questions (i.e., 0–10). The therapist
also helps Jerrod come up with new goals for future growth as well as reflecting on
past goals achieved. Prior to the beginning of this session his PHQ- 9 score was 2
which is in the middle of minimal depression range, which, for all practical pur-
poses, is where most individuals score who do not consider themselves to be
depressed. Segments from the transcript of the session are presented here.

THERAPIST: As we wind down our work together, I’d like to review the goals we
set at the start of your treatment. Can we spend a few minutes on that?
JERROD: Sure. That’s fine.
THERAPIST: OK, good. One of your main goals was to improve your mood. On a scale
from 0–10, how would you rate the extent to which you’ve attained this goal?
JERROD: I’d say 9. I feel a lot better and I’m relieved. I felt terrible for so long and
now I can really tell there’s a big difference.
THERAPIST: Can you share more about that?
JERROD: Yeah. I used to wake up feeling like things were so depressing––this
feeling of doom, like the day wasn’t going to get any better. I was just riding
waves of irritability. Just dragging along––you know? I feel much better now.
Like a new person, actually.
THERAPIST: It’s good to hear that. I’m happy that you were able to experience this
lift in your mood and feel better now. The next goal on our list was to
increase your motivation. To what extent do you feel you reached that goal,
from 0–10?
JERROD: I think around a 9 also. My motivation has stayed pretty high lately. Things
spiral from doing one thing to doing the next and I feel like I’m in a groove. I
can handle things better and enjoy going out, which before felt like a chore.
THERAPIST: So overall things seem to be going well––you’re more motivated and
enjoying yourself. Your third goal was to participate in more activities and
events. How would you rate yourself on achieving that goal?
JERROD: Probably 8. I’m really busy so I can’t always enjoy myself. But before I felt
so low that I barely went out, and even when I did go out, I didn’t have fun.
I’m enjoying myself much more now and have been in the past few weeks. I
wasn’t getting any kind of relaxation or stress relief before I came to see you.
THERAPIST: Because you weren’t enjoying the things you were doing?
150 The Final Sessions

JERROD: Yeah, exactly. I feel relief that I was able to accomplish this because that’s
important to me.
THERAPIST: So you’re enjoying yourself and are able to relax now. (Pause) Can you
tell me about the goal of changing your pattern? Going from perfectionistic
and overly focused on details to being able to let things be? On a scale from
0–10, how much have you achieved that?
JERROD: I’d say 8. I’ve definitely calmed down a lot and can let things go when
they’re not perfect. Instead, I’m focusing on the big picture. Before I was
easily side-tracked by small details but now, I’m more able to let it go.
THERAPIST: I’m very happy to hear that. You’ve put a lot of work into making
these changes for yourself and it sounds like you’re reaping the benefits.

Commentary
Jerrod gave consistently high ratings for his goal achievements. These ratings are
reflective of his shift to a more adaptive pattern. Had Jerrod not shifted to a more
adaptive and reasonably conscientious pattern, his ratings would have been lower
due to harsh self-criticism. Still, it is likely that his ratings are lower than 10,
given his attention to detail and ongoing stress from course work, which is normal
and understandable.

JERROD: Thank you. I’m definitely less perfectionistic now. I wouldn’t even con-
sider some of these things before. I’m realizing that perfection is actually not
achievable, and I have gotten myself upset in the past for nothing. Learning
that has probably been the most impactful. I also benefitted a lot from
behavioral activation. I feel very accomplished that I can maintain my moods
and little things don’t ruin my week.
THERAPIST: OK, so you’ve been using the Query Sequence and behavioral activation
and you’ve found that you can very nicely control your moods. That’s great!
JERROD: Yes, exactly. Before I came here, I’d wake up thinking “Well, I’m just
going to have a terrible day.” I’d just be annoyed and irritated because I didn’t
think I could turn things around. Instead, practicing the techniques, I’ve
learned that I can actually change my mood.
THERAPIST: So, you’ve noticed that through some effort on your part, you can
change both your thinking and your moods. And also, some setbacks don’t
cause you to give up on your whole day?
JERROD: Exactly. Yes.
THERAPIST: Of all the changes you’ve made, which has been the most important in
regard to your daily functioning?
JERROD: Uh, definitely stopping and considering alternative thoughts and beha-
viors. That has been really helpful, especially if I’m feeling overwhelmed.
 The Final Sessions 151

THERAPIST: Can you give me an example of a time when you used that technique?
JERROD: Yeah. Just the other day my friend kept texting me because he wanted to
hang out. I had a lot of work to do so I started getting annoyed, thinking
“he’s such a slacker––doesn’t he realize some of us actually do our school-
work?” But then after I paused, I realized that it was actually nice of him to
want to hang out with me and include me in his plans. I felt a lot better and
I was actually able to concentrate on my work.
THERAPIST: So, you stopped and thought about the things that were going through
your mind and causing some of your irritability. After that, you were able to
think about an alternate thought and redirect your mood and concentration?
JERROD: Yes. Exactly.

Commentary
Jerrod recalled a situation that triggered both his mood and maladaptive pattern.
However, instead of blindly following through with his pattern, he was able to
implement his relapse prevention plan and think of alternative thoughts. This
allowed him to thwart the typical irritability he would have experienced had he
followed the train of thoughts he was having, resulting in worse consequences. This
instance is reflective of third-order change, as Jerrod was able to facilitate his own
intervention independently. Additionally, these events help to increase his confidence
that he can continue to do so and maintain the progress he had achieved.

THERAPIST: I am pleased to hear that you’ve managed to use the techniques and
that it’s had a positive impact on your life as a result. Can you tell me about
some of the things you’ve learned throughout this process?
JERROD: Well, I had no idea how perfectionistic I was before. I also didn’t realize
how much of an obstacle it was to my life. I could never live up to my own
standards, so I was always striving and never reaching. It caused me to be
obsessed with little things.
THERAPIST: Okay, so you were able to notice your patterns and see some of the
perfectionistic tendencies actually got in the way of what you were able to
accomplish.
JERROD: Yes. I also noticed that I was being too critical with other people. I’m
inpatient and quick to decide that people aren’t doing their best. Whenever
I’ve paused to take perspective, things have gone better for me. I don’t get
caught up as much in my thoughts.
THERAPIST: OK, so it seems that you’ve noticed that you can be critical of others
and when you slow down, you can choose what to focus on by choosing
alternative thoughts.
JERROD: Yeah.
152 The Final Sessions

THERAPIST: Have you noticed anything different in your relationships with other
people because of this?
JERROD: Yes, absolutely. I feel like I’m a better person––compassionate and caring.
My relationships have gotten better because I don’t lose my patience as much
with other people or I feel less irritated. I’m not holding everyone else to
such an impossibly high standard so I’m able to enjoy myself and go out with
my friends
THERAPIST: That’s great. I’m delighted that you have been able to improve your
relationships as well as your personal well-being. Have you thought about any
changes you want to make from now on?
JERROD: Yeah, well I’d like to be freer. Spontaneous, you know? I mean, I don’t want it
to get to the point where I’m impulsive, but I’d just like to have a good time and
do things without planning. That’s kind of a struggle for me still.
THERAPIST: And what would spontaneous look like for you?
JERROD: A couple of weeks ago our professor told us about a trip to a new pro-
duct design center upstate with the class. All of my classmates were going to
stay in a hotel over the weekend and explore the city. I was waitlisted and
when the spot opened up, I declined because it was at last minute. I felt like
I didn’t have enough time to prepare but now I regret it and wish I had
gone. A more spontaneous me would’ve gone!
THERAPIST: That certainly sounds like a workable goal. Would it be possible for you
to try some of the techniques we’ve worked on to help you with that goal?
JERROD: Yeah. I think I could. I have improved in finding alternative thoughts so I
could try it for this goal.

Commentary
The therapist and Jerrod discussed lessons learned throughout their therapy. A shift in
his maladaptive pattern is reflected in his ability to discuss his perfectionistic pattern
in an objective manner. Additionally, he was able to do so without triggering self-
criticism or getting down on himself. He also indicated spontaneity as a new goal.
This also reflects a shift in his pattern as his initial goal was to become more reason-
ably conscientious; his spontaneity far surpasses his initial goal, which shows an
increased ability to withstand some of the discomfort that emerges as he gives up
control. Finally, his goal is indicative of a desire for more social connection, as he has
found it rewarding to relax and spend time with others thus far.

THERAPIST: That’s great. Might we review your relapse prevention plan from last
session?
JERROD: Absolutely. I’m really glad we worked on that.
 The Final Sessions 153

THERAPIST: So, as far as your triggers, I noted that your main triggers are stressful
circumstances which are likely to bring up self-criticalness, perfectionism,
and isolation.
JERROD: Yes. I definitely have to stay alert so that I notice when I’m doing that
stuff. If I pay attention to my mood, I’m more likely to catch it. That’s what
it usually depends on.
THERAPIST: Can you elaborate on that?
JERROD: Well, I used to just go with it when I was being perfectionistic and iso-
lating. I didn’t realize that it was connected to my mood or that I had any
control over it. I also didn’t think it was important to deal with it because I
just thought that’s how I was. Now, I’m noticing that if I pay attention to the
triggers that affect my mood, I can do something about it.
THERAPIST: That’s a great awareness. Some of the warning signs we discussed were
feeling of apathy and irritability, which typically point to starting to feel depressed.
JERROD: Yes, that’s true. Now I know that I can get to work on my strategies, so
things don’t escalate.
THERAPIST: And which specific strategies do you think you’ll use?
JERROD: Behavioral activation and thought stopping, for sure. I can start there.
THERAPIST: I think those are great strategies. You also indicated that you noticed that
the threshold of your irritability decreases when your pattern is triggered.
JERROD: Right. Without realizing that, I don’t think I could do anything about it.
Now, knowing more about it, I can change things and have better results.
THERAPIST: It seems like it has been empowering to realize that you have so much
control over your mood and pattern.
JERROD: Absolutely. I feel like I’m in charge now.
THERAPIST: Great. You’ve made so many important changes––it’s great to see you
doing so well. Now that we’ve gone over your relapse prevention plan, I’d like
to discuss follow-up sessions. In the Informed Consent form from the
beginning of therapy, there are contingencies about follow-up session, but
given how much you’ve achieved in therapy, it doesn’t seem like you need
follow-up sessions. Would you agree with that?
JERROD: Yes, I think so too. I was able to accomplish everything we talked about
in the beginning. I didn’t think I’d be able to deal with depression and stress,
but I didn’t realize I could change my strategy for how I was going about
these issues. I also can’t believe I didn’t use medication.
THERAPIST: Absolutely, and without medication! It sounds like you’re feeling a
sense of empowerment with how much control you’ve noticed you have over
your thoughts, behaviors, and mood. And, if later on it seems like you’re
getting down and the strategies aren’t working, you can always get in touch
with me here and schedule another session.
154 The Final Sessions

JERROD: (Pause) Yes, that puts me at ease. Thank you.

THERAPIST: OK, Jerrod. I am truly happy about all of the progress and changes
you’ve made. I’ve appreciated our time together and seeing you work toward
what’s important to you.
JERROD: Thank you. I’m so thankful for all of your help. You really listened and
helped me through a hard time, and I’ve learned a lot about myself.
THERAPIST: Thank you!

Commentary
To conclude, the therapist reviewed Jerrod’s relapse prevention plan once again
and gaged Jerrod’s readiness for termination. The possibility of future sessions was
discussed and a course of action agreed upon. Jerrod terminated therapy having
achieved both first- and second-order goals, and was highly motivated to maintain
his gains and prevent future relapse. Here is a summary of Jerrod’s goal ratings:
Improvement in Mood 9; Increase in Motivation 9; Increase in Pleasure and
Enjoyment 8; Shift to a More Adaptive Pattern 8.

Conclusion
Jerrod was initially referred to psychotherapy because he was not eager to take medi-
cation for his presenting problem. Given that he responded well to therapy and was
able to increase his mood with Pattern Focused Therapy, medication was not indicated.
This chapter presented sections of transcripts from Jerrod’s final two sessions.
The termination phase of Pattern Focused Therapy is illustrated this chapter. At
the start, the therapist reviewed the progress he had made and prompted him to
collaborate on a relapse prevention plan. First- and second-order goals’ progress
were reviewed. The therapist then helped Jerrod identify some triggers of symp-
toms and early warnings signs that his maladaptive pattern might resurface.
Thereafter, strategies were collaboratively discussed in order to facilitate coping
with triggers and symptoms after the end of therapy. The session concluded with
prompts for further personal growth goals and encouragement to reach out and
schedule future sessions if necessary.

References
Beck, J. S., & Beck, A. T. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press.
Cucciare, M., & O’Donohue, W. (2008). Clinical case conceptualization and termination of
psychotherapy. In W. O’Donohue & M. Cucciare (Eds), Terminating psychotherapy: A clinician’s
guide (pp. 121–146). New York, NY: Routledge.
Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn, I. M. (1998). A meta-analysis of the
effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49(1),59–72.
 The Final Sessions 155

Heaton, J. A. (1998). Building basic therapeutic skills: A practical guide for current mental health
practice. San Francisco, CA: Jossey-Bass.
Marlatt, G. A., & Gordon, J. R. (1985) Relapse prevention: Maintenance strategies in the treatment of
addictive behaviors. New York, NY: Guilford Press.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
Sperry, L. (2010). Highly effective therapy: Developing essential clinical competencies in counseling and
psychotherapy. New York, NY: Routledge.
Sperry, L., & Binensztok, V. (2019a). Learning and practicing Adlerian therapy. San Diego, CA:
Cognella.
Sperry, L., & Binensztok, V. (2019b). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Sperry, L., & Carlson, J. (2014). How master therapists work: Effecting change from the first through
the last session and beyond. New York, NY: Routledge.
Chapter 9

Interventions for Optimizing

Treatment

In my clinical experience, there are three pathways or trajectories that therapy can
take: (1) go smoothly; (2) get stuck from time to time; or (3) derail and drop out.
The first trajectory, “go smoothly,” is nicely supported with research on clients’
experience of successfully completing therapy published by Wampold and Imel
(2015). They report that while some clients progress quickly through therapy, i.e.,
3–6 sessions, others proceed more slowly. Still, overall, both types of clients do not
use “extraordinary” amounts of therapy. The average number of sessions used by
both types was 7–9 (Wampold & Imel, 2015). Should the therapist try to “nudge”
the slower client along to finish sooner? So far, this matter has yet to be addressed
in the psychotherapy literature.
The second trajectory, “get stuck from time to time,” is common among clients
who have many things that they want to talk about, and not uncommonly will
veer off one from topic to another. The therapeutic corrective is to more effec-
tively redirect the conversation back to the key focus of treatment. The first
section of this chapter “Establishing and Maintaining a Treatment Focus” provides
such a strategy and illustrates its application.
The third trajectory, “derail and drop out,” is particularly troubling. These
clients experience difficulties in treatment that unless therapists deal with them
effectively, mean the clients are likely to drop out or have a premature termi-
nation. Published dropout rates suggest that up to one half of clients who begin
treatment do not successfully complete it. Often quoted is a meta-analysis of
125 studies which reported a dropout rate of 47% (Wierzbicki & Pekarik,
1993). Because this study was published more than two decades ago and since
there have been several changes in how psychotherapy is provided now, it is
necessary to consider data from more recent studies. One of the largest meta-
analyses published included 669 studies representing 83,834 adult clients. In this
study, which better reflects psychotherapy practice today, Swift and Greenberg
(2012) found the dropout rate was 19.7%.
 Interventions for Optimizing Treatment 157

Still the rate is high. While there are several reasons why clients leave therapy
prematurely or derail it temporarily, many involve the ineffectual therapeutic
interventions therapists use with client at risk for drop-out. Fortunately, there
are a number of effective therapeutic interventions for maintaining clients in
treatment (Swift & Greenberg, 2015). The second and third sections of this
chapter provide some advanced therapeutic interventions for dealing with
complicating situations that can derail the therapeutic process. These include
transference-countertransference enactments and common therapy interfering
behaviors.

Establishing and Maintaining a Treatment Focus

An accurate case conceptualization allows a therapist to develop a treatment focus as
appropriate interventions are selected (Sperry & Sperry, 2012). This process is akin to
narrowing the broad scope of a floodlight which illuminates an entire worksite to a
spotlight that illuminates a specific section of the project at hand (Sperry, 2010). The
treatment focus functions as an action plan, or guide, toward achieving the treatment
goal. As a result, focused treatment improves the probability of more successful out-
comes in treatment. “There is now a convincing body of empirical evidence indicating
that therapist ability to track a problem focus consistently is associated with positive
treatment outcomes” (Binder, 2004, p. 23).
This section provides a discussion of a method of specifying a treatment focus
as well as a discussion of the necessity of focusing treatment. Then, an illustration
is provided on how the treatment focus is formed in Pattern Focused Therapy.

Establishing a Treatment Focus

In the past, therapists were trained to provide “undivided attention” to the client’s
feelings, body language, words, and concerns. The field of psychotherapy espoused the
view that the client’s lead should be followed and that clinicians should not establish
directive or evaluative environments. Therapists “should” express interest and
empathic responses to what the client wants to discuss and should “never” give advice.
Although this viewpoint may have been conducive to the open-ended, long-term
approaches to therapy in the past, it is not conducive to the short-term, account-
ability-based, system of third-party payers and their demands (Sperry, 2010). Thus,
therapists are increasingly expected to focus treatment. In order to accomplish this,
therapists must learn the skill of selective attention. Otherwise, they risk becoming
overwhelmed by following every branch of the virtually endless decision trees that
surface before them. The treatment focus not only serves as a path to treatment, it
also “serves as a stabilizing force in planning and practicing therapy in that it
158 Interventions for Optimizing Treatment

discourages a change of course with every shift in the wind” (Perry, Cooper, &
Michels, 1987, p. 543).
How is a treatment focused specified? The therapist identifies the treatment
focus through developing the case conceptualization. The basic theme of the case
conceptualization serves to further specify the focus (Sperry & Sperry, 2018). It is
no surprise that since the case conceptualization is founded on the conceptual
framework of the therapist, the treatment focus is often informed by the thera-
pist’s theoretical orientation. For instance, in Solution Focused Therapy, the focus
is on exploring exceptions and finding workable solutions. In Pattern Focused
Therapy, the focus is established on identifying maladaptive patterns of behavior
and thoughts.
Jaime is a 26-year-old third-generation Mexican American male who, until
recently, was employed as a high school science teacher. He described symptoms
associated with social anxiety disorder. Jaime reported feeling anxious around
others, including teachers, students, and administrators at the school where he
worked. He stated that his anxiety got so bad that he could not lecture even if for
a short while and had difficulty instructing students during lab experiments and
other assignments. In the past week, he took a medical leave from the job. His
physician referred Jaime for psychotherapy because he was not able to tolerate
anxiety medication.
Jaime is a single child and the only son of moderately acculturated Mexican
American parents. His parents are college professors in the sciences. He reported
that although his family was close, his parents were not particularly affectionate.
Jaime reported an uneventful childhood. He stated that he never had a best friend
because his parents often moved when either one or the other achieved a promo-
tion. Therefore, he only had a best friend for approximately a year or so. He stated
that his anxiety around others began during his elementary years. On the other
hand, he excelled in science during high school and was awarded a four-year
National Science Foundation college scholarship so that he could teach science. His
parents were proud and thrilled about this achievement and they encouraged him to
remain in the sciences, so he completed his B.Sc. degree in physics and was hired at
a private high school. Jaime continued to like science but experienced a level of
discomfort around students. However, given the central focus on lab experiments in
his program, he was able to work largely with students on a one-on-one basis.
Unfortunately, this came to an end at the beginning of the current school year as
the headmaster modified the science curriculum and made lab work subservient to
teacher lectures. After a few days of the school year, Jaime began to experience high
anxiety levels, tightness and discomfort in his chest, and difficulty breathing.
The following case conceptualization was developed: Jaime’s pattern is to move
away from others as he anticipates criticism, humiliation, or rejection for making
 Interventions for Optimizing Treatment 159

mistakes. Consistent with an avoidant pattern, he isolates from others due to fear of
rejection. On the other hand, his extremely high standards set him up for the
assumption that he will make mistakes. The association between making mistakes
and rejection contributes to Jaime’s symptoms of social anxiety and his cycles of
social avoidance. In turn, the avoidance behaviors, through decreased opportunities
for social engagement, prevent Jaime from learning the exaggeration and inaccuracy
of his beliefs. Subsequently, Jaime has been mistakenly attributing low rates of
rejection and mistake-making to his avoidance pattern.
The following maladaptive pattern, and the supporting interpretations and
behaviors, are provided in the next section and identified as the treatment focus:

1 Avoiding situations that are likely to produce mistakes in order to reduce the
risks of being rejected and increase the risks of safety.
2 Believing that others will criticize him, especially for making mistakes.
3 Believing that there is an inherent link between mistakes and rejection or
abandonment.
4 Behaving in avoidant ways which serve to exacerbate or maintain the inaccuracy
of such beliefs.

The treatment focus with Jaime was aimed at his avoidance pattern. Jaime came to
understand that the safeguarding of isolation led to increased and overwhelming
feelings of loneliness. He agreed to engaging in several behavioral experiments to
increase social contact with others while minimizing the risk for making mistakes in
resulting circumstances. In place of experiencing rejection or abandonment, as he had
predicted, he experienced acceptance and enjoyment while engaging with others.

Maintaining the Treatment Focus

The clinical observation that treatment outcomes are significantly improved when
therapists maintain a treatment focus is beginning to be recognized in the research
(Binder, 2004). Nevertheless, maintaining the treatment focus is not as uncomplicated
as it may appear. Given the complex and changing lives of clients, it is expected that
they will desire discussion about the events that occur in their lives between sessions.
Commonly, these concerns are outside the purview of the treatment focus. The
challenge for therapists is to “track” the treatment focus, “flexibly modifying the
content as new information arises and digressing from the initial focus as circum-
stances dictate” (Binder, 2004, p. 100). This chapter will provide a brief discussion of
the value of maintaining a treatment focus. Then, a case example and transcription
will be provided to illustrate how a therapist can guide the client in “staying on track,”
especially given a client who easily shifts the focus to other issues or concerns.
160 Interventions for Optimizing Treatment

The primary reason for “staying on track” is that, if the focus is lost, the
treatment risks not achieving the specified treatment goals. However, maintaining
this track is difficult especially as clients tend to shift the focus to less threatening
or more comfortable topics, whether consciously or unconsciously. Thus, shifts
from the treatment focus can slow or disrupt the therapeutic momentum and
influence the success of treatment. In these cases, the therapist faces “decision
points,” in which they can decide to choose various appropriate responses to the
client. The therapist’s choices directly influence the success, or lack thereof, in
maintaining the treatment focus (Sperry, 2010).
It goes without saying that maintaining a focus in treatment can be significantly
challenging, especially for beginning therapists and trainees. Typically, because of
limited familiarity with focusing techniques, beginning therapists and trainees tend
to relate to client “shifts” with statements that convey empathy or questions to
clarify. These responses can take the session in a different direction from the
primary focus of the treatment. Only as therapists increase their awareness of
shifts or “decision points” do they attempt to re-establish the focus of treatment.

Case Study: Tracking the Treatment Focus

The case that follows illustrates how therapists effectively maintain the treatment
focus. The transcription of the case following the overview will illustrate four
“decision points” in which the therapist will weigh various options before pro-
ceeding. The therapist will endeavor to maintain or “track” the themes of the
session on choice and empowerment. This presents a challenge as the themes are
somewhat ironic. The goal for the therapist, on one hand, is to promote choice
and empowerment whereas, on the other hand, the therapist must limit, reframe,
refocus the client’s attempts to shift the focus. This is a result of the limited
amount of time in the session and the therapist’s duty to maintain the focus. The
therapist must decide whether to maintain the focus when the client shifts the
conversation or follow the client’s lead, even if for a short while.
Julia is a 29-year-old married female, who is seeking therapy for overwhelming
feelings due to demands from her workplace, family, and personal life. She reports
experiencing anxious depression, with occasional insomnia. Julia is a third-generation
African American, currently working as a beautician. She also has a 10-year-old
daughter. Julia is highly acculturated. The assessment revealed that her issues and
proclivity for pleasing others are primarily driven by her personality and not by
culture. Julia and the therapist agreed to a contract of ten sessions of individual
psychotherapy. In the first session, the therapist identifies the pattern. Julia seems to
meet others’ expectations in a theme of “pleasing servant.” That is, she pleases
others and disregards her own needs. Collaborative goals were established for Julia
 Interventions for Optimizing Treatment 161

to become more centered and empowered, to develop adaptive relationships with

her husband, her parents, and her child. The treatment was to be focused on
empowerment and choice. The second and third sessions were focused largely on
Julia’s relationship with her mother. Julia’s mother had relegated child rearing to her
grandmother and it was agreed, as Julia’s expectations for treatment were primarily
to establish a healthy relationship with her mother, that she would discuss with her
mother and assert that she wanted her to have the role of a mother from there on.
At the outset of the fourth session, Julia was markedly dysphoric and stated
that she had been “depressed and feeling down all week.” She also reported that
her sleep had been disrupted by her ruminations about future difficulties. Unable
to independently control these ruminations, the therapist allotted approximately 5
minutes to the instruction and practice of breath retraining (described in detail in
Chapter 4). She was able to follow along with good outcomes. Approximately
halfway through the session, she stated:

CLIENT: I’ve just been so depressed this week. I feel like I’ve had such big setbacks.
I’m constantly thinking about what comes next and it really gets me down.

Decision Point 1
Given the triggers, predisposing factors and maintaining factors for anxious
depression, the therapist could have followed and provided an explanation of the
clinical aspects of depression or maintained the treatment focus on the client’s
pattern (i.e., “pleasing servant”). The therapist chooses to maintain the treatment
focus. The dynamic aspects of her feelings and other issues and how they are
connected to the themes of self-empowerment and choice are emphasized.

THERAPIST: It sounds like you have been really struggling this week. You have been
thinking about having setbacks and anticipating what comes next.
CLIENT: Yeah, and those thoughts are overwhelming.
THERAPIST: That’s why some of the strategies to deal with these issues involve
engaging in activities even when it’s hard. Do you remember the activities we
talked about last week?
CLIENT: Yes, but I don’t want to do anything when I get like this. I get into a funk
and everything just stops. I don’t want to out, I don’t want to do laundry, I
don’t even want to get out of bed.
THERAPIST: Okay. Do those seem like choices to you?
CLIENT: Yeah. (Chuckles) I guess I choose to do that.
THERAPIST: What do you think could be the purpose of “choosing” depression?
162 Interventions for Optimizing Treatment

CLIENT: Maybe it’s a way for me to not feel or have to confront the things I have
to do. Maybe it’s an excuse to procrastinate.
THERAPIST: So avoidance is the purpose of your depression?
CLIENT: (Smiling) I guess. That’s one way to not do what I want.
THERAPIST: (Pauses)
CLIENT: It’s just that it’s really difficult. (Pause) I was thinking about our last con-
versation. I ended up getting down on myself because I was passive instead
of aggressive. In the end, I end up paying for it again.
THERAPIST: I see.
CLIENT: It’s hard for me to tell people how I feel. I know I don’t have to be mean,
but still I’m afraid. So, I’ve been thinking about being more assertive.
THERAPIST: So far, you’ve been afraid to be assertive.

Decision Point 2
The therapist detects that Julia is starting to discuss another issue. Following her lead
toward another theme could result in a derail of the treatment focus. However,
assertiveness is linked to empowerment, so he thought about how to proceed. The
therapist used “so far” as a therapeutic device that was initiated in the first session.
This device allows the client to take some responsibility for the possibility of being
more empowered in the future, which was connected to the focus on empowering
her and encouraging her decisions instead of continuing the “pleasing servant” pat-
tern. Then, there was another shift toward the primary focus.

CLIENT: So far, yes.

THERAPIST: Have you been using that qualifier in the past few days? “So far”?
CLIENT: Yeah, a couple of times. But I was focused on the negative things. You
know––not doing what I wanted to do.
THERAPIST: Is it possible that you’re using depression as fear and avoiding the
things you want to do? Is “fear” accurate?
CLIENT: Yeah, that’s accurate.
THERAPIST: Then it sounds like there are negative results: you feel guilty because
you don’t do anything. (Pauses) Do you think you could give yourself per-
mission to not do anything?
CLIENT: (Fidgeting) I guess. But when I think about it, the thing that scares me
the most is being assertive. I don’t really know why but it’s like someone
would have to push me out of an airplane.
THERAPIST: I see. I just can’t figure out why. It seems like that results in a lot
of pain.
CLIENT: Oh, yes, it does.
 Interventions for Optimizing Treatment 163

THERAPIST: I also can’t figure out what it is about the pain that’s appealing. If
you’re not going to do something, why not do something else you might like?
Say playing music [she is a musician] or something else. Instead of lying down
on the couch, maybe go out shopping or call a friend? You know––give
yourself permission to not do housework.
CLIENT: Those would be much better choices.
THERAPIST: They seem like the less depressing choices. If you’re not going to do a
task, what use is it to feel badly or depressed about it? Wouldn’t it be more
kind to give yourself permission and feel good about giving yourself a break?
CLIENT: It’s that I don’t feel this way when I have company or others are visiting. I
feel like I’m a loner and I need to make friends. I’m just afraid.

Decision Point 3
The focus here seems to have shifted toward her lack of friends. The therapist could
have engaged with her and this topic, commiserating or finding an appropriate
assignment to address friendship skills training. However, the therapist maintained
the primary focus of treatment.

THERAPIST: So, if the purpose of the fear is to avoid the tasks, what would it be
like to give yourself permission?
CLIENT: I don’t feel depressed that often. And I’m starting to realize that it shows
up because I’m avoiding things rather than facing it.
THERAPIST: I have some different ideas. It seems like making yourself miserable is
something you’ve been good at. I just don’t know if its primary cause is
avoidance. I mean, you’ve raised a daughter, graduated from college, and
you’re employed full time. You also ended an abusive marriage and take care
of your father and grandmother who are aging.
CLIENT: And yet I don’t take care of myself. I constantly make myself miserable.
THERAPIST: What do you think is the purpose of that?
CLIENT: I really don’t know. (Pause) I was kind of melancholic even as a child. I
wouldn’t let myself get too happy because I was afraid I would miss things that
were important. I thought I’d forget to turn in a paper on time or things like
that and then bad things would happen. I wouldn’t allow myself to get too happy.

Decision Point 4
The therapist has several options here: empathize with the client; ask follow-up
questions about the client’s childhood and issues with melancholy; or stay on track,
maintaining the focus on the “pleasing servant” patterns.
164 Interventions for Optimizing Treatment

THERAPIST: It seems like you have a lot of practice in taking care of others while
neglecting your own needs.
CLIENT: Yeah. If I do something for me, then I won’t be doing anything for someone else.
THERAPIST: I see. So, if you do something for yourself and don’t do something for
someone else, what would happen?
CLIENT: I think people would be disappointed.
THERAPIST: And what do you think the result of that disappointment could be?
CLIENT: I don’t know. I think maybe they’d say that I was selfish or something.
THERAPIST: So what if you said something like “why don’t you do that for me?”
CLIENT: Oh. (Uncomfortably) I’m not sure about that.
THERAPIST: Sounds like you’d be taking care of yourself. (Pause) Will that get you
in trouble with others?
CLIENT: (Pause). There are times when I think it would be really nice if someone
took care of me, but I’d feel weird. I’m terrible at accepting compliments.
THERAPIST: So, you’re not very skilled at accepting compliments. So far.
CLIENT: Yeah. So far. (Smiling) I think it’s corny, but I’ve been thinking about
putting up notes––like Post-its around the house to remind myself of the
things I’ve accomplished. I think it would be good, instead of thinking of all
the negatives or all the things I haven’t done.
THERAPIST: You have the choice to put up reminders of accomplishments instead
of thinking about all of the failures.
CLIENT: I think I need to be really public about it at first. Maybe later I can just
think about it.
THERAPIST: It sounds like you’re suggesting something that could break away from
your pattern. It sounds like it’s definitely worth a try. What’s something that
you’d write on one of your Post-its?
CLIENT: “You’re a great mom.” Or something like that.
THERAPIST: Those kinds of reminders can really make a difference. It all comes
down to choices. If you choose to think about something that went wrong,
you’re likely to feel bad. On the other hand, if you choose to think about
something that went right, you will feel good.
CLIENT: That’s what happens to me almost every day. I miss one thing and then I’m
thinking about it all day and other things like it. It can really get me down. I
guess I just have to take things one step at a time and make small progress.
THERAPIST: Do those seem like choices? Thinking about it all the time?
CLIENT: I guess.
THERAPIST: And do those choices help you?
CLIENT: Not at all.
THERAPIST: If what you want to do is avoid something, you don’t have to stew on
it. That’s a choice you can make. If you avoid something and you feel bad
 Interventions for Optimizing Treatment 165

about it, that’s really two problems. You can eliminate the second problem by
simply choosing to do something else. Maybe something that makes you feel
better about the situation or about yourself.
CLIENT: Yeah, that makes sense. I don’t have to beat myself up about it.
THERAPIST: This could be a way to break the pattern. You could think of alter-
native things that you could do that don’t result in bad feelings or thoughts.
The therapist wraps up the session. Julia is assigned to practice breath
retraining at bedtime and as needed throughout the day. An appointment for
a subsequent session is scheduled.

Commentary
In this session, the therapist was effective in keeping the session on track with the
treatment focus. Some of the client’s attempts to shift the topic were borne out of
avoidance and wanting not to discuss core dynamics of putting others’ needs first
and her pleasing disposition. She is very articulate and so it seemed that she would
seamlessly shift to topics that were less uncomfortable. However, when redirected
and refocused, she was able to focus on her pattern and core dynamics with ease
and even suggest her own intervention.

Transference and Countertransference

All therapeutic endeavors are based on the quality of the therapeutic alliance. On one
hand, there are facilitative conditions to an effective therapeutic alliance. On the other
hand, there are conditions that impede the development and maintenance of it. The
focus of this section is transference and countertransference and in particular trans-
ference-countertransference enactments which have the potential to––and often
do––interfere with the therapeutic alliance (Sperry, 2010). Accordingly, they can have
a detrimental influence on therapeutic outcomes. The beginning of this section will
cover transference and countertransference, focusing on enactments. Then, transfer-
ence and countertransference will be discussed in terms of how it can be resolved.
Finally, transcriptions from two cases will be presented to illustrate the enactments
and their resolution.

Transference, Countertransference, and Enactments

Current relationships are often affected by previous ones. Therefore, a person can
meet someone in the present who reminds them of a colleague or romantic rela-
tionship from the past, whether consciously or subconsciously. However, most com-
monly, individuals have little to no insight into the fact that they may be “transferring”
thoughts and feelings from past relationships onto their current relationships.
166 Interventions for Optimizing Treatment

Additionally, conscious awareness of re-enacting unfinished business with past rela-

tionships is also uncommon. Another phenomenon which stems from past relation-
ships and transfer to current ones is expectations. Individuals come to expect that
certain individuals will behave in specific ways, due to past relationships that are
unrelated. For instance, a graduate student may meet their statistics professor and
react to them the same way, and have similar expectations of them, as they had of
their high school algebra teacher. The student may come to be surprised if their new
professor is less academically demanding and relaxed than her previous teacher. This
resulting confusion stems from internal distortions that are not suited to present
expectations of current roles (Good & Beitman, 2006).

Transference and Countertransference

Transference is defined as an occurrence in which clients transmit feelings,
thoughts, and expectations onto their current therapist that stem from past
relationships (Sperry, 2010). Similar to active elements, such as trust and
collaboration in current relationships, past relationships also contain active
elements that clients and therapists bring to their working relationship. These
active elements can be detrimental to the therapeutic relationship, of which
transference is one. The distortions caused by transference can be a huge
problem for the therapy process (Good & Beitman, 2006).
Transference is not exclusively negative. Instead, these forms of re-enactment
of the client’s common patterns of relating can also take a positive form and will
typically involve unfinished business. Clients re-enact how they previously felt when
treated in a comparable way. Most commonly, transference occurs when a client’s
unfinished business is triggered by an inadvertent statement from the therapist.
Similarly, when therapists transmit feelings, thoughts, and expectations onto
their clients, the phenomenon is known as countertransference. These distortions
can be similarly detrimental to the therapy process. Countertransference can also
take positive or negative forms. Regardless of therapeutic orientation, there is
growing consensus that countertransference can function as a valuable source of
data about the client (Gabbard, 1999).

Subjective Countertransference vs. Objective Countertransference

A distinction has been made between subjective countertransference and objective
countertransference. Subjective countertransference refers to the therapist’s feel-
ings or responses to the client, based on the therapist’s own personal history,
issues, or sensitivities. In other words, the therapist’s reaction to the client––either
positive or negative––is activated by the therapist’s own unresolved issues or
 Interventions for Optimizing Treatment 167

unfinished business. In contrast, objective countertransference refers to the feelings

and reactions the therapist experiences toward the client which are activated by the
client’s feelings and behaviors rather than the therapist’s own issues (Kiesler, 2001).
Practically speaking, objective countertransference is evident when group of therapists
meet in a group setting with a client and all five come away from that encounter with the
same emotional reaction to the client. To demonstrate the phenomenon of objective
countertransference I will ask students in a graduate course to watch ten minutes of an
intake evaluation and then ask each to write down their personal reaction to the client.
Typically, their responses are essentially the same, except of course, if a student’s own
unfinished business was activated by the client’s manner. This exercise is very useful in
demonstrating the difference between these two types of countertransference.

Transference-Countertransference Enactments
Considered “separate” phenomena in the past, there is an increasing number of clin-
icians and researchers who maintain that the best understanding of counter-
transference and transference is from a relational viewpoint or model. The current
emphasis is on the client and therapist interaction, whereas in the past it was solely on
the client. From this perspective, the client and therapist co-create enactments and
are viewed as equal participants, representing transference and countertransference
configurations (Sperry, 2010). The therapist’s role is to trigger and shape responses.
The client’s role is to respond. Therefore, transference can be understood through
two factors: the client and their past, and the dynamics of the interpersonal rela-
tionship between the client and therapist. Transference involves “the here-and-now
experience of the client with the therapist who has a role in eliciting and shaping the
transference” (Ornstein & Ganzer, 2005, p. 567). For instance, a client who grew up
in a family characterized by emotional distance and flagrant abuse may demonstrate
difficulty with emotional disclosure in therapy. When prompted by the therapist,
similar feelings may result in aloof, withdrawn, irritated, or angry behavior.

Recognizing Transference and Countertransference

Transference and countertransference are common in therapy settings, although more
common expressions occur in long-term therapy. This is especially likely in therapies
that emphasize here-and-now feelings (Binder, 2004; Gabbard, 1999). As mentioned
previously, positive or negative transference or countertransference manifestations can
surface. It is crucial for the therapist to recognize indications and signs of both. These
include feelings, behaviors, and fantasies.
Common feelings reflective of transference are anger, hostility, hurt, jealousy,
and distrust. Some common behaviors reflective of transference are excessively
168 Interventions for Optimizing Treatment

criticizing the therapist, coming late for sessions, and seeking out personal infor-
mation about the therapist. Some common fantasies reflective of transference are
dreaming about the therapist, being in love with the therapist, becoming a col-
league of the therapist, and harming the therapist. Common feelings reflective of
countertransference are irritation, boredom, excessive pride in client progress,
and resentment or excitement about seeing the client. Some common behaviors
reflective of countertransference are extending session time, ending session early,
asking the client for favors, or failure to deal with client boundary violations such
as excessive phone calls. Some common fantasies reflective of countertransference
are dreaming about the client, becoming a close friend of the client, having sex
with the client, or harming the client (Good & Beitman, 2006).

Dealing with Transference-Countertransference Enactments

In current therapy training programs, recognizing and resolving transference and
countertransference issues are, unfortunately, not prioritized in the didactic por-
tion. These topics may not surface in supervision either, unless a trainee brings it
up and introduces the discussion (Sperry, 2010). This section and subsequent
materials and cases are provided based upon the principle that in order for trai-
nees to competently practice therapy, they must be able to effectively resolve
issues of transference and countertransference. It is critical to address concerns of
transference and countertransference straightforwardly and proactively to prevent
unfortunate or detrimental interpersonal surprises.
Numerous methods have been proposed for managing transference. Gelso et al.
(1999), for example, proposed five methods: (1) narrowing the focus to the
immediate relationship; (2) interpretation of the meaning of the transference; (3)
promoting insight into the enactment of transference using questions; (4) transfer-
ence education for the client; and (5) self-disclosure from the therapist.
Likewise, variants for strategies to deal with countertransference have been sug-
gested for therapists to avoid countertransference enactments. A research-based
strategy has been proposed to aid therapists in preventing enactments of their inter-
nal reactions. These strategies include: self-insight; self-integration (i.e., possession of
healthy character traits); anxiety management; empathy; and the ability to con-
ceptualize (i.e., the therapist’s ability to utilize theory to ascertain the client’s dynamics
in the relationship) (Gelso & Hayes, 2007). Self-insight and self-integration are par-
ticularly critical in order for therapists to have an adequate understanding of the
situation in which the countertransference transpired, to include boundary issues
between the therapist and client. Additionally, self-insight and self-integration are
needed for the therapist’s own psychological health, especially as they can manage and
effectively use the therapist’s internal reactions to facilitate therapeutic change.
 Interventions for Optimizing Treatment 169

Using countertransference therapeutically with clients depends on the therapist’s

level of self-integration. Clearly, optimal therapeutic assistance to clients also depends
on the resolution of unfinished business on the part of the therapist. Self-reflection
and supervision are two avenues that have proven helpful in processing and resolving
countertransference issues; however, in terms of chronic problems with counter-
transference, personal therapy may also prove necessary (Gelso & Hayes, 2007).
The methods described thus far, among others, can be useful to resolve some trans-
ference and countertransference issues, after the fact. However, what methods can be
employed in sessions as they arise? An increasingly proactive, here-and-now approach and
protocols will be briefly described in the following section. This approach is presented
in order to address and resolve immediate transference enactments, but also effect a
corrective emotional experience. That is, the approach seeks to facilitate a client-
therapist interaction that delineates the maladaptive pattern essential to the enactment
(Levenson, 1995), which may serve to prevent future transference enactments.

Protocol for Resolving Transference Enactments

A four-step process for recognizing transference enactments and dealing with it
effectively is described below. Essentially, the therapist:

1 Identifies the origins of the transference in the client’s past.

2 Assists the client in remembering and processing how the other person in
the client’s past reacted to the emotionally charged context.
3 Assists the client in relating a description of the therapist’s reaction in the present.
4 Assists the client in examining differences and similarities between the therapist’s
behavior and the behavior of the past client’s relationship. The therapist under-
lines the differences to emphasize a new corrective experience.

This protocol is illustrated in the following case example. McCullough (2005;

2015) offers a similar method.

Illustration of Resolving Transference-Countertransference

Enactments
It is fascinating that over the years, when asked, clinicians reliably indicate two
types of countertransference reactions that they have had with clients. Nearly
always, they indicate feelings of being exacerbated with client reactions. The
second is “falling in love” with, or being sexually attracted to, their client (Sperry,
2010). The following scenario of transference enactment illustrates the first type
and demonstrates how to recognize and quickly resolve it. The case is inspired by
170 Interventions for Optimizing Treatment

McCullough (2005) and illustrates how it is quickly resolved with the client
experiencing a corrective experience.
Cecilia is a 37-year-old single, never-married, Italian American female. She was
referred by her physician, Dr. Marino, for evaluation and treatment of her anxiety
and recurrent worry. She has never engaged in psychotherapy in the past and had
some skepticism about its effectiveness. However, she followed up on the appoint-
ment due to her trust in her doctor, with whom she has been with for most of her
life. Dr. Virginia Jones had been in practice for several years and regularly received
referrals from Dr. Marino. Dr. Jones learned that Cecilia was the only child of her
parents in her initial evaluation. She also learned that both of Cecilia’s parents had
passed away the year prior in a car accident. Cecilia disclosed that she had been a
“worry wart” throughout her life, but things had deteriorated further since her
parents’ death. Cecilia stated that her father had been demanding and critical, reg-
ularly nitpicking and fighting with her mother. She described him as a self-effacing
alcoholic. She denied any history of sexual or physical abuse, but it was apparent
that she had been faced with substantial and sustained emotional and verbal abuse
from her father, as well as emotional neglect from her mother. Since childhood,
Cecilia worried about doing right by her father. She also worried that she could not
count on her mother to protect her. However, she completed her college studies,
became a nurse, and began to work at an extended care facility. Cecilia denied any
substance use but disclosed that she chain-smokes in her attempt to “calm my
nerves.” Dr. Jones’ treatment plan indicated that resolving relationship issues with
Cecilia’s parents had been a treatment goal that they mutually agreed upon. Addi-
tionally, Dr. Jones noted that negative transference enactments were likely to sur-
face. At the start of the fifth session, Cecilia states:

CLIENT: Why do I keep screwing up?

THERAPIST: What do you mean?
CLIENT: Last week I missed our session because I was running very late.
THERAPIST: I see. It was unfortunate that we couldn’t meet last week.
CLIENT: You’re disappointed with me, huh?
THERAPIST: Why do you say that? What is disappointing?
CLIENT: That I screwed up. I overslept and was super late, missing our appointment.
THERAPIST: Well, you made a mistake. (Pause) I make mistakes all the time. So do
a lot of other people.
CLIENT: I guess I’m expecting to get punished for that. I came really late and it
probably messed your whole rhythm off for your day. (Client becomes tear-
ful)The conversation suggests that transference is surfacing. Dr. Jones checks
on this and begins to process it therapeutically. She prompts Cecilia to recall
memories of feeling hurt by her father’s anger and demanding nature.
 Interventions for Optimizing Treatment 171

THERAPIST: Right now, I’m wondering how your father might’ve reacted to this
situation. What do you think he might’ve done if you had slept through plans
with him?
CLIENT: (Pauses, sobs and breathes deeply) Oh jeez! He would’ve gone com-
pletely crazy! He’d start yelling and cursing at me. Then I’d just cry and
run to my room. I’d stay there for hours because I’d be terrified of what
he’d do.
THERAPIST: I’m betting that you’re experiencing some of that pain right now.
(Pause) I want to ask you another question, but I want us to maintain eye
contact when you answer. Would that be okay?
CLIENT: (Blows her nose) Okay.
THERAPIST: What was my reaction to you missing your appointment last week?Dr.
Jones’ prompt helps Cecilia examine the differences between her father’s
behavior and her own behavior as they react to her mistakes and failures.
CLIENT: You said it was too bad that we couldn’t meet.
THERAPIST: Yeah. Now, maintaining this engagement with me, could you describe
my reaction to you missing our appointment. Make sure to point out as
much detail as you can about my reactions both last week and this week––
my tone, my word choice, and my facial expressions.
CLIENT: (Looking confused, she stops sobbing) I don’t really know how to describe it.
THERAPIST: I think it is very important. Would you be willing to try?
CLIENT: Alright. (Pause) Last week you told me you were sorry we couldn’t meet.
It sounded like you meant it. Today you said that it was too bad, and you
told me that both you and other people make mistakes. You didn’t yell or
curse at me. You didn’t make me feel stupid. I don’t really know––I can’t tell
by your reaction. I’m not used to being treated like this.
THERAPIST: Did I react at all like your dad used to?
CLIENT: Absolutely not! Not at all. (Pause) I’m not scared around you.Dr. Jones
continues, now starting to facilitate a corrective emotional experience.
THERAPIST: Why aren’t you scared around me, especially after making a mistake?
CLIENT: I don’t know. I haven’t really thought about it. I don’t think that you’re
going to intentionally hurt me. (Pause) It’s weird. I’m not used to trusting
others, but I think I can trust you.
THERAPIST: I’m very happy that this is your experience with me! (Pause). What do
you think this means about our relationship?
CLIENT: It means that I can be myself around you. (Smiles) I don’t think I’ve ever
been this way with anyone else.
THERAPIST: It sounds like you’re entering a new phase in your life. I think it’s very
important to reflect on the importance of what you just shared with me and
172 Interventions for Optimizing Treatment

what you learned about yourself. (Pause) In our work together going for-
ward, I want us to build upon this experience and insight.
CLIENT: I felt really bad when I came in today but I’m feeling better now. I can’t
remember the last time I felt like this.
THERAPIST: Have you ever shared a moment of happiness with someone else?
CLIENT: No. I really don’t think so.
THERAPIST: I think it’s really important to enjoy that. I’m very happy for you as well.

Commentary
In this session, Cecilia’s reaction to having missed a therapy appointment was a
transference enactment. This was due to unfinished business in her relationship
with her father, who would behave in critical and demanding ways toward her
about even the smallest of mistakes. The corrective emotional experience she
shared with Dr. Jones can serve to supercharge the course of treatment. Dr. Jones’
anticipation of the transference enactment enabled her to prepare and respond to
it effectively. This also prevented a premature termination that could have been
likely had Dr. Jones responded to Cecilia with a display of frustration or even mild
rejection. Instead, not only did Dr. Jones prevent a poor outcome, but she likely
facilitated healing and growth.

Recognizing and Resolving Therapy Interfering Factors

Marsha Linehan (1993; 2015) introduced the term “treatment interfering beha-
viors” to describe behaviors that clients engage in within and between sessions
that obstruct the therapy progress. Common examples of these behaviors are
arguments that surface with the therapist, not showing up to scheduled appoint-
ments, refusing to engage in the therapy session, and overstepping the therapist’s
boundaries, such as by asking personal questions or attempting to go over time.
This term provides a designation for the class of behaviors that can present a
barrier in therapy and impede progress. However, Linehan’s designation centers
solely on the client. On the other hand, there are a multitude of kinds of impe-
diments to treatment progress that can be observed in a clinical setting. Herein,
the designation “therapy interfering factors” is adopted as it includes a broader
scope. It includes client behaviors but also acknowledges the influence of the
therapist, the therapeutic alliance, and other factors that can impede progress in
treatment.
In order for treatment to succeed, therapists must identify, predict, and resolve
treatment interfering factors. Skilled therapists anticipate these factors at the
outset of the therapy and as early as the first meeting with the client, typically
while collecting developmental and social details of the client’s history. Factors that
 Interventions for Optimizing Treatment 173

could impede the therapy progress as well as other challenges and obstacles must
be included in the case conceptualization. Beyond that, potential strategies for
facilitating these obstacles and factors must be considered before the factors sur-
face throughout the process of treatment. This chapter lists and describes various
interfering factors: the client, the therapist, the client-therapist relationship, and
treatment. Subsequently, strategies for resolving these specific interfering factors
are illustrated.

Types of Therapy Interfering Factors

Various therapy interfering factors have been observed in clinical situations. These
include the client, the therapist, the client-therapist relationship, and treatment
factors (Beck, 2005; Ledley, Marx, & Heimberg, 2006). Here are some common
examples. Client-based interfering factors include refusal and outright resistance,
ambivalence, treatment interfering core beliefs or automatic thoughts, and using
diversionary techniques. Therapist-based interfering factors include therapist
errors such as an inaccurate or inadequate case conceptualization, as well as
therapist inexperience, incompetence, or negligence. Interfering factors related to
the client-therapist relationship include alliance strains and ruptures, and trans-
ference-countertransference enactments. Treatment factors include inadequate
case conceptualization and utilizing an intervention that may be contraindicated
for a particular client.

Protocol for Recognizing and Resolving Therapy Interfering Factors

The first step in reducing the influence of interfering factors is recognition. The
protocol provided herein covers some common therapy interfering situations.

1 Determine the operative interfering factor or factors. For example, shifting

to more comfortable topics when uncomfortable, avoiding self-disclosure,
and noncompliance with homework.
2 Determine the explanation or reason for the interfering factor. Among client
factors that are particularly common are interfering beliefs and the unwill-
ingness to deal with the consequences of change. Typically, this means not
wanting to take responsibility for themselves and face difficult tasks that are
currently avoided.
3 Continue to focus on shifting from a maladaptive pattern to an adaptive
pattern while at the same time identifying skill deficits which can be
addressed with one or more ultra-brief interventions.
174 Interventions for Optimizing Treatment

4 Consistently indicate and point out to the client when the topic is shifted and
encourage the client to identify and address the feeling and thought they find
distressing.

Strategies for Resolving Therapy Interfering Factors

Three therapy interfering factors are described in this section and a strategy is
illustrated for dealing with each. Given that client interfering behaviors are most
common, all three examples will involve such behaviors. The first and third cases
are inspired by Beck (2005). The second case is inspired by Ledley et al. (2006).

1. Dealing with a Client’s Interfering Beliefs and Behavior

A client’s underlying core beliefs or schemas are identified as the root of the cli-
ent’s therapy interfering behaviors in the following example.
Julianne is a college sophomore who sought out services at her university
counseling center due to difficulty in selecting a major. After completing three
semesters in core classes, she was asked to declare a major, which brought up
some conflict for her. She reported that her parents wanted her to obtain a
degree in accounting in order to work for the family business. Her own inter-
ests lie in teaching art or being an anthropologist. However, she stated that she
did not think she had the “right stuff” to be an elementary school teacher.
During the initial evaluation, she disclosed that she was the second of four
children. She described herself as the sickly “little runt.” She described her
mother as emotionally withdrawn and demanding and her father as physically
abusive. The family owns a small printing company that was hardly successful.
The therapist attempted to establish a treatment focus after the initial evalua-
tion. The following was Julianne’s response:

CLIENT: This is useless. I don’t know how this is going to help me.
THERAPIST: What’s useless right now?
CLIENT: I don’t really know.
THERAPIST: What seems to be the main challenge right now?
CLIENT: I told you already! They want me to choose a major!
THERAPIST: And that’s difficult for you––making decisions, and especially a decision
about your career.
CLIENT: (Loudly) I just don’t want to deal with it! I don’t want to make any
decisions! Not just career decisions!
THERAPIST: Isn’t the third semester the point in time when students typically
declare a major?
 Interventions for Optimizing Treatment 175

CLIENT:I’m not ready to do that. My advisor is crazy if she thinks she can force
me to decide on being a teacher or a business major or anything else.

Julianne had completed the Personality Belief Questionnaire (Beck, 2005). This
helped the therapist recognize Julianne’s hopeless, incompetent, and vulnerable self-
beliefs. It also indicated beliefs about others being demanding, rejecting, hurtful, and
critical. Further prompting revealed the following assumptions and rules: “I’ll be
alright if I avoid difficult decisions,” “I’ll be safe if I blame others,” and “If I let my
guard down, I’ll be hurt.” Her overdeveloped coping strategies were rooted in these
rules. These strategies were: avoiding major decisions, blaming others, and guarding
against being harmed by others. This particular configuration is common in indivi-
duals with Borderline Personality Disorder. However, the therapist decided that
indicating a definitive diagnosis was premature. However, he realized that Julianne’s
core beliefs, assumptions, and coping strategies had surfaced, and they provided an
opportunity to recognize the root of her treatment interfering behaviors, mainly
resisting discussion of the presenting problem.

THERAPIST: So, is there a problem that we can address right now?

CLIENT: I don’t know. I feel like nothing is going to make a difference. It’s hopeless.
THERAPIST: Do you think we can work on your feelings of being hopeless? Do you
want to talk about your parents or school?
CLIENT: I don’t know. Whatever works.
THERAPIST: Would it be possible to begin with the thoughts “Nothing will make a
difference. It’s hopeless”?
CLIENT: I guess.
THERAPIST: How much do you believe right now that making a decision about
your major won’t make a difference?
CLIENT: (Pause) A lot.
THERAPIST: I hear you. (Pause) Could you tell me what the disadvantages are if
you did not choose a major?
CLIENT: I probably couldn’t get into a major for another semester so I couldn’t
take advanced courses. It would push everything back.
THERAPIST: Anything else?
CLIENT: My parents would be all over me and my dad would probably follow
through with his threat of cutting off my tuition and board this semester.
THERAPIST: And what are the advantages of choosing a major?
CLIENT: It would definitely get my parents off my back. I would keep hanging out
with my friends and have classes with them. That would be cool.
THERAPIST: So, there are advantages and disadvantages. Right now, do the advan-
tages or the disadvantages seem to be stronger?
176 Interventions for Optimizing Treatment

CLIENT: I guess the advantages by a little bit. I just feel overwhelmed when I think
about it.
THERAPIST: How overwhelming would it be on a scale from 1–100, 100 being
extremely overwhelming.
CLIENT: I would say, like, 65.
THERAPIST: Okay, so moderately overwhelming. It doesn’t sound totally hopeless,
does it?
CLIENT: Yeah, I guess not. Not when you put it like that.

Commentary
In the first session of therapy, Julianne’s coping strategies were clearly operative. She
demonstrated feeling hopeless, avoiding career decisions, guarding against real or
perceived harm, and she blamed others about her conflicts or discomfort. These
strategies also clearly accounted for Julianne’s therapy interfering behavior, namely,
resisting discussion about the presenting problem. Having recognized these dynam-
ics, the therapist indirectly challenged the underlying belief of hopelessness through
having her weigh advantages and disadvantages. The indirect nature of this inter-
vention was chosen because if challenging abruptly, the therapist risked Julianne
prematurely terminating treatment. Therapy interfering behaviors that are reflective
of the client’s coping strategies were illustrated in this case. Additionally, it provided
an example of how early in the therapy these can surface. The strategies are also
particularly likely to surface as the therapist endeavors to focus treatment, as this
process can be laden with conflict or discomfort.

2. Dealing with Clients Who Use Diversionary Tactics

Seeking therapy and arriving at treatment settings do not equate to willingness to
address the presenting problem for all clients. Some clients, particularly those who
experience varying levels of ambivalence, engage in diversionary tactics and avoid
change. Diversionary tactics are comprised of client behaviors which divert, distract,
delay, or deflect attention from addressing issues or change efforts that the client
seeks therapy for. For example, many clients report new and overwhelming circum-
stances that surface in their lives that they want to address instead of focusing on the
treatment that was specified or agreed upon. They may also minimize the importance
of the initial concern or the discomfort it creates in their lives. On the other hand,
they may express skepticism of the chosen interventions or treatment. All of these
strategies are diversionary tactics that clients may demonstrate.
The following case example demonstrates the therapist’s recognition of tactics
of delay due to the client’s apprehension towards treatment.
 Interventions for Optimizing Treatment 177

Sanford is a 29-year-old male who is seeking treatment for increasing agor-

aphobia. He is employed as an attorney and has been struggling with agoraphobia
for approximately 8 months. He reports being first diagnosed by his primary care
physician and starting on medicine for a short while. Sanford stated that due to
unacceptable side effects, he stopped his medication and sought therapy. He met
with a psychodynamically-oriented therapist for five sessions and stated, “I didn’t
find it useful.” As of late, he found himself homebound at an increasing rate,
which began to interfere with his practice as an attorney as well as his plans for
marriage. When the therapist first introduced exposure treatment in the initial
session, Sanford seemed reluctant and fearful of an intervention that would make
him come in contact with his current fears. However, he agreed to the protocol
which was to begin in the following session.
During the second session, Sanford stated that he was extremely distraught
because his partner at the law firm was mad that he did not make it to a
deposition, and he wanted to discuss it. In the following session, Sanford brought
up concerns that his girlfriend was threatening to call off the engagement unless
he showed improvement. Noticing a pattern of diversion, the therapist anticipated
that Sanford would present another crisis in the upcoming session; therefore, he
devised a plan to directly deal with it. As Sanford brought up yet another crisis––
his father having been in a car accident––at the start of the fourth session, the
therapist asked:

THERAPIST: Have you noticed a connection between your anxiety and agoraphobia
and what’s been happening in your life these past few weeks?
CLIENT: Yes. I’ve been stressed and it’s making me scared to go out.
THERAPIST: Right. That’s a useful reflection. What do you think about how the
relationship is going in the other direction? Could the anxiety be playing a
role in the stressors you’ve had recently?
CLIENT: I don’t really know. What do you mean?
THERAPIST: Well, consider the situation three weeks ago when Sally told you she
might break off the engagement. Could anxiety have anything to do with that
situation?
CLIENT: Are you joking? That’s what the whole thing was about. She said she was
just sick of it. I mean, I can’t do anything anymore! I can’t go to the gym,
travel, or even go to the restaurants or movies. We used to be inseparable
and now with this stuff I can’t do anything.
THERAPIST: And what about the problems at your law firm recently?
CLIENT: My partner has been really frustrated with me because we were working
on two cases simultaneously with very tight deadlines. Then I didn’t make it
178 Interventions for Optimizing Treatment

in because I was scared to drive on the highway, and he was livid. He had to
drop his case to tend to that.
THERAPIST: Can you notice the direct relationship between those issues and
your anxiety?
CLIENT: Yeah.
THERAPIST: Then, last week your dad was in an accident and that’s what you
wanted to address. For the past three weeks we’ve talked about all of the
stressful things that have been happening in your life. (Pause) Would it be
possible for there to be another way we could address your problems?
CLIENT: I don’t know. When I get here, I just think about how things have gone in
the week.
THERAPIST: What if there was another way to address those kinds of stressors and pre-
vent them from happening in the following week? Would you be interested in that?
CLIENT: (Sarcastically) I wish that was possible.
THERAPIST: We could look at this more closely––if anxiety and agoraphobia are
directly linked to your ongoing issues, what could happen if we address the
anxiety directly?
CLIENT: So if I worked on my anxiety, Sally wouldn’t have threatened me with
calling off the engagement and my law partner wouldn’t be furious with me.
My life would just be great?
THERAPIST: There is no way to know what could have happened. What I’m
saying is that maybe if we focus our work, things could improve, and you
may have better outcome next time you have a relationship or work
problem.
CLIENT: So, what you’re saying is that I’ll have an easier time dealing with things if
I work on my anxiety and it gets better?
THERAPIST: Would that make sense?
CLIENT: Well, right now Sally and I don’t have the best relationship––I’m not even
sure she wants to spend time with me––I’m already worried about my next
deadline and I can’t even leave my apartment!
THERAPIST: Would you be curious to see what would happen if we stay focused on your
panic for the next few sessions? See what it does for your life outside of here?
CLIENT: Are you talking about practicing those exposures out there?
THERAPIST: Yes. That’s exactly what I mean.
CLIENT: I don’t know if I want to do that. Are there any alternatives?
THERAPIST: We’ve discussed alternatives before. Exposure came up as the most
feasible treatment for you. If medication didn’t work out for you because of
the side effects and your previous therapy experiences led to some insights
but your symptoms worsened, exposure seemed like the treatment of choice
when we discussed it about a month ago.
 Interventions for Optimizing Treatment 179

CLIENT: Yeah, I remember that, and I know that I agreed to it but I’m afraid that
if it doesn’t work I’ll just be hopeless and stuck for ever. Then Sally will leave
me for sure and––I just get really uncomfortable talking about this.
THERAPIST: (Empathically) I can see how this affects you and how difficult it is for
you to discuss this. This is really difficult work. That first step may seem like
the scariest of all and those who take it often become more confident that
they can proceed with the rest of it. (Pauses) Thinking back, this interven-
tion has been successful for all of the clients I’ve coached through it. I’m
confident that it would work for you as well.
CLIENT: I know you said that, but I don’t know if I believed you. I really want to
believe that it would work.

The therapist in this case maintained a high level of patience with the client.
The client was allowed to ventilate his concerns, which was necessary to
strengthen the therapeutic alliance. The client was, in a sense, testing the
therapist prior to trusting him fully and his clinical judgment. Rather than
confront the anxiety and agoraphobia directly, the therapist linked these issues
to the client’s ongoing concerns. This became an avenue for both discussing the
client’s ongoing stressors and a way back toward the treatment focus, as the
therapist redirected the session.

3. Dealing with Client Refusal

In the following example, a client’s refusal will be facilitated in the case for
which high reactance is the indicated therapy interfering behavior. That is, the
individual has reactions to efforts to control him or her. Confrontation or
coercion of the individual or withdrawal and acquiescence are two typical
ways of responding to this and other forms of resistance. A third type of
response is therapeutic. Rather than confronting the client or giving in, the
therapist reflects feelings or content and rolls with the resistance (Miller &
Rollnick, 2002).
Morton is a 44-year-old male who has been experiencing chronic depres-
sion (low level) for the past three years. He is employed as the chief infor-
mation officer for an insurance company and prides himself on his
independence. Recently, Morton began therapy at a mood disorders clinic.
The clinic routinely utilizes rating scales and screeners. At the outset of the
second session, which involves a structured interview for evaluation, the
therapist asked:
180 Interventions for Optimizing Treatment

THERAPIST: Would it be alright if we checked on your depression? Have you

completed the rating scale for depression?
CLIENT: (Forcefully) No!
THERAPIST: I see. The rating scale is something I use to assess how you’ve been
feeling since the last time we met. Would you be okay feeling it out after
session today?
CLIENT: What’s the point? I don’t feel like filling anything out.
THERAPIST: Okay. We could try another way of assessing your mood. Can you
estimate your mood on a scale from 1–10? 10 being the best and 1 the worst
possible mood?
CLIENT: I don’t know. (Pause) I said no. I don’t like doing this, it’s too simplistic.
THERAPIST: Okay. Could you tell me in your own words how you’ve been feeling
this week as opposed to the other weeks?
CLIENT: I don’t know. Rotten, I guess.
THERAPIST: I understand. (Pause) (Empathically) It sounds like it’s been a really
rough week.
CLIENT: Yeah, it’s been hard.
THERAPIST: What was going on when you felt like that?
CLIENT: Just the whole thing was bad.
THERAPIST: I just want to make sure I understand. Could you describe what was
bad about it? Was it the beginning, middle, or the end of the week?
CLIENT: I already said it was all bad.
THERAPIST: Where there any times that weren’t so bad? Was there maybe some-
thing on TV that was good or interesting? Did you meet with anyone or have
even a pleasant moment?
CLIENT: The Jets game was on. They were playing the Patriots. It was a good
game.
THERAPIST: Awesome! You know, the reason I asked about your moods was
because if we find out what was good or uplifting, then maybe you can do
more of that. On the other hand, if it was bad, then maybe we can talk
about changing something. (Pause) Overall, compared to two weeks ago,
how would you say your mood was? Did you at least enjoy the game this
past week?
CLIENT: (Pause) It really wasn’t so different. I think it actually might’ve been
worse.
THERAPIST: Okay. It’s important for us to continue to check in on your mood at
the start of each session. That’ll help me understand if we’re headed in the
right direction or if we need to modify and change course. Would that be
okay with you?
 Interventions for Optimizing Treatment 181

Commentary
The therapist’s flexibility demonstrates willingness to compromise as well as respect
for the client. Statements such as, “Is that alright with you?” show respect directly by
seeking permission and the client’s consent to continue in the direction the therapist
desires to go. In this case, the client’s reactance is high. This factor continues to drive
the client’s refusal. Therefore, insisting that the client fill out the forms for the clinic
might have strained the therapeutic alliance severely. Instead, the therapist became
aware of the reactance and rolled with the resistance.

CLIENT: (Somewhat reluctantly) I guess it’d be alright.In the following session, the
therapist gently probes the client for willingness to complete the rating scale.
THERAPIST: Do you think it would be okay if I asked you to rate your mood for
this past week? Would that frustrate you?
CLIENT: Yes, it will.
THERAPIST: Okay, well then, I won’t ask. Could I ask you what your experience is
like when I ask you about your mood?
CLIENT: I just get frustrated. It’s not that easy to rate my mood.
THERAPIST: Well, even if it is complicated, do you think it’s important for me to
understand your level of sadness or distress?
CLIENT: I guess. I just want to talk about other things.
THERAPIST: I see. What’s something you want to talk about? What do you want to
focus on for this session?
CLIENT: Things are pretty rocky at the office. There’s a suit against the store and I
have to be around for a lot of hours––way more than my boss allotted for it.
I just get overwhelmed and I feel like I’m going to lose it. I feel like I’m going
to freak out and start screaming so I have to leave.

Commentary
The therapist once again demonstrated flexibility and rolled with the client’s
resistance. Agreeing with the client’s focus and processing it over the next four
weeks resulted in Morton becoming more even keeled in his mood. Eventually,
Morton even thanked the therapist for his help. He also expressed willingness to
utilize the rating scale, at least for some of the time. Morton’s diminishing reac-
tance was the outcome of the therapist’s flexibility.
At first, the client’s refusal is empathic and strong because he does not want to
be told what to do. Trainees are drawn to this case because they predict that an
impasse in therapy consistently equates to early termination or “treatment failure.”
The therapist’s ability to “roll with the resistance” both encourages and surprises
students and trainees as they can see the effects on the therapeutic alliance as well
182 Interventions for Optimizing Treatment

as treatment outcomes. If unconvinced that this “third way is the therapeutic

way” prior to discussing this case, trainees are certainly convinced afterwards.

Conclusion
Wouldn’t it be nice if all clients were easy to work with and therapy always went
smoothly? The reality is that some clients are not particularly easy to work with
and the course of some therapies do not go smoothly. The corrective usually
involves efforts to fine tune and enhance the treatment process and the ther-
apeutic alliance. This chapter has been included to provide trainees and practicing
therapists with some strategies and tactics for decreasing premature termination.

References
Beck, J. (2005). Cognitive therapy for challenging problems: What to do when basics don’t work. New
York, NY: Guilford Press.
Binder, J. (2004). Key competencies in brief dynamic psychotherapy: Clinical practice beyond the
manual. New York, NY: Guilford Press.
Carlson, J. (2006). Psychotherapy over time. Washington, DC: American Psychological Association
(DVD).
Gabbard, G. (1999). An overview of countertransference: Theory and technique. In G. Gabbard
(Ed.), Countertransference issues in psychiatric treatment (pp. 1–25). Washington, DC: American
Psychiatric Press.
Gelso, C., & Hayes, J. (2007). Countertransference and the therapist’s inner experience: Perils and
possibilities. Mahwah, NJ: Lawrence Erlbaum & Associates.
Gelso, C., Hill, C., Mohr, J., Rochlen, A., & Zack, J. (1999). Describing the face of transference:
Psychodynamic therapists’ recollections about transference in cases of successful long-term
therapy. Journal of Counseling Psychology, 46, 257–267.
Good, G., & Beitman, B. (2006). Counseling and psychotherapy essentials: Integrating theories, skills,
and practices. New York, NY: Norton.
Kiesler, D. J. (2001). Therapist countertransference: In search of common themes and empirical
referents. Journal of Clinical Psychology, 57(8), 1053–1063.
Ledley, D., Marx, B., & Heimberg, R. (2006). Making cognitive-behavioral therapy work: Clinical
process for new practitioners. New York, NY: Guilford Press.
Levenson, H. (1995). Time-limited dynamic psychotherapy. New York, NY: Basic Books.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorders. New York,
NY: Guilford Press.
Linehan, M. (2015). DBT skills training manual, 2nd edn. New York, NY: Guilford Press.
McCullough, J. (2005). Treating chronic depression with disciplined personal involvement. New York,
NY: Springer.
McCullough, J. (2015). CBASP as a distinctive treatment for persistent depressive disorder: Distinctive
features. New York, NY: Routledge.
Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change, 2nd ed.
New York, NY: Guilford Press.
Ornstein, E., & Ganzer, C. (2005). Relational social work: A model for the future. Families in
Society, 86, 565–572.
 Interventions for Optimizing Treatment 183

Perry, S., Cooper, A., & Michels, R. (1987). The psychodynamic formulation: Its purpose,
structure, and clinical application. American Journal of Psychiatry, 144, 543–551.
Sperry, J., & Sperry, L. (2018). Cognitive behavior therapy in professional counseling practice. New
York, NY: Routledge.
Sperry, L. (2010). Highly effective therapy: Developing essential clinical competencies in counseling and
psychotherapy. New York, NY: Routledge.
Sperry, L., & Carlson, J. (2014). How master therapists work: Effecting change from the first through
the last therapy session and beyond. New York, NY: Routledge.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and
confidence. New York, NY: Routledge.
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A
meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559.
Swift, J. K., & Greenberg, R. P. (2015). Premature termination in psychotherapy: Strategies for
engaging clients and improving outcomes. Washington, DC: American Psychological Association.
Wampold, B., & Imel, Z. (2015). The great psychotherapy debate: The evidence for what makes psy-
chotherapy work, 2nd ed. New York, NY: Routledge.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional
Psychology: Research and Practice, 24(2), 190–195.
Chapter 10

Pattern Focused Therapy in

Integrated Care Settings

What are the mental health needs of clients—called patients––in integrated care
settings and what role, if any, do mental health providers have in such practice set-
tings? These are timely questions as the delivery of health care services in America
continues to change and evolve. This chapter not only addresses these questions but
also sketches an exciting future for mental health providers in a new practice
setting. It also describes some of the basic knowledge and tools needed to practice
successfully in this setting. Because integrated care setting typically limits ther-
apeutic encounters to sessions of 20–30 minutes’ duration rather than 45–60-
minute sessions in conventional psychotherapy settings, a different core ther-
apeutic strategy and different interventions are needed. Fortunately, Pattern
Focused Therapy provides that core therapeutic strategy and is easily and effec-
tively practiced in very short time frames.
This chapter begins with data on mental health needs in primary care settings.
It then identifies the different ways in which mental health services are provided
in three different models of integrated care practice. Next, it describes how Pat-
tern Focused Therapy can serve as the core therapeutic strategy for direct clinical
services provided in such settings. Then, a clinical case illustrates how a therapist
uses a core therapeutic strategy which incorporates ultra-brief interventions to
successfully treat a medical patient with panic attacks in four sessions.

Mental Health Needs in Primary Care Settings

Of those seeking medical care, some 70 percent present with or are diagnosed
with related psychological conditions, such as generalized anxiety disorder, panic
disorder, depression, bipolar disorder, and chronic pain, as well as troublesome
health behaviors like sleep problems, nicotine use, sexual problems, and weight
issues (Hunter, Goodie, Oordt, & Dobmeyer, 2017). Recognition and treatment
of these disorders and health behaviors are important since they can trigger,
exacerbate, or perpetuate medical symptoms and impaired functioning. These
 Integrated Care Settings 185

same problematic health behaviors are also present in those seeking conventional
psychotherapy. However, until recently, most therapists simply ignored these
health behaviors even though these exacerbate or otherwise complicate the client’s
psychological condition.
Both research-based health care policy and reimbursement sources are
increasingly “disallowing” this common therapist response. A recently published
national study of the 40 million Americans insured by Blue Cross Blue Shield
provides very compelling evidence for the provision of integrated health care
(Blue Cross Blue Shield Association, 2017). It was reported that mental health
and substance use disorders significantly impact not only the physical health and
well-being of Americans, but also their longevity and productivity. Collectively,
depression, anxiety and mood disorders, and substance disorders have the greatest
impact on Americans’ health compared to any health condition, followed by
hypertension, diabetes, and high cholesterol.

Mental Health Practice in Integrated Primary Care Settings

In the standard primary care model, a primary care provider (PCP)––usually a
physician, MD or DO, or an advanced practice nurse (APRN)—is supported by
nurses (RNs) and medical assistants (MAs). In the new primary care model, called
“integrated primary care,” a health care team provides treatment. This team
consists of at least one PCP, one or more RNs and MAs, as well as a therapist or
other mental health clinician, usually called a behavioral health consultant or BHC.
The goal of providing integrated primary care is to achieve the Triple Aim,
which refers to the three keys to improving health care in the USA. They are:
(1) increase patients’ health care experience, including quality of care and
patient satisfaction; (2) improve the health of the population; and (3) reduce
health care costs (Berwick, Nolan, & Whittington, 2008). Research is clear that
providing mental health or behavioral health services in integrated settings
definitely results in decreased cost, primarily because of reduced emergency
room and hospital admissions. Because integrated care improves the identifica-
tion of undiagnosed conditions and concerns, these patients are more likely to
receive needed mental health services.
How might a therapist or other mental health clinician be involved in inte-
grated case settings? It is useful to think about a continuum of integration of
mental health services which range from non-integrated to fully integrated. It
consists of three basic models:

 Coordinated Model: here the therapist is an externally employed partner who

provides mental health services to a specific primary care practice.
186 Integrated Care Settings

 Co-Located Model: here the therapist is on-site and provides mental health
services to selected patients utilizing the conventional psychotherapy model.
 Fully Integrated Model: here the therapist is a full-time provider who provides
mental health services, within an integrated health team in a specific primary
care practice.

The first two models are also known as partially integrated, in contrast to the
third which is fully integrated (Sperry, 2018). Particularly in fully integrated set-
tings, the therapist’s role is to address a broad spectrum of mental health needs
with the aim of early identification, quick resolution, long-term prevention, and
wellbeing for primary care patients. As a core member of the primary care team,
the therapist provides consultation to other team members on mental health
issues related to physical health conditions as well as direct clinical care. Typically,
the therapist is expected to perform 8–10 consultations, usually in 15–30 minutes
time frames, each clinical day with patients, PCPs, and other team members
(Sperry, 2018).

Pattern Focused Therapy in Integrated Care Setting

We’ve described Pattern Focused Therapy in this book as a brief therapeutic
approach for easily and effectively identifying and changing a patient’s maladaptive
pattern of thinking, feeling, and behaving to a healthier and more adaptive pat-
tern. Utilizing the core therapeutic strategy of Pattern Focused Therapy, called
the Query Sequence, it accomplishes this by replacing the non-productive
thoughts or interpretations and behaviors that underlie the individual’s maladap-
tive pattern with more adaptive ones (Sperry & Binensztok, 2019a). The aim is to
achieve second-order change. Other interventions, particularly ultra-brief ther-
apeutic interventions (cf. Chapter 3), such as behavioral activation, behavioral
rehearsal, breath training, and stimulus control, are employed as adjunctive
treatments to achieve first-order change, i.e., to reduce symptoms and impaired
functioning.
Because its core therapeutic strategy is brief and easily implemented, and has
very few contraindications (i.e., acute psychosis and acute cognitive impair-
ment), Pattern Focused Therapy is a very good fit in integrated primary care
settings. It is particularly well suited to integrated clinic settings where thera-
pists are expected to perform 8–10 brief consultations in 5–30 minutes time
frames. The successful use of this approach with depression, anxiety, sleep
problems, chronic pain, weight problems, and diabetes is described and illu-
strated in the book, Ultra-Brief Cognitive Behavioral Interventions: The Cutting-Edge
of Mental Health and Integrated Care Practice (Sperry & Binensztok, 2019b).
 Integrated Care Settings 187

Treating Anxiety Symptoms in an Integrated Care Setting

While anxiety disorders are commonplace in mental health care settings, they are
also present in primary care settings and account for up to 20 percent of client
complaints (Hunter, Goodie, Oordt, & Dobmeyer, 2017, p. 61). Because anxiety
symptoms occur on a continuum, some medical patients might not meet the full
criteria necessary for a DSM-5 anxiety disorders diagnosis. Nevertheless, these
symptoms may be quite distressing and deserve effective care. Anxiety disorders
have been identified as contributory factors in a number of medical problems as
well. Thus, they can be treated on their own in the primary care settings or
addressed as part of the treatment for other medical disorders.

Assessment and Screening Instruments

Assessment of anxiety in integrated settings requires both a diagnostic and func-
tional assessment. Interview questions should be primarily closed-ended in order
to gather all necessary information quickly.
The functional assessment should include information about how anxiety affects
the client on a daily basis and interferes with regular functioning. Markers of
functional assessment include sleep, tension, aches and pains, difficulty con-
centrating, and related functions. Triggers for symptoms should also be explored
as well as factors that make the symptoms better or worse. This assessment
should also include the patient’s related behavioral changes, worrying about future
attacks, and attempts to avoid more attacks. Finally, therapists should determine if
the patient uses any substances that may be contributing to symptoms, such as
caffeine. It is important to note any prescribed or over-the-counter medication for
anxiety taken as well as the patient’s level of compliance with prescribed medica-
tions. The most common screeners used are:

 Subjective Units of Distress (SUDS). The Subjective Units of Distress scale is a

useful, informal tool to rate a client’s level of anxiety (Wolpe, 1969). Ratings
on the scale range from 0–10 or from 0–100. This scale is useful for both
patients and therapists to assess the intensity of symptoms and the distress
and disturbance they cause. It is also a useful measure to monitor progress
through therapy and after interventions.
 The Generalized Anxiety Disorder-7 (GAD-7). The GAD-7 is a 7-item questionnaire
that corresponds to the DSM-5 criteria for Generalized Anxiety Disorder
(Plummer, Manea, Trepel, McMillan, & Simpson, 2016). Each question is rated
on a 4-point scale from 0–3 where 0 = not at all, 1 = several days, 2 = more
than half the days, and 3 = nearly every day. Clients rate their experiences for
the previous two weeks. The scoring for the GAD-7 is as follows: 0–4 =
188 Integrated Care Settings

minimal or none, 5–9 = mild, 10–14 = moderate, 15–21 = severe. The GAD-7
has been shown to be useful in screening for Generalized Anxiety Disorder,
Panic Disorder, and Social Anxiety (Bardhoshi et al., 2016).

Pattern Focused Therapy in an Integrated Care Setting:

Clinical Illustration
The application of Pattern Focused Therapy in a primary care clinic is illustrated
in the following case. Jenny is a 23-year-old Caucasian female referred to coun-
seling by her PCP, William Jeffers, M.D., for symptoms of anxiety with inter-
mittent panic attacks. Two weeks prior to referral for therapy, he had started
Jenny on Klonopin, an anti-anxiety medication. Clinic policy is that therapy is the
main treatment for diagnosable anxiety and depressive conditions and medication
is used to support that treatment. The plan was for a short course of medication
to sufficiently reduce anxiety (panic attack) symptoms so that Jenny could more
effectively engage in the therapeutic process.
The clinic’s policy regarding the provision of mental health treatment was
discussed with Jenny: up to four therapy sessions, of 30 minutes duration, can
be offered to patients with the provision that one to two additional sessions may
be offered if indicated, or the patient can be referred for extended treatment
outside the clinic. For patients successfully completing four sessions, one follow-
up session is typically scheduled, which patients can decide to keep or cancel,
depending on how well they are doing. All appointments with the therapists are
scheduled as 30-minute sessions, and sessions are typically scheduled biweekly
which allows time for patients to practice assigned therapeutic tasks and max-
imize treatment gains.
It was agreed that Jenny would be offered four sessions with the provision for a
follow-up session if indicated. She would also continue with scheduled appoint-
ments with her PCP for a medication review and her therapist would be present
for a discussion of discontinuing medication. After her second session with the
therapist, Jenny would meet for a 15-minute medication monitoring appointment
with her PCP, attended by the therapist. At that appointment Jenny reported that
her symptoms had greatly improved, and she agreed to be weaned off her medi-
cation over the next two weeks. Her fourth session with the therapist was
scheduled for three weeks later and she agreed to get in touch with her PCP if
there were issues in weaning and stopping the medication.
Session plans and Chart Notes are provided for all sessions. Because of space
limitation, transcription segments and commentaries are provided only for the
following sessions: 1, 2, and 4.
 Integrated Care Settings 189

Session 1

Session Plan
The GAD-7 will be taken just prior to the session. Then, a brief diagnostic
evaluation and functional assessment with the goal of identifying the presence
of DSM-5 symptom disorder(s) and personality disorder(s). Treatment goals
will be set for the course of therapy. Client will be instructed in SUDS as a
way of monitoring and controlling her anxiety symptoms. Psychoeducation
about presenting symptoms, which the PCP’s referral note suggest are panic
attacks, will be provided. Presumably, the client will learn and experience how
her response to her symptoms and maladaptive pattern actually exacerbate
them. Her breathing pattern will be observed and if shallow and/or hyper-
ventilative, one or more ultra-brief interventions, i.e., breath retraining will be
introduced, practiced, and assigned as homework. Finally, the therapeutic
strategy and process, as well as expectation for her engagement, will be dis-
cussed and homework assigned.
The following transcription segment illustrates how this breath retraining is
introduced and implemented.

THERAPIST: I’ve been observing your breathing and it seems like you take short and
shallow breaths. Diaphragmatic breathing, which is taking slower breaths
from your abdomen, can help you to calm down. Clinically we call it breath
retaining. Have you ever heard of it?
JENNY: I’ve heard it mentioned but don’t know much about it.
THERAPIST: Okay, why don’t we try it out? I can demonstrate. My belly will rise
and fall as I’m breathing. It can help if you put your hand on your stomach.
Take a couple of normal breaths and then deepen your breathing. Are you
noticing any difference?
JENNY: Yes, I can feel my belly really rising as I breathe.
THERAPIST: Excellent. That can help to monitor your breath. You can also try to
purse your lips as you breathe––as if you’re blowing bubbles. Would you be
willing to give that a try?
JENNY: Sure.
THERAPIST: Good. You’re doing very well. Let’s see if we can practice. Try to keep
the pace and take one breath every 8–10 seconds.
JENNY: OK, I think I get it.
THERAPIST: OK, Jenny, you have done excellent work today. I’m going to provide
this log so that you can keep track of your exercises. It’s important to write
down the date and for how long you practiced.
JENNY: OK, I’ll try.
190 Integrated Care Settings

THERAPIST: Excellent. Now, on a scale from 0–10, 10 being very important, how
important is it for you to practice this?
JENNY: Around a 9. I really want to improve my anxiety.
THERAPIST: Great. And on the same scale, what is your level of confidence that you
can complete them?
JENNY: Probably 6. I think I can do it, but I’m worried that it won’t work and it’ll
stress me out.
THERAPIST: I see. What do you think might bring that number up to about a 7 or 8?
JENNY: I would feel more confident if I can practice at least once a day this week.
THERAPIST: Very good. I think you can do this. I’m interested to see what your
progress looks like on our next appointment.

Commentary
Jenny responded well to the intervention and was able to learn and practice the
breathing retraining exercise.

Chart Note
Jenny presents to therapy with constant, uncontrollable worry and intermittent
panic attacks. A GAD-7 score of 12 indicates moderate anxiety. She clearly
presents with panic attacks—three in the last two months but did not meet full
criteria for Panic Disorder. It is noteworthy that she reports SUDS scores for
these attacks in the 80–90 range whereas levels of 90–100 are more typical of
Panic Disorder. She met only three of the DSM-5 criteria for Dependent Per-
sonality Disorder. Nevertheless, she displays a dependent personality style with a
maladaptive pattern of taking care of others while neglecting herself. The
functional assessment indicated sub-clinical symptoms of anxiety and panic,
consistent with her GAD-7 scores. Her symptoms interfere with her quality of
life and ability to concentrate at work.
Two treatment goals were discussed and agreed upon: reduction of panic
symptoms and better at meeting her own needs as well as those of others.
Likely interventions, including psychoeducation, breath retraining, thought
stopping, or other ultra-brief interventions, will be incorporated when
appropriate. Pattern Focused Therapy will address her pattern and its role in
maintaining her anxiety and panic symptoms. Progress will be monitored with
SUDS and GAD-7. She states she is tolerating Klonopin and notices some
reduction in symptoms. She appears to be a good candidate for four-session
short-term therapy.
 Integrated Care Settings 191

Session 2

Session Plan
Before the session Jenny will take the GAD-7. As the session begins, she will be
asked to rate her anxiety in terms of SUDS. Then, her breath retraining log will
be reviewed. Because she mentioned disturbing thoughts associated with her
symptoms and anticipatory anxiety of having another panic attack, a thought
stopping intervention will likely be introduced, practiced, and assigned.

THERAPIST: Hi, Jenny, it’s nice to see you again.

JENNY: Hi. Nice to see you too.
THERAPIST: So, how has your anxiety been this week?
JENNY: A bit better, but not by much.
THERAPIST: Can you tell me more about that?
JENNY: I still feel nervous and anxious all the time.
THERAPIST: And, last time we met, you said it was getting in the way of the things
you have to do on a day-to-day basis. How is that going?
JENNY: Yes. It’s still hard for me to do the things I have to do, like cooking and
chores, but it has been a bit better.
THERAPIST: I see. What were your SUDS rating on some of those bad days?
JENNY: Probably around 60 to 70.
THERAPIST: That’s pretty uncomfortable. (Pause) But, I’m happy to hear that it has
improved some. How did it go with your breathing exercises? Did you bring
your log?
JENNY: It went alright. I did it for four days but only five minutes a day. I don’t
think that’s very good.
THERAPIST: Well, you were able to do it for most days this week––I think that’s a
very good start.
JENNY: I guess, yeah––that’s good.
THERAPIST: It really is good. I’m wondering if today we could address some of the
thoughts we discussed last time. I think it would help, along with the
breathing, to ease some of the anxiety and panic.
JENNY: Yeah, we could do that. Those really are annoying.
THERAPIST: I wonder if you could tell me again some of the detailed thoughts you have?
JENNY: Okay. Well, I mostly worry about people––then I start getting in my head.
THERAPIST: For example?
JENNY: Like that my mom is alone. My dad died and she’s all alone. What if
she chokes on her food or falls down? Nobody would be around to help
her. What if someone breaks in? That’s the kind of thing that comes into
my mind.
192 Integrated Care Settings

THERAPIST: I can see that you care very much about her. What do you do when
those thoughts enter your mind?
JENNY: I call her sometimes, but she rarely answers. She’s probably asleep or busy.
It usually happens when it’s late. I know she’s probably okay, but I can’t seem
to stop worrying about it.
THERAPIST: What else do you worry about?
JENNY: My brother. He drinks too much. He has an okay job and takes care of
himself, but I’ve seen him drink a lot on a couple of occasions.
THERAPIST: And what is the nature of the thoughts you have about this?
JENNY: Kind of the same as with my mom, that he will drink and drive––crash his car.
There was this one person on TV that slipped in the shower after drinking and
died. I can see that happening in my mind. Very vividly! I picture him falling and
really hurting himself, with no one around to help him or call someone.
THERAPIST: These very vivid thoughts seem to be very distressing for you.
JENNY: They are. And I also worry that something will happen to me and I won’t
be able to be there for my family. My mom would be devastated.
THERAPIST: These thoughts seem very difficult. It takes a lot of courage to deal
with them.
JENNY: Yeah, I guess I deal. I just don’t think I’m doing very well at it. They can
stick around for hours until something else distracts me.
THERAPIST: I’m hoping that some of the tools we discuss and use here will help
you to better deal with the thoughts and reduce your anxiety.
JENNY: Yes, I’d like that.
THERAPIST: Good. The first thing we’ll talk about is an exercise called thought
stopping. Essentially, the idea is to stop the thoughts you’re having so that
they don’t escalate or hang around for hours as we’d discussed. Throughout
the exercise, you’ll find that you’re more in control of your thoughts, as
opposed to the other way around.
JENNY: Ok, I’m hoping it’ll work out, but I’m not too sure.
THERAPIST: Some skepticism is normal and expected, especially since you’ve been
dealing with this for a long time. We can try it out together and see how
things go. Is that alright?
JENNY: Alright.
THERAPIST: One of the thoughts you mentioned was about someone breaking into
your mother’s house.
JENNY: Yeah, I think that’s the worst one.
THERAPIST: OK, focus on that thought and I will issue the stop command. When
you have the thought in your mind very vividly––someone breaking into her
house––raise one finger. OK?
JENNY: Okay.
 Integrated Care Settings 193

Commentary
When Jenny concentrates on her thought and raises her finger, the therapist
will loudly say, “Stop!” This will startle her and distract her from distressing
thought. They will repeat this exercise approximately 20 times in a row.
Then the therapist will instruct Jenny on how to practice thought stopping
on her own.

THERAPIST: Stop!
JENNY: Oh my God! That really scared me. I didn’t think that would be that loud.
THERAPIST: OK, how did it go?
JENNY: I’m not really thinking about it now. It’s sort of a snap back to reality.
THERAPIST: Where is the thought now?
JENNY: Oh. Gone, I guess. That’s interesting.
THERAPIST: OK, so we are going to repeat this exercise about 20 times. This is so
that you can get used to it and begin to do it on your own.
JENNY: Alright.
THERAPIST: So, concentrate on the thought again. Make it the same thought of
someone breaking in. When you have it clearly and vividly, raise one
finger.

Commentary
After completing this exercise 20 times, the therapist instructs Jenny to apply it
to her own as disturbing thoughts arise.

THERAPIST: You’ve really done a good job today, Jenny. Some of the things I’ve
asked you to do have been challenging, I’m proud of you for hanging in
there.
JENNY: Thank you. I am feeling proud of myself too.
THERAPIST: So, do you think you can practice this when you’re having those
bothersome thoughts?
JENNY: Yeah, I think I can.
THERAPIST: You can do this by yourself if you just yell “Stop!” loudly in your head.
You don’t have to do it out loud. However, it may be best to start practicing
somewhere where you can do it out loud. It also helps to picture a big stop
sign when you’re doing it.
JENNY: OK, I can do that.
THERAPIST: Great. Now, to go a step further, it can really help to replace the
upsetting thought with a pleasant one after you give the “Stop!” command.
JENNY: Oh, OK. I could try that.
194 Integrated Care Settings

THERAPIST: Can you think of any pleasant images?

JENNY: I can think of sitting with and petting my cat. Or maybe going somewhere nice.
THERAPIST: For example?
JENNY: I could think of going to the beach or sitting at this outdoor café in Paris I
really liked.
THERAPIST: That sounds great. Now, there is one more thing.
JENNY: What?
THERAPIST: It’s not likely that you will stop worrying altogether. Some worry is
natural and part of life, but we just don’t want to be worrying all day. It
can help to set up a time to worry. Maybe 20 minutes in the morning and
20 minutes at night. I suggest setting a timer so that you can stop when
the time is up.
JENNY: So, you want me to worry on purpose?
THERAPIST: I want you to set aside some time to worry. Is there a good time in the
morning? You want to be consistent with the times.
JENNY: Maybe 7:30. I usually get up before 7 and that’s before I have to work.
THERAPIST: Ok, so let’s try from 7:30 to 7:50. What about at night?
JENNY: Probably around 8 p.m.
THERAPIST: Ok, so 7:30 a.m. to 7:50 a.m. and then 8 p.m. to 8:20 p.m. Here’s a
log so that you can monitor your progress.
JENNY: Ok. That’s kind of weird but I can try. So, this is in addition to doing the
breathing exercises and stopping my thoughts?
THERAPIST: Yes.
JENNY: OK, I’ll do my best.

Commentary
After addressing Jenny’s panic symptoms in the previous session, the therapist
introduced two ultra-brief interventions to help Jenny deal with her anxious
thoughts in this session. She was responsive to thought stopping and, although
somewhat skeptical, agreed to try the worry time intervention.

THERAPIST: Good. Now, as we did before, how would you rate from 0–10 how
important it is for you to complete the worry and thought stopping activity?
JENNY: Around an 8.
THERAPIST: Good. Now on that same 0–10 scale, how would you rate your
confidence?
JENNY: I think a 5. I’m not sure about worrying on those specific times or that I
can do it for only 20 minutes.
THERAPIST: That makes sense. What would have to happen to go from a 5 to a 6 or a 7?
 Integrated Care Settings 195

JENNY: I’ll probably feel more confident if I see myself stop the thoughts.
THERAPIST: You’ve done very well today, and it seems like you’re getting the hang
of it. I think these exercises can really be helpful.
JENNY: Yes. I’m really hoping it will.
THERAPIST: I look forward to discussing your progress at our next meeting.

Chart Note
Jenny reported decreased anxiety symptoms with a GAD-7 scores of 10 and
SUDS scores in the 60s or below, indicating a decrease since the last session.
She was able to practice breath retraining and learn the thought stopping tech-
nique. The functional assessment indicated sub-clinical symptoms of anxiety and
panic, consistent with her GAD-7 score. Treatment will continue to focus on
breathing retraining and thought stopping. In subsequent sessions, Pattern
Focused Therapy will be used to address the role of her maladaptive pattern in
maintaining her anxiety and panic symptoms.

Session 3

Session Plan
The GAD-7 will be taken just prior to the session. First, her experience with
weaning and discontinuing her medication will be discussed. Because Dr. Jef-
fers’ chart note from earlier this week indicates that Jenny had very little
discomfort with the weaning process, the focus here will be on her anxiety
and SUDS levels as her Klonopin was weaned and discontinued. Next, her
experience and logs with breath retraining, thought stopping, and worry time
will be reviewed and discussed. She will be introduced to the Query Sequence
by processing a recent situation. Finally, brief mention will be made that her
next session involves termination and a review of her overall progress.

Chart Note
Jenny’s GAD-7 score of 8 is now at the top of mild range. This indicates
that she has experienced considerable improvement from the last session.
Her SUDS levels during the medication weaning process ranged from 60
down to 30, and 30 appears to be her baseline. She responded well to the
Query Sequence. She agreed to continue logs on breath retraining and
thought stopping. She appears ready for termination which will be the focus
of session 4.
196 Integrated Care Settings

Session 4

Session Plan: Termination Session

The GAD-7 will be completed prior to the session. She had now been weaned off
her medication completely for more than a week, presumably without withdrawal
or other side effects. Her weaning experience will be processed along with SUDS
ratings. Next, a problematic situation will be processed with the Query Sequence
with a focus on the influence of her dependent pattern. If indicated, another
ultra-brief intervention will be employed. Next, termination is discussed, begin-
ning with a review of gains made on the treatment goals set in session. Finally,
third-order change efforts will be discussed along with scheduling of a follow-up
session in three weeks which she could cancel if her improvement continued and
she did not consider it necessary.

THERAPIST: Hi, Jenny, I’m happy to see you. I see a lot of improvement in your
GAD-7 scores.
JENNY: Yes, I’ve been feeling a lot better. Especially since last time.
THERAPIST: It’s good to hear that. On the Anxiety Scale from 0–10, how would
you rate your anxiety since we met last?
JENNY: Most days it’s about a 6, but I have had some 7s.

Commentary
Now that Jenny’s symptoms have improved and she has no issues with her medica-
tion, the Query Sequence will be used again to shift Jenny’s maladaptive caretaking
pattern to a more adaptive one. Because her anxiety is largely related to interactions
with her family, in which she is overly concerned with others while ignoring her
own needs, the query sequence will be tailored to process such situations.

THERAPIST: I’m very happy to hear that. That’s a definite improvement. Do you
recall that we discussed your maladaptive pattern as taking care of others’
needs while ignoring your own needs? (Query-Pattern)
JENNY: Yeah. I remember.
THERAPIST: Would you be willing to discuss that in our session today?
JENNY: Sure. That sounds okay.
THERAPIST: Ok, can you think of a situation recently when this pattern surfaced?
(Query-1)
JENNY: Um, yes. The other day at my mom’s house.
THERAPIST: OK, can you tell me what happened, beginning to end?
 Integrated Care Settings 197

JENNY: Well, I was over at my mom’s house and walked into the kitchen and saw
her standing on a chair and reaching into a cabinet! She could’ve asked me to
get it and I would have! I freaked out and my heart skipped a beat.
THERAPIST: OK, what happened after that?
JENNY: I started yelling at her––asking her what she was doing. She brushed it off
and acted like it was no biggie. Then we got into a huge argument because I
was serious, and she finally realized it. She said I needed to grow up. It made
me so mad.
THERAPIST: Was that the entire event?
JENNY: Yes.
THERAPIST: Okay, so I want to make sure I’ve heard you correctly. You were at
your mother’s house and when walked into the kitchen, you saw her standing
on a chair and reaching into the cabinets. You were scared that she was
going to hurt herself and told her not to do that. Then, instead of listening,
she laughed it off and you two got into an argument. Is that accurate?
JENNY: Yes.
THERAPIST: OK, can you tell me what was going through your mind at the time?
What kind of thoughts did you have? (Query-2)
JENNY: I thought she was going to fall and die!
THERAPIST: So that she might fall. Any other thoughts?
JENNY: I wondered what other dangerous things she does when I’m not around.
More for me to worry about!
THERAPIST: Okay, so you thought about other things that she might do to cause
herself harm.
JENNY: Right.
THERAPIST: Anything else?
JENNY: Honestly, I thought that she didn’t care about how I felt about this kind of
thing––that it was inconsiderate of her, you know?
THERAPIST: And what did you do during that situation? (Query-3)
JENNY: I yelled at her, “Are you serious?! Why are you doing that?!”
THERAPIST: So you started yelling. What else?
JENNY: I told her that she was a crazy old lady. I’m not proud of it.
THERAPIST: Alright. Anything else you remember doing?
JENNY: Yeah, when she got down, I slammed the chair against the table.
THERAPIST: Okay. Sounds like you were very frustrated. What were you hoping to
accomplish in this situation? (Query-4)
JENNY: I wanted her to stop putting herself in dangerous situations.
THERAPIST: Is that something that you have control over?
JENNY: Not really. I can’t control her.
THERAPIST: Right. Can you think of an outcome that could have been in your control?
198 Integrated Care Settings

JENNY: It would’ve been nice if she at least listened to me.

THERAPIST: So, a good outcome would have been to express your concerns more
effectively?
JENNY: Yeah.
THERAPIST: And what actually ended up happening? (Query-5)
JENNY: Like I said, we started arguing. It was awful.
THERAPIST: So, did you get what you wanted in that situation? (Query-6)
JENNY: Not at all.
THERAPIST: OK, would you be willing to discuss some alternate ways it could have
turned out differently? (Query-7)
JENNY: Sure.
THERAPIST: Great. So, your first thought was, “She’s going to fall and die.” Do you
think that thought was helpful or hurtful in getting what you wanted––
effectively expressing your concerns? (Query-8)
JENNY: It wasn’t helpful because that’s when I started getting anxious. I couldn’t
think straight after that.
THERAPIST: So it hurt the outcome because it triggered your anxiety. What do you
think would be an alternate thought? One that would not trigger your
anxiety.
JENNY: Um, I guess she looked okay on the chair. Maybe that she wasn’t going to fall.
THERAPIST: So, instead thinking, “She looks stable on the chair.” And how would
that be helpful?
JENNY: I wouldn’t start in with all the worry.
THERAPIST: OK, and your second thought was, “I wonder what other things she
does when I’m not around.” Did that thought help you or hurt you get your
desired outcome?
JENNY: It hurt because then I was angry on top of being worried.
THERAPIST: So it was upsetting. What is a substitute thought?
JENNY: If I stopped thinking about it. Or instead that she can take care of herself.
THERAPIST: So, she can take care of herself. How would that have helped?
JENNY: Well, she’s an adult. I would just stop worrying about her.
THERAPIST: OK, good. And the third thought was that she doesn’t care about how
you feel. Did that thought help or hurt in getting what you wanted?
JENNY: It hurt. I know she’s not like that.
THERAPIST: So, what would be a more helpful thought?
JENNY: That it’s not about me. She was just doing something she needed to do and
it’s not about me.
THERAPIST: OK, so that you were completely unrelated to what she was doing.
How is thinking that helpful?
JENNY: I would’ve just let things be.
 Integrated Care Settings 199

THERAPIST: Yes, that makes sense. Now, your first behavior was yelling at her. You
yelled something like, “Seriously?” Do you think that helped you or hurt you
to successfully communicate your concerns? (Query-9)
JENNY: It wasn’t helpful because she hates when I yell. That’s actually what started
the argument.
THERAPIST: Alright. Then what would be a more helpful behavior?
JENNY: I could’ve tried offering to help instead.
THERAPIST: So, you could’ve offered?
JENNY: Yeah, definitely more helpful than starting a yelling match.
THERAPIST: Good. And then the second thing you did was call her a crazy old lady.
Do you think that helped or hurt you get your desired outcome of commu-
nicating your concerns?
JENNY: No, it definitely hurt. I’m not really communicating effectively if I’m calling
her names.
THERAPIST: Then what would have been more helpful behavior?
JENNY: Just keep my cool and not call her names.
THERAPIST: Okay, and finally you slammed the chair against the table. Was that
helpful or hurtful in getting what you wanted?
JENNY: Hurtful. That’s when she lost her cool.
THERAPIST: OK, so it’s hard to communicate when neither of you keeps their cool?
JENNY: Yeah, for sure.
THERAPIST: So, what is a different behavior that could have helped you get what
you wanted?
JENNY: I could have kept my cool and spoken calmly. I could’ve said something like,
“Mom, I’m worried about this. Can we talk?”
THERAPIST: So you would be asking to talk to her instead of expressing your anger
through slamming the chair?
JENNY: Yeah.
THERAPIST: I think some of your alternative thoughts and behaviors could definitely
lead to effective communication. Do you see yourself implementing these?
JENNY: Yes, I think I can.
THERAPIST: Good. So, on a scale from 0–10, where 10 is very important, how
would you rate how important it is for you to change the pattern of taking
care of others while neglecting yourself? (Query-10-1)
JENNY: I would say 10. Extremely important. I want to be able to deal with
situations that make me upset and anxious.
THERAPIST: Excellent. It sounds very important to you. Now on the same 0–10
scale, how would you rate your confidence that you can change that pattern?
(Query 10-2)
JENNY: Oh, probably around 7.
200 Integrated Care Settings

THERAPIST: What would need to happen to get to an 8?

JENNY:I just worry that I won’t actually be able to do it in the moment.
THERAPIST: I see. It can be difficult to do things differently in the moment, espe-
cially when we’re not used to it. That’s why it can be very important to
practice and see what it is like to do it. Would you be willing to try that
with me?

Commentary
Engaging in behavioral rehearsal will not only give Jenny a chance to practice her
new skills and alternative behaviors, but also confidence in her ability to change
her pattern to a more adaptive one. The form that behavioral rehearsal takes here
is role-playing which focuses on Jenny’s primary area of concern: her caretaking
behavior and associated worries.

JENNY: Yeah, we can do that.

THERAPIST: OK, can you think of any scenarios in the near future in which you
might be able to use the skills we discussed?
JENNY: Actually, yes. I’m supposed to go to dinner with my mom and brother. It’s
nice but also stressful.
THERAPIST: What do you find stressful about it? Can you tell me more?
JENNY: Well, I worry about his drinking. Whenever I say something, it ends up in
an argument. Also, my mother is hell-bent on driving herself, which leads to
an argument between us. I always get worked up and worried about it.
THERAPIST: OK, so things typically end up in an argument. What are the events
that lead up to that?
JENNY: Well, I offer to drive my mom, but she refuses. Then I tell her she’s too old
and she gets offended. Then I start yelling at her about how hard-headed she is.
THERAPIST: I wonder if we can do a role-play of this. Imagine that I am your mom.
Think about some of the alternatives we just discussed. What would be the
first thing you say to me?
JENNY: OK. Mom, can I pick you up to go to dinner?
THERAPIST: No, thanks. I want to drive.
JENNY: Um, you sure? It would be more convenient.
THERAPIST: No. I want to drive myself.
JENNY: OK. Well, I just want to say that I worry about you and want to make sure
you’re safe.
THERAPIST: I can see that, and I appreciate it. I just think you could stand to give
me some credit. I can take care of myself.
JENNY: OK. Well, can you please feel free to ask me if you ever do need anything?
 Integrated Care Settings 201

THERAPIST: Yeah, I can do that. (The role-play ends) How did that go for you,
Jenny? You did really well and kept your cool nicely.
JENNY: Yes, it felt different, but good.
THERAPIST: And what do you think about using this strategy with your mom when
you speak to her?
JENNY: I think I can do it. I think it’s really important for me to stay calm and
remember that she’s stronger and more capable than I give her credit for
sometimes. And, I really just want to be there for her.
THERAPIST: Wonderful! (Pause) Since this is our termination session, it is impor-
tant that we review our progress. You may recall that we set some goals for
treatment the first time we met. Shall we review those?
JENNY: Sure. Let’s do it.
THERAPIST: There were two goals we discussed and agreed upon. The first was to
reduce and hopefully eliminate your panic symptoms. How did we do on
that one?
JENNY: We definitely met that one. I haven’t had a panic for over a week now.
And, I can deal so much better when I’m stressed and anxious. Overall, I
think I’m as good as I’ve ever been, and maybe even better.
THERAPIST: That’s great. Congratulations! (Pause) The second goal was for you to
be better at meeting your own needs along with meeting the needs of others.
To what extent did you meet that one?
JENNY: (Pause) I am taking better care of myself. I am different. And, yes, my
pattern now seems a lot healthier. (Pause) I don’t think I would have ever
imagined that would have happened in such a short period of time.
THERAPIST: Well, the more adaptive it is, that is, the more you take care of
yourself while you’re taking care of others––instead of just taking care of
others––the better it will be for you and for others too.
JENNY: I can see that. Wow!
THERAPIST: You’ve done remarkably well and I’m proud of your progress and our
work together!
JENNY: Me too! (Pause)
THERAPIST: (Pause) As we discussed at our first session, we would meet for four
sessions and then review progress. If sufficient, we would stop our meetings
with the proviso that a follow-up session would be scheduled which you
could decide to keep or cancel.
JENNY: Yes, I recall. (Pause) Sure, I’m ready to set the follow-up appointment,
although at this point, I don’t think I’ll need it.
THERAPIST: Well, it has been very encouraging to watch you become more your
own therapist lately. That’s what we call third-order change. You’ve not
only effectively used the interventions you learned here on your own, but
202 Integrated Care Settings

you’re also beginning to care of yourself as you take care of others. That
basic shift in your pattern helps all the way around, including undercutting
your symptoms.

The remaining 3 minutes were spent finalizing termination, scheduling the follow-
up in three weeks, and extending well wishes for the future.

Commentary
Processing the role-play continued. The remainder of the session focused on
assessing progress toward the treatment goals mutually established in the first
session. She agreed that she had met both her treatment goals and was feeling
much better and is more confident.

Chart Note
Jenny reports no appreciable anxiety symptoms since our last session. Her
GAD-7 score of 4––the minimal level of anxiety––suggests she is ready for
termination. The session focused on her dependent pattern using the Query
Sequence to therapeutically process a recent problematic situation. She was
also introduced to and practiced behavioral rehearsal. Treatment gains were
discussed, and she agreed that she had met her treatment goals and stated: “I
think I’m as good as I’ve ever been and maybe even better.”
She also agreed to continue breath retraining and thought stopping on her
own as needed. Also discussed was scheduling a subsequent session in three
weeks which she could cancel if her improvement continued and she did not
consider the session was needed. She is already relying on her own resources to
deal more effectively which is indicative of third-order change and readiness for
termination.

Conclusion
Pattern Focused Therapy is well suited for clinical practice in integrated pri-
mary care settings. A case example illustrated the process of assessment,
interventions, a focus on first-, second-, and third-order change, and progress
monitoring that is characteristic of Pattern Focused Therapy. This very brief
treatment included both the Query Sequence and three ultra-brief interven-
tions implemented over the course of four short-term therapy sessions.
 Integrated Care Settings 203

References
Bardhoshi, G., Erford, B. T., Duncan, K., Dummett, B., Falco, M., Deferio, K., & Kraft, J.
(2016). Choosing assessment instruments for posttraumatic stress disorder screening and
outcome research. Journal of Counseling and Development, 94(2), 184–194.
Berwick, M., Nolan, A., & Whittington, J. (2008). The triple aim: Care, health and cost. Health
Affairs, 27, 759–769.
Blue Cross Blue Shield Association (2017). Blue Cross Blue Shield Association report finds link
between a population’s health and a growing economy, higher incomes and lower unem-
ployment (March 29). Retrieved from www.bcbs.com/news/press-releases/blue-
cross-blue-shield-association-report-finds-link-between-populations-health
Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral
health in primary care: Step-by-step guidance for assessment and intervention, 2nd ed. Washington,
DC: American Psychological Association.
Plummer, F., Manea, L., Trepel, D., McMillan, D., & Simpson, A. (2016). Screening for anxiety
disorders with the GAD-7 and GAD-2: A systematic review and diagnostic meta-analysis.
General Hospital Psychiatry, 39, 24–31.
Sperry, L. (2018). You’re needed on the team! Your role in practicing mental health counseling
in integrated care settings. Advocate Magazine, 41(3–4), 20–22.
Sperry, L., & Binensztok, V. (2019a). Learning and practicing Adlerian therapy. San Diego, CA:
Cognella.
Sperry, L., & Binensztok, V. (2019b). Ultra-brief cognitive behavioral interventions: The cutting-edge
of mental health and integrated care practice. New York, NY: Routledge.
Wolpe, J. (1969). The practice of behavior therapy. New York, NY: Pergamon Press.
Index

Locators in bold refer to figures and tables.

adaptive patterns: case conceptualization 36, brief therapeutic interventions 48, 63; see also
37, 38–39; case illustrations 54–55, 61; final ultra-brief therapeutic interventions
sessions 150, 152; middle sessions 138;
pattern 17–18, 30–31; pattern focused care settings see integrated care settings
therapy premises 45; pattern identification case conceptualization: case illustration
19–20; pattern recognition 21 52–53, 104–105; clinical formulation 31;
anxiety: assertive communication 65; case clinically useful 37–41; core therapeutic
illustrations 158–159, 170, 188–202; strategies 34; cultural formulation 32–33;
diagnostic screening 22; exposure 11; definition of 29; diagnostic formulation 30;
Generalized Anxiety Disorder-7 (GAD-7) explanatory and predictive power 36–37;
87, 187–188, 195–196, 202; integrated first session 101; pattern and 16, 30–31, 92;
care settings 187–188; mindfulness 72–73; pattern focused therapy practice 46–47;
scale measure 88; Subjective Units of perpetuants 32; precipitant 30, 37–38;
Distress (SUDS) 87, 187, 191; thought predisposition 31–32; presentation 30,
stopping 75; treatment goals 33 37–38; purpose and use 29–30; treatment
Anxiety Scale 88 challenges 40–41; treatment focus 34, 158;
assertive communication 54, 64–65 treatment formulation 33; treatment goals
assessment: case conceptualization and 37; 33; treatment interventions 35; treatment
cultural 28; diagnostic 21, 22–23, 101, obstacles and outcomes 36; very brief
109; duration of 27; first session 98–99, conceptualizations 41–42
100–101; functional 23–25, 101, 187; case of Eliana 52–61
goals 26; implications for treatment case of Jaime 158–159
planning 27; integrated care settings 187; case of Jerrod 104–118, 120–129, 130–136,
outcomes 26–27; pattern and 16; purpose 137–139, 144–154
and use 18, 28–29; risk and protective case of Jenny 188–202
factors assessment 25 case of Julia 160–169
awareness see client awareness Choice Therapy 11
client awareness 90–91
Beck, A. 69 client logs 27
behavioral activation 65–66, 117, 122 client motivation: Motivational Interviewing
behavioral rehearsal 67 45, 90; positive expectations 90
Binensztok, V. 77 client refusal 179–182
biological vulnerabilities 31 client-therapist bond: fostering a bond
breath retraining 67–68, 190, 191, 202 99; permission seeking 106;
brief case conceptualizations 41–42 transference-countertransference
Brief Patient Update form 85 165–172; see also therapeutic alliance
 Index 205

clinical formulation 31 etiological factors 31–32

clinical outcomes monitoring 8–9 evidence-based approaches 6–8, 51–52
clinically useful case conceptualization 37–41 evidence-based practice 2, 6–8, 51–52, 80
Cognitive Behavioral Analysis System of experience, of psychotherapists 3–4, 91–92,
Psychotherapy (CBASP): in pattern 93–94
focused therapy 12, 13, 44–45; Query expertise of therapist 94
Sequence 47–48; replacement 11 explanatory power 36
cognitive defusion 11, 68–69 exposure 11, 178–179
cognitive disputation 10, 69–70 Eysenck, Hans 93
cognitive restructuring 10
cognitive-behavioral therapy (CBT) 12, 34, family, social vulnerabilities 31–32
44, 142, 144 feedback: clinical outcomes monitoring 8–9;
Columbia Suicide Severity Rating Scale developing expertise 94; outcomes
(C-SSRS) 86 assessment 81–83; pattern focused therapy
concluding therapy see final sessions, pattern practice 48–49; psychotherapist quality 3;
focused therapy see also progress monitoring
consent see informed consent final sessions, pattern focused therapy 141;
coping skills 73–74, 176 case illustration 144–154; termination
core beliefs 174–176 141–142; termination tasks 142–144; see
core therapeutic strategies: case conceptualiza- also dropout (from therapy)
tion 34; common strategies 9–12; integrated first session, pattern focused therapy 98; case
care settings 186 illustration 104–118; essential tasks
corrective experiences 91 98–104, 118–119
countertransference 165–172 first-order changes 92
cultural assessment 28 first-order goals 102, 105, 114
cultural formulation 32–33 focus treatment 91–92
culturally sensitive treatment 35–36 functional assessment 23–25, 101, 187
Current Opioid Misuse Measure (COMM) 89
Current Procedural Terminology (CPT) Generalized Anxiety Disorder-7 (GAD-7) 87,
4–5, 12 187–188, 195–196, 202
goals: assessment 26; review of progress 143,
depression: assertive communication 65; 150; of treatment 28, 33, 102
behavioral activation 65–66; case
illustrations 52–61, 104–118, 135, 141, habit reversal 70–71
144–149, 161–163; client refusal HALT (Hungry, Angry, Lonely, Tired) 143
179–180; Cognitive Behavioral Analysis health issues, predicted trends in psychotherapy
System of Psychotherapy 47; common 5–6
measures 85–86, 101; diagnostic Health Maintenance Organization (HMO) 6
screening 22 homework: assertive communication 65;
diagnostic assessment 21, 22–23, 101, 109 case illustration 54, 55, 61; cognitive
diagnostic formulation 30 disputation 70; first session 103–104;
diagnostic impression 104 mindfulness 73; treatment focus 34;
distancing 11, 68–69 typical session 51
diversionary tactics 176–179
dropout (from therapy) 156–157 informed consent 98, 100, 114
Drug Abuse Screening Test (DAST) 88 initial change 103
duration of assessment 27 initial session see first session, pattern focused
duration of sessions 4–5, 5, 12, 63, 184; see therapy
also ultra-brief therapeutic interventions Insomnia Severity Index (ISI) 88
integrated care settings: case illustration
Ellis, A. 69 188–202; mental health needs 184–185;
ethics, evidence-based approaches 7–8 mental health practice 185–186; pattern
206 Index

focused therapy 186, 202; predicted Outcomes Rating Scale (ORS) 83, 84, 137
trends 5–6; treating anxiety 187–188 outcomes research 45
interfering factors 172–182
interpersonal functioning 31, 33, 53; see also Partners for Change Outcome Management
personality System 83
interpersonal strategies 38; see also Patient Health Questionnaire-9 (PHQ-9)
client-therapist bond 85–86, 101, 104, 118, 120
interpretation, psychotherapy 10–11 Patient Intake form 85
intervention see brief therapeutic interventions; Patient Uptake form 85
treatment; ultra-brief therapeutic pattern 18; assessment 16; case conceptualization
interventions 16, 30–31, 92; first session 101–102; key
terms 18; middle sessions 136; in pattern
last session see final sessions, pattern focused focused therapy 16–18
therapy pattern focused therapy: components 45–49;
length of sessions 4–5, 5, 12, 63, 184 contemporary trends 12–13; origins
limit setting 71–72 44–45; pattern in 16–18; premises 45;
third-wave CBT approaches 12
maintaining factors (perpetuants) 18, 32 pattern focused therapy practice 44, 49–50;
maladaptive patterns: case conceptualization case illustration 52–61; evidence-based
36, 37, 38–39; focus treatment 91–92; practices 51–52; process and sequence
middle sessions 136, 137, 138; pattern summary 50; typical session 50–51; see
17–18, 30–31; pattern focused therapy also final sessions, pattern focused therapy;
premises 45; pattern identification 19; first session, pattern focused therapy;
pattern recognition 21 middle sessions, pattern focused therapy
medical assistants (MAs) 185 pattern identification 18–20, 20, 46, 91–92
mental health providers see integrated care pattern recognition 19–21
settings pattern shifting 47
middle sessions, pattern focused therapy PCL PTSD Checklist 87–88
139–140; purpose of 120; session 2 plan PEG Pain Scale 88–89
and case illustration 120–129; session 3 perpetuants 18, 32
plan and case illustration 130–136; session personality: cultural formulation 32–33;
4 plan and case illustration 137–139 treatment challenges 39, 40–41;
mindfulness 72–73 vulnerabilities 31–32; see also interpersonal
modification of behavior 11 functioning
Mood Scale 86, 121 Pfund, R. A. 1–2
motivation see client motivation Polaris MH 84–85
Motivational Interviewing (MI) 45, 90 practice see pattern focused therapy practice;
movement types 38 psychotherapy practice
practice-based evidence 4, 80
Norcross, J. C. 1–2 precipitant 18, 30, 37–38
nurses 185 predictive power 36–37
predisposition 18, 31–32
objective countertransference 166–167 presentation 18, 30, 37–38
obsessive-compulsive personality style 41, primary care providers (PCPs) 185
104–105, 112, 118, 135 Prochaska, J. O. 1–2
optimization see treatment optimization professional prognostication 1–3
OQ-45 83, 85 professional training see training
outcomes assessment 26–27; common progress monitoring: case illustrations 54–55;
measures 26–27, 48–49; definition 80–82; clinical value 82–83; common measures
indicators of success 80, 89–94; measures 48–49, 86–88; definition 80–82;
and screeners 83–89; see also treatment practice-based evidence 4, 80; purpose of
outcomes 26–27; see also feedback
 Index 207

protective factors assessment 25 short-term therapy practice 4–5, 5, 28–29

psychological vulnerabilities 31 Silverman, W. H. 2
psychotherapist quality 3–4 skills training (for individuals experiencing
psychotherapist training see training psychological disturbance) 11; see also
psychotherapy practice: contemporary training
changes 1; outcomes research 45; pattern social context of therapy 99–100, 102
focused therapy contemporary trends social isolation case 52–61
12–13; predicted trends 4–12, 13; social vulnerabilities 31–32
professional prognostication 1–3; research Sperry, L. 44, 77
questions 3–4; see also pattern focused stimulus control 74–75
therapy practice strengths 25, 50, 53
psychotherapy research 3–4 subjective countertransference 166–167
PTSD screening 87–88 Subjective Units of Distress (SUDS) 87,
quality of psychotherapy 3–4, 93–94 187, 191
success indicators 80, 89–94; see also
Query Sequence 47–48, 49; case illustrations outcomes assessment
56–60, 117, 123–124, 129, 138–139, suicide, Columbia Suicide Severity Rating
147, 196–199; integrated care settings Scale (C-SSRS) 86
186; middle sessions 124–129, 135, 136,
139; typical session 51; ultra-brief termination 141–144; see also dropout (from
therapeutic interventions 63 therapy); final sessions, pattern focused
therapy
rapport 99, 106 therapeutic alliance 89–90, 99–100, 165, 179
Reality Therapy 11 therapeutic orientation 34, 51; see also core
relapse prevention 73–74 therapeutic strategies
relapse prevention plans 143, 145–146, 148, therapist effect 94
151, 154 therapy interfering factors 172–182
relationships see client-therapist bond; therapy pathways 156
interpersonal functioning third-order changes 92–93
replacement 11 third-order goals 103
risk factors assessment 25 third-wave CBT approaches 12, 34, 44
routine outcome monitoring 80–82, 83 Thomason, T. C. 2
thought stopping 75–76
Sackett, D. 7 training: developing expertise 94;
schemas 174–176 evidence-based approaches 6–8; skills
screening: diagnostic assessment 21, 22–23; training (for individuals experiencing
integrated care settings 187 psychological disturbance) 11
screening instruments 26, 98, 187 transference-countertransference 165–172
second-order changes 92–93 treatment: case conceptualization and 37;
second-order goals 102–103, 105 challenges 39, 40–41
selective attention 157–158 treatment focus 157–160; case conceptualization
self-efficacy 73–74 34, 158; case illustration 158–159,
self-insight 168–169 160–169; treatment optimization
self-integration 168–169 157–160
self-therapy 142 treatment formulation 33, 142
Session Rating Scale (SRS) 51, 83, 84, 100, treatment goals: assessment 28; case
118, 136 conceptualization 33
sessions see final sessions, pattern focused treatment interventions 35
therapy; first session, pattern focused treatment obstacles and outcomes 36
therapy; middle sessions, pattern focused treatment optimization: case illustration of
therapy focus 160–169; interfering factors
sexual attraction, client-therapist 169–170 172–182; therapy pathways 156;
208 Index

transference-countertransference activation 65–66; behavioral rehearsal 67;

165–172; treatment focus 157–160 breath retraining 67–68; cognitive
treatment outcomes: assessment 26–27; clin- defusion 68–69; cognitive disputation
ical outcomes monitoring 8–9; definition 69–70; definition 63; habit reversal 70–71;
80–82; goals 28; indicators of success 80, homework 103–104; limit setting 71–72;
89–94; maintaining gains 144; outcomes middle sessions 130; mindfulness 72–73;
research 45; psychotherapist quality 3–4 protocols 64, 64; relapse prevention
treatment planning 27, 85; see also core 73–74; stimulus control 74–75; thought
therapeutic strategies stopping 75–76; use of 76–77; see also
triggers 143 brief therapeutic interventions
triple aim (of health care) 6, 185
very brief therapeutic interventions see brief
ultra-brief therapeutic interventions: assertive therapeutic interventions; ultra-brief
communication 64–65; behavioral therapeutic interventions