Pattern Focused Therapy

Highly Effective CBT Practice in Mental Health and Integrated Care Settings

Len Sperry

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000080087
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

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.

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 occurring in psychotherapy practice: (1) increasing expectations and demands for reimbursement 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 conducted 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).

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) evidence-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 treatments increasingly conducted by master’s-level professionals involving evidence-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 indicated 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 documentation 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 evidence-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.

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 psychotherapy is not only effective but is very effective. In fact, the effects of psychotherapy 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 factors—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 outcomes. These include the therapeutic alliance, empathy, realistic expectations, 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 services, 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.

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 interventions 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 sessions), 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.

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

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 settings, the mental health provider will assume the role of behavioral health consultant 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 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 professionals 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 ...

Table of contents

• Cover
• Endorsements
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• Introduction
• 1. Pattern Focused Therapy and Psychotherapy Practice: Today and Tomorrow
• 2. Pattern: Assessment and Case Conceptualization
• 3. Practicing Pattern Focused Therapy
• 4. Ultra-Brief Therapeutic Interventions
• 5. Outcomes Assessment and Indicators of Successful Treatment
• 6. The First Session
• 7. The Middle Sessions
• 8. The Final Sessions
• 9. Interventions for Optimizing Treatment
• 10. Pattern Focused Therapy in Integrated Care Settings
• Index