Socratic Method of Teaching & Learning Psychotherapy 12_8_2023.pptx

The Philosophy and Practice of Clinical Outpatient Therapy
Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, Certified Clinical Trauma Professional
Executive Director, Western Tidewater Community Services Board

DISCLAIMER
The purpose of training is to help improve one’s practice
of therapy through a deeper understanding of methods.
This material is intended to augment, not replace, the instruction and practice
expectations of one’s home agency or Community Services Board.
As such, the ideas presented herein are simply those that assist me in my work
and in my understanding of human motivation and pathology.
____________________ . ____________________

I trained with Dr. Robert (Bob) Sherman, who guided my work from 1980 until his retirement and relocation from New York City, in 1992.
Bob, was an AAMFT Clinical Supervisor, author, co-founder of Adlerian Family Therapy, a long-time Fellow at the North American Society
of Adlerian Psychology, and Chair of the Department of Marriage and Family Therapy (MFT) Graduate Programs at Queens College which
he founded, where I degreed in MFT, Guidance, and School Administration, and where I served as faculty in 1986 and 1987.
During this time I joined small group instruction at the Adler Institute of NYC with Kurt Adler (1980), Bernard H. Shulman (1980), Harold
Mosak (1980,1981) and Steven Zuckerman (1982, 1983), learned hypnogogic induction from Martin Astor (1980), and attended live-
practice seminars with Maurizio Andolfi (1981), Adia Shumsky (1982), Carlos Sluski (1983), Murray Bowen (1984), James Framo (1985),
Bunny Duhl (1986), Monica McGoldrick (1987), Carl Whitaker (1988), Jay Haley (1989), Salvador Minuchin (1990, 1991), Salvador and
Patricia Minuchin (1991) and Peggy Papp (1992).
In 1990, I joined Dr. Richard Belson, Director of the (Strategic) Family Therapy Institute of Long Island, in a 2-year, live-supervision
practicum treating chronic, highly intractable problems. Belson, an intimate collaborator with Jay Haley and Cloe Madanes at the Family
Therapy Institute of Washington, D.C. (1980 to 1990), was on faculty at the Adelphi School of Social Work and serving as a senior Fellow
on the editorial board of the Journal of Strategic and Systemic Therapies (1981 to 1993).
I am indebted to these remarkable clinicians and the indelible mark they have left on our field.
I am especially grateful to Bob, for his training, encouragement, and love.
-Demetrios Peratsakis, MSEd, SDSAS, LPC, ACS, CCTP, Executive Director, Western Tidewater Community Services Board
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Training in Modeling and Teaching the Practice of Therapy

There are literally hundreds of models of therapy, each with its own perspective on human behavior. It is important then to first clarify the
assumptions under which these notes are predicated:
1. Our interpretations drive our feelings and actions. As social beings, these express in our relationship systems and effect our desire to trust and
to be intimate. They also drive our identify and sense of worth and are employed to affirm intimacy, fealty, and social bonds. Given the critical
nature of social belonging, a fundamental priority to personal thriving and to societal evolution, betrayal, in its varied forms and perturbations,
is the most traumatic and insidious psychological injury.
2. Psychological problems originate from unresolved interpersonal conflict and trauma. These emerge or are triggered by significant life events,
such as loss, enduring hardship, abuse or prolonged isolation. The ensuing pain results in depression (sorrow) and anxiety (fearfulness) fueled
by overlapping feelings of Guilt, Anger and Shame (GASh). The strategies we employ to remedy and avoid pain, may help us cope, but they
may also evolve into lifelong defenses that grow progressively antisocial with overuse. This, in essence, is the origin of psychopathology.
3. The goal of therapy is to aide adjustment and adaptation to the changes of life, as well as to provide support and solace to the need to heal
trauma, reconcile conflict or remedy injustice.
4. The therapy session is the primary venue for the practice of new ways of thinking, feeling and behaving, as well as a medium through which
clients, as well as counselors, can experience intimacy and acceptance. As a serious agent of change, the therapist actions are never quite
neutral and should be viewed as either therapeutic or counter-therapeutic. Therein, lies the impetuous for additional education and training and
the teaching of methods and technique.
5. Supervision is a transformational process, that includes the Supervisor, Counselor and Client. The resonance (isomorphism) within these
relationships permits the opportunity for self-reflection and self-discovery (metamorphosis). The Socratic Team Method for Clinical Case
Supervision encourages mentorship, collaboration and learning for growth.

Notes on the Training Slides: This PowerPoint provides a brief outline of the Socratic Team Case Supervision Model, a powerful framework
for counselor training and continuous skill refinement. The model is particularly helpful across all staffing levels, pulling small groups of
counselors and case managers together to review casework and improve client care. By its design, the model provides a structured and dynamic
format that fosters creativity, teamwork and progressive skill development in theory, methods, and practice.
While training events can be helpful, its much more beneficial to have continuous skill development built into the very design of the program.
This is especially true if the model promotes critical thinking and shapes the manager as a clinical resource. Several programs, such as P-ACT,
ACT, FEP, SOR, MST, and FFT, already employ a similar team discussion and group supervision format. Adding evidenced based methods as
part of their meetings greatly enhances their existing team structure.
Supplemental Materials: Staff knowledgeable in the basics of assessment, case conceptualization, and the development of a strong Therapeutic
Alliance benefit from more advanced skill development. Several subjects, key to a sound clinical footing, have been included in the slide deck
under Supplemental Materials:
Set A: All Counselors & Case Managers
1. Ruling Out Neurobiomedical Issues
2. Understanding Psychological Problems
3. Triangles & Triangulation
4. Challenging the Symptom and the Presenting Problem
5. Prescribing Directives, Disengaging & Redirecting Power Plays
Set B: Residents, Licensed Clinicians, and Seasoned Practitioners
5. Learning to Treat & Heal Depression
6. Symptom Origination, Development, and Expression
7. Safe-guarding Tendencies and the Psychopathology of
Overreliance on Avoidance Strategies
9. 10 Techniques All Clinicians Should Employ
Revised: December 29, 2023_9:28 am
Please note: material intended for periodic review is marked by a “cool Freud” sticker
material intended for advanced practice is marked by an “AP” star

2. Treatment Planning
Strategizing the Course of Treatment
Developing an overall approach to treatment, deterring goals, and
formulating the strategies and methods for problem resolution and
work toward achieving desired improvements and growth.
3. Intervention
Change Tactics & Methods
Getting from point A to point B and implementing and
refining the problem-resolution strategies and tactics for
change, goal achievement, and growth. This includes
selecting the most appropriate interventions, from the
hundreds of techniques available and ensuring that
evidenced based principles and tenets drive their
selection and use.
1. Assessment
Problem Analysis & Case Conceptualization
Understanding the elements of the case, the reason for treatment, the
client system and the particulars of the problem and why it emerged
now. It includes an analysis of the life-stage, issues associated with
major life tasks, strength and resiliency factors, and an overall
appreciation of the source of the pain, what needs to change or be
resolved, and who needs to participate or help and how?
# 3
Intervention
#1
Assessment
# 2
Treatment
Planning
These areas compliment one another and
should be in continual refinement across
the life of the counseling episode.

The format, small groups of counselors and case managers brainstorming practice objectives for the treatment of
complex syndromes and conditions, fosters personal and professional growth. Skill development occurs in
 Complex Problem Solving
 Critical Thinking
 Reasoning
 Creativity and Innovation, and
 Teamwork
These build Self-confidence and promote interdepartmental cooperation. As each counselor acquires greater
mastery in leading and teaching clinical practice, complementary skills are refined and become second nature:
 Effective Communication, Self-assurance, and Assuming Leadership Responsibilities
 Collaboration with Co-Workers
 Thinking Outside the Box and Adapting New Strategies
 Improvement in Organization and Time Management Skills
 Development of a Stronger Work Ethic
 Deepening of One’s Understanding of Human Problems and Client Care, and
 An Increase in One’s Knowledge and Expertise in the Field.

Socrates
Groups or
“Teams”
 Small group supervision & practicum experience
 8 - 12 members (ie. QMHPs, CMs, CSACs, LEs, Licensed staff)
 90 min – 2 hours; coffee and food is encouraged 
 Emphasis on brainstorming & critical reasoning (Socratic Method)
 Led by any seasoned clinician who acts as the Facilitator
 Apprenticeship model: format develops leadership and clinical supervision skills and fosters “future” facilitators, who
then may lead their own “teams”
Genograms
 Genograms provide a simple, yet highly sophisticated assessment tool; including key nodal events and trends, relationship dynamics,
core belief mythologies and value systems.
 Genogram presentations serve as a focal point for brainstorming, strategy planning, and examining alternative ways to intervene and
influence change
 Members learn from each other’s casework and can partner for co-therapy, peer supervision, and mutual support. Group supervision
paves the way for Socratic Circles and advanced practices, including live supervision and Greek Chorus
 Genograms expose possible traps, triggers, and vulnerabilities for the clinician and the clinical supervisor (Isomorphism)
Role Play
 Experienced clinicians use Role Play to model technique and coach members on the mechanics or How To’s of practice
 Role Play promotes confidence and allows group members try out, rehearse, and refine new techniques as well as to innovate and
explore alternative ways of interacting, including “What Ifs?”, “Do Overs”, and “Let’s Try This…”
 Role Play helps members experience the client’s perspective and can help participants work through unresolved issues
 Role Play enables members to assume a more active, directive stance which is critical for encouraging leadership
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3
1
Copy Slide for All Team Members

Team Supervision is a small group “practicum” experience that brainstorms treatment options.
1. Team Members brainstorm and problem-solve clinical case solutions. This generates new perspectives for the Presenter, promotes critical thinking, and encourages
group learning and peer cohesion. Casework serves as impetus for clinical discussion, instruction on special topics, modeling, coaching, and role-plays.
2. Members are discouraged (restricted) from advising one another or the Presenter. Instead, Members are challenged as to how they would handle the particular case or
some portion of it, real or imagined. The facilitator asks provocative, Socratic-style questions to the team, either in random or round-robin fashion: “If this was your
case, tell us how you would handle this?” “Let’s say your client tell you they are relocating and has 5 more sessions. Tell us what you might do, session by session”.
“If you could get anyone to participate who would that be and Why?”. “If you could change anything with this case, what would it be and how would you do it?”
3. Case collaboration promotes co-therapy and team-therapy options, in-session consultation, and peer supervision.
4. Sharing common ups and downs builds confidence, staff morale, and interdepartmental teamwork
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“What if…?”
“Why not try…?”
“What do you think
about this?”

1. More economical use of time, costs and expertise.
2. Skill improvement through vicarious learning, as supervisees observe peers conceptualizing and intervening with clients.
3. Group supervision enables supervisees to be exposed to a broader range of clients and syndromes than any one person’s caseload
4. The normalization of supervisees’ experiences
5. Supervisee feedback of greater quantity, quality and diversity; other supervisees can offer perspectives that are broader and more
diverse than a single supervisor
6. Quality increases as novice supervisees are likely to employ language that is more readily understood by other novices
7. The group format enriches the ways a supervisor is able to observe and monitor a supervisee
8. The opportunity for supervisees to learn supervision skills and the manner in which supervisors approach providing guidance
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1. About Assessment
 What/who has brought this client to therapy?
 What are some of the main stressors at this time?
 Why do you think the problem emerged now and not 6
months ago? What has changed?
 Is this a psychological or neurbiomedical problem?
What makes you say so? What about___?
 Who actively participates in the problem?
 Who else does the problem effect? How so?
 What stage of the life-cycle is the client in? What are
the normative processes & tasks involved?
 What is likeable about the client? Not likeable?
 How is anger handled? Intimacy?
 Why this symptom? Why not some other symptom?
2. About Treatment Planning & Strategy
 What’s best, individual, couple or family therapy?
 What model or approach would work well here?
 If the Presenting Problem wasn’t the problem, what –or
who, do you imagine might be? How so?
 Prior history of treatment? Successes? Failures?
 Who has the power to bring this client back?
 Who should attend session and why?
 After joining, what’s the first thing you would try? And
then what? And then? What next?
 How many sessions will the PP take to remedy?
 What should be the therapist’s main concern?
 How can the life tasks be better adapted to?
General Challenge Questions (continued)
 Why do you think I/she asked that question?
 What does ___ mean?
 How does ___ apply to everyday life?
 What do we already know about this?
 How does this relate to what we have been talking
about? What makes if different?
 How could you verify/ disapprove that?
 Can you give me an example?
 Are you saying ______ or ______ ?
 Do you agree or disagree with _______?
 Why is that happening?
 Show me how_____ ?
 What do you think causes _______ ?
 Why is __________ happening?
 What alternative ways of looking at this are there?
 Who benefits from this?
 What are the strengths and weaknesses of ______?
 How are _____ and _____ similar? Different?
 How could you look another way at this?
 What should we do next? And then?
 Name some possible unintended the consequences?
 How does ______ fit with what we learned before?
 Why is _______ important?
 What does the symptom do for the client?
 What other information do we need?
 What’s your reasoning for that conclusion?
 How might therapy fail? What could you do/not do to
help ensure it doesn’t? What else?
 If we flipped a switch and everything was as it should
be, what would it look like?
 What does this teach you about yourself?
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About Interventions
 How does the client respond to your directives?
 What would you try if the client was open to it?
 What have you tried elsewhere that might work here?
 What might you try even if you were unsure of the
client's reaction? How might you obtain permission?
 The client’s attendance has been/becomes spotty. What
can you do to address it? What if it continued?
 You discover the client won’t share a secret. How might
you handle it? What if it risks harm?
 Explain how you might introduce a particularly off-
putting suggestion or very tricky intervention?
 Who needs to get aligned with whom? How?
 How might you disengage these powerplays?
 How does ___ affect ___?
 How does ___ tie in with what we learned before?
5. General Challenge Questions
 What is another way to look at it?
 How would another therapist handle this?
 Would you explain why it is necessary or beneficial,
and who benefits? Why is ____ best?
 What are the strengths and weaknesses of ____?
 How are _____ and _____ similar?
 Can you rephrase that, please?
 Please explain why/how ________ ?
 What would happen if ________ ?
 What could you have done different?
 What would you try again, with another case?
 How has therapy been succeeding? Failing?
 If you were supervising someone else’s handling of this
case, what would you have them do and why?
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“Client” = individual, couple or family

Genograms are required for case presentation, assessment and case conceptualization
1. Genograms provide a common assessment tool for case studies and supervision
2. Members learn from each other’s casework, including assessment, treatment planning, methods of
intervention and special topic areas, such as depression, paraphilia or work with couples.
3. Genograms place the client(s) in a relational context and promotes thinking in systemic terms
4. Genograms take the focus off the Presenter and makes the supervision process collaborative
5. Genograms point to client foundation beliefs about roles, rules, gender, loyalties, myths, mistaken
beliefs, familial trends and characteristics
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A genogram is a family tree that emphasizes the emotional connection between its members and the nodal events, milestones and
attributes that hallmark its history. It is a powerful tool for assessment, and intervention, that benefits the therapist as well as the client
system. It places focus on the relationship system and the core beliefs structures that each member carries into the outside world.
In addition
1. It reveals the medical, behavioral health, educational, occupational, and social history of its members
2. It reveals core assumptions and beliefs about race, gender, religion, roles, and responsibilities
3. It reveals family dynamics and helps the therapist make better assessments
4. It documents key dates and illuminates the individual and familial landmarks, including rites of passage, graduations, marriages,
deaths, births, birth order, and other ceremonies or social events and that help define those experiences
5. It reveals the etiology of mistaken beliefs, attitudes and fictional ideals and intergenerational legacies, loyalties, and myths
6. It speaks to membership affiliations of who is in and out, close and distance and includes markers for intimacy, estrangement,
conflict, and emotional cut-off
7. It speaks to issues of power and authority and provides insight as to how members interpret and express love, anger, and joy
8. It provides information as to intergenerational transmission including of key biopsychosocial issues such as trauma, depression, and
anxiety, and points to ways that pain is expressed including gambling, addiction, paraphilia, neurosis and psychosis.
Genograms may also be used directly with clients. It makes the therapeutic process more collaborative and helps remove blame and
shame from the client’s experience of their family and the development of their problem.
Benefits of Using Genograms
2

1. Presenting Problem & Nodal Events
a) Case Outline: the Presenting Problem, including nodal events
surrounding its recent onset, who participates and how (denotes
purpose of problem). The sequence of behaviors surrounding the
presenting problem (who does what when?) denotes who
participates in maintaining the problem or symptom.
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2. Family Constellation: Display family membership and nodal events for at least three generations
 the client’s name, age, gender , occupation, spouse/partner, children, parents and siblings
 the wider family such as grandparents, uncles, aunties, and their pairings and children (include names, birth dates, ages, gender, occupation ,
highest level of education, dates of marriage, divorce, death, etc..)
 how persons are related and the relationship between family members (adoptions, marriages, sources of stress/support, alliances/collusions, etc..)
 clinical and health issues such as child/partner abuse, drug and alcohol dependency, anxiety, depression, heart conditions, cancers, diabetes, etc...
 ethnic and cultural history of the family
 socioeconomic status of the family
 major nodal events and recent trigger issues, such as pregnancies, illnesses, relocations, or separations
3. Family Atmosphere: Track and Interpret family beliefs and relationship patterns, conflicts, etc...
 post the client’s symptoms/concerns and trace similar patterns across member relationships
 look at roles and rules that may have bearing on the presenting problem (s); post myths, legends and value statements
 look at life-cycle, nodal events and triggers for timing surrounding the presenting problem(s)
 demarcate, by dotted inclusion lines, members who participates/in the presenting problem
 client(s) and therapist (s) share observations and interpretations from the genogram
b) Treatment Overview: including previous therapy
experiences and their outcomes, frequency and number
of sessions to date, attendance pattern, regular
participants and members refusing to attend or excluded.
c) Challenges and Quagmires: “sticky” places and
“triggers”. Known and possible pitfalls and areas of risk.
Note:
The more detailed the
information, both factual
and anecdotal, the better.
It may be collected from
several sources including
the referring agent, the
client (s), the assessment,
session work, neighbors,
family members and
friends.
A common practice is to
return to a particular
genogram to add
information, as well as to
mark and gauge treatment
progress.

Genograms Reveal Relationship Structures & Emotional Boundaries
Example: parents disengaged from one another; mother enmeshed with son
M F
...........
S
Sample Genogram
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 mapped as
Boundaries represent the emotional integration of the relationship between individuals and subsystems. When overly reactive or co-dependent
(enmeshed) they foster difficulties with individuation, a primary process of independence, maturation and adulting. When overly detached
(diffuse) emotional responsiveness is lacking and renders the members toward isolation and feeling inadequately supported. These extremes, often
intergenerational social responsiveness styles, are exacerbated at times of distress or due to prolonged trauma, conflict and periods of despair.
Mapping of boundaries,
hierarchies and subsystems
was developed as a short-
hand method of relationship
description by the Structural
school of family therapy.

Members refine their clinical practice through Modeling & Role-play (Re-enactment)
1. Modeling (Demonstrating/Teaching) technique by more experienced counselors provides “learning by observing”
2. Coaching by facilitator provides fine-tuning of verbal and behavioral interventions
3. Role-play provides members opportunities to try out, smooth and rehearse new techniques (behavior rehearsal and refinement).
“Do-overs” and “Let’s try this or in this way” fosters experimentation, creativity, and nimbleness.
4. As confidence grows, the group may elect to participate in more Advanced Practice formats including Co-therapy, Team
therapy, Multiple Family Group Therapy, Open Forums and Live Supervision
5. As confidence grows, Team members take turns facilitating the group and later establish their own Supervisory Teams
3

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Benefits of Modeling & Role Play
Modeling (teaching) technique & Role-Playing (behavior rehearsal) provide more effective method of instruction and skill refinement
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“What I hear, I forget. What I see, I remember. What I do, I understand.”
-Xunzi (340 - 245 BC)
 Modeling
 Role Play

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Role Play is a Superior Medium for Skill Acquisition
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”Students are directly active during the role play, so it is more effective in “embedding concepts” into
their long-term memory. The excitement of the role play, the interaction and stimulation to visual,
auditory and kinesthetic styles of learning helps a broad range of learners” - Yasmeen Rafaq

Empty Chair and Sculpting
are powerful techniques,
each with several
variations. They attune
focus and allow for
immediate modulation of
intensity and force.
Once a new Team or Group has been instructed on the “rules”, format, and how to construct and craft a Genogram, its best to get them mobilized and
out of their usual “comfort zone”, preferably by asking for volunteers and having them walk through a demonstration and role-play. “Empty Chair”
and “Sculpting” are two, excellent techniques for energizing the new Socratic Team and helping them to experience the power of Modeling and Role-
Play. These techniques have the added benefit that they promote team spirit, group cohesion and team-work.
1. Members become energized and interactive; the process communicates that therapy can be playful and fun, a learning, instructive
experience and an opportunity to try something different, to be imaginative and think and behave in a different way.
2. Members learn to assume a position of authority gaining confidence over leading session and how to command or direct session work.
3. Members learn to think and work in relational terms, to see human interaction and conditions in temporal and spatial terms.
4. Members learn to think and work in the here-and-now, to adapt, to be innovative, nimble and responsive in fostering change.
5. Members learn how to make covert processes overt and to simplify complex operations into manageable steps.
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Sculpting
3

•Role-Play sample:
Use of
visualization
technique
1. Client (s)
• Therapist rehearses
modeled technique.
• Tries “Do-overs”
and variations.
2. Therapist
 Coach guides practice
 Gives feedback/Adjusts
 Directs “re-dos”
 Signals starts/stops
3. Coach
The Lead Clinical Trainer/Facilitator models the tactic or technique and then circulates among the Triads, each led by a “coach” working with a “client”-”therapist"
pairing. As each member assumes one of the three disparate “roles” they gain perspective and an understanding of the dynamic of change and the therapeutic process.
1. Lead Clinician/Facilitator divides the
Team Members into Triads with 3
distinct roles: Client; Therapist; Coach
2. Lead Clinician/Facilitator
introduces, explains, and Models
selected technique
3. Lead Clinician/Facilitator sets the
task, keeps time, and directs action,
pacing and change-ups
Lead
Clinical
Trainer
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3 Teaching Triads: Training for Small Group Skill Instruction
Rotating Roles (Client, Therapist, Coach) for the Practice and Rehearsal of Technique

1. What Is It?
 A group learning experience for training in counseling and psychotherapy.
 Supervision often leaves the presenter overwhelmed with suggestions and feeling as if they might not have faired well with their work. A
more helpful format places responsibility on each of the Team members and generates more possible ways of working.
2. What Are The Learning Targets?
The counseling process has three (3) interconnected parts. Counselors need continuous skill improvement in each:
1) Assessment & Case Conceptualization: What seems to be the problem? Is it a crisis or chronic condition? Who does it effect and
how? What is the social, historical, and cultural context? What are the client’s strengths, coping skills, risks and motivation for change?
2) Treatment Planning and Strategy: What needs to change and how? What are the steps that need to be taken? Is a particular
theoretical orientation or hypothesize about the nature of the problem indicated? How do legal, medical, psychological, or medication
issues factor into planning and the development of goals? Who needs to participate and what practical issues are likely to support or
impede attendance or progress?
3) Interventive Tactics and Techniques: What specific tactics and interventions may help facilitate behavior change and prompt
experimentation in new ways of being? How will work be directed and underlying issues, such as power-struggles, trauma, depression,
and feelings of guilt and shame be remedied?
Background

3. Team Membership; Who Participates?
 As a train-the-trainer model, the Team Supervision experience is intended for group case supervision, training on expert subject material and
the apprenticeship and tutoring of counselors working toward clinical supervisor status. Membership includes the facilitator who serves in a
coaching and proctor role (Lead Clinical Trainer), counselor supervisees and 1-3 facilitators-in-training working toward a level of
confidence and competency to facilitate Team Supervision groups of their own using the same format.
 Options for Team Member Composition
1. Homogenous Team: Counselors share a comparable level of expertise or role; ie. all LEs, all QMHPs, or all TDT staff
2. Mixed Team: Counselor have varied levels of expertise or roles and are pooled from various programs, such as ES, PSR, OP
4. What is the Team Size and Schedule?
1. Sessions run for 1. 5 to 2-hours, every two weeks, with a maximum number of participants of no greater than 20
2. This scheduling accommodates 1 facilitator working with 2 groups, 1X each per week, for up to 40 counselors. When live practice
(direct client therapy) is planned, the Team membership should not exceed 12, with 6-8 a preferable group size.
5. What Tools facilitate the Team Process?
1. Use of the Genogram for a) case conceptualization and b) as a common presentation tool. Cases material provides for instruction on a)
process, such as how to transition parents into couple therapy and b) special topic subjects, such as working with addiction, domestic
violence or paraphilia. This provides counselors variety in types of client profiles and syndromes.
2. Use of the Team’s group members for Cross-training and Brainstorming over treatment goals, strategy and planning.
3. Use of Role-play to actively rehearse and practice tactics and technique and maximize working in the here-and-now in session.
In addition, the LCTs should provide periodic hand-outs and reading assignments on counseling theory, technique and special topic areas
and schedule all meetings in a comfortable room with easel and markers and adequate space and chairs for role-play practice.
Lead
Clinical
Trainer
(LCT)
Counselors LCTs-In-
Training Team
Background

As a Socrates Group or practicum group experience, the facilitator’s role is to create a classroom-like experience that challenges each clinician’s
knowledge and skill level. A main objective of the experience is to practice and refine technique through role-play and re-enactment of session dealings
The facilitator actively
1. Gatekeeps against “Advice-Giving”
Prevents members from “advising” the presenter or others: No direct advice permitted or advice-giving under the guise of asking leading
questions, asking for clarification or wondering and musing out loud
2. Provokes Critical Reasoning through “Socratic Questioning”
Stimulates critical thinking by questioning and challenging group members as to how they would handle some particular aspect of the
counseling session or intervention, then using comments from the current speaker to challenge another, and so on.
3. Trains Skill Refinement through Role-play and Re-enactment
1) Structures role-plays between members so they have an opportunity to practice and refine their skills to enact an intervention or tactic
2) Demonstrates technique by directly modeling its introduction, use and variations
3) Coaches member in “therapist” role by fine-tuning their verbal and behavioral interventions
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Background

Supervision may leave the presenter overwhelmed with suggestions and feeling as if they might not have faired well with their work.
A more helpful format places responsibility on each of the Team members and generates more possible ways of working.
1. Draw Genogram: The presenter is asked to draw the case genogram and indicate the following
 The presenting problem and a history of its onset
 Who lives at home/is involved in the presenting problem
 Who has attended session and number of sessions to date
 Their overall treatment strategy
2. Collect Info: The supervisor allows a period for information gathering (no case recommendations) by the
members
1) Presenting Problem & Nodal Events
a) Case Outline: the Presenting Problem, including nodal events surrounding its recent onset, who participates and how
(denotes purpose of problem). The sequence of behaviors surrounding the presenting problem (who does what when?)
denotes who participates in maintaining the problem or symptom.
b) Treatment Overview: including previous therapy experiences and their outcomes, frequency and number of sessions to
date, attendance pattern, regular participants and members refusing to attend or excluded.
c) Challenges and Quagmires: “sticky” places and “triggers”
2) Family Constellation (structures and sociodemographic profile data)
3) Family Atmosphere (dynamics within the relationship systems)
Background

3. Challenge Presumptions: The supervisor challenges the group, “round-robin” fashion, on how they would handle the case:
1) “You just inherited this case from the current counselor. Tell us, specifically, what you would do and how you would proceed?” or
“You only had 5 sessions left to get to the goal of therapy; explain what you would do each session, session by session?”
2) “You’ve been asked to come into session as a consultant. What’s the 1 thing you would try to accomplish in 1 session and how?”
3) “Using the other members in a role-play, show us how you would make that (move, tactic, technique) happen.”
General Questions to the Team
 Why is the client/family seeking treatment at this particular time? Why this particular problem? What has changed? What if the
Presenting problem was NOT the true problem but masked an underlying issue. What would it be? (purpose of symptom)
 What would you do if a member critical to resolving the problem refused to attend or the client refused to have them attend?
 Who has the power to bring the client(s) back?
 How might they defeat the therapist or how might the therapist be most likely to fail?
 If a co-therapist or consultant was brought in, how would you structure their role? What would wish for them to accomplish?
 If you were supervising this case what direction/instruction would you give the therapist?
 If you were to work from a different theoretical premise, what would you try and how would you approach the case?
 What specific intervention would you wish to try or employ in the next session?
4. Button-Up: The supervisor wraps up the “feedback” and
 Points to how best to work with issues common to this kind of issue, case or client;
 Cautions about possible “blind spots”
 Points to areas for clinical improvement and professional development
Background

Engaging group members in a dialogue that helps them imagine new possibilities fosters impromptu clinical strength.
The Facilitator challenges members, at random or “round-robin”, to explore how they might approach the presenter’s case:
1. Why is therapy being sought at this particular time? Why not a month ago or 6 months ago? What has changed? And, why this particular
problem? Ask yourself, if the Presenting Problem was NOT the actual problem, what else -or who else, might be?
2. Who can identify a specific intervention they would wish to try with this case? Using group members for role-play show us how you might go
about trying that.
3. Suppose you just got assigned this case. What would you do first? And then what? And then? And after, that what would you do?
4. Suppose you were trained in a different counseling style. How might you approach this case differently if it was Functional Family Therapy
(FFT)? Emotionally Focused Therapy (EFT)? What about Dialectical Behavior Therapy (DBT) or Brief Strategic Therapy?
5. You learn that you only have 5 sessions left due to an unplanned relocation. What will you try, session by session, before you end?
6. What do you do when, during a one-on-one, the client drops the following “bomb” and ask you not to disclose it to anyone:
a) “I have been seriously considering ending my life, have a specific plan, and don’t want to be talked out of it. I simply came to say Good-Bye!”
b) “I’ve been cheating on my partner for several months, and I’m unsure if I want to remain with them or separate.”
c) “ I was drinking and committed a serious crime (murder, arson, Medicaid fraud). Nobody knows, but it would definitely get me sent to jail?”
d) “I’ve been having some disturbing, invasive thoughts about you, as my therapist. They’re very sexual in nature”.
6. Someone critical to the case refuses to attend session or is excluded from participating. How would you get them in?
7. If this case was to trigger your past or pose serious pitfalls or sand traps, what would it be? Who would make you feel that way?
8. See also Sample Socratic Questions slide.
30
Sample Socratic Question Session Starters
Background

31
This is a simple, but very powerful method by which to brainstorm and encourage
new possibilities by pushing the line of thinking “further down the road”.
Think of it as a train ride and have the individual (s) imagine what’s at the very next stop.
And then the next one. And the one after that. And then so on.
The following, line of questioning works very well:
“Tell us what you would do?”
“And then what would you do?”
“And then what?”
“And then what might you do?”
“And then?”
“And how would you go about doing that?”
“And then what would you do?”
“And then what?”
“And then……….?”
Socratic Method of Drilling Down
Background

There are several formats for training in advanced methods of clinical practice.
Three are highlighted in the following slides:
The “Open Forum”; “Live Supervision Therapy”; and Multiple Family Therapy.

 In Live Supervision, you are in charge and responsible for the outcome of therapy/treatment
 Ensure everyone’s welfare, protecting the rights of the client as well as their safety
 Ensure an agreed upon format and have everyone follow the same model of treatment
 Decide, in advance, the extent of disclosure with clients of the team’s strategies and techniques
 Be prepared to redirect, block, reframe, or side-line directives by non-lead counselors
 Formats may include Supervisor/Counselor(s) alternating, Lead, Tag-team, Good Cop/Bad Cop
 Require that all participants practice before the group
 Require that supervisee is fully prepared to present their case
 Do not permit mocking, horse-play or ridicule of clients or other counselors (either side of mirror)
 Follow 1 or 2 cases from first session to termination, whether the supervisee sees a concern or not
 Demonstrate: how to effectively interview (therapy is competent interviewing; J. Haley)
 Demonstrate: how to move into the client’s emotional sphere, and then keep inching forward
 Demonstrate: how to introduce in-session tasks and force work by remaining undistracted/on-task
 Demonstrate how to introduce and reach agreement on the need to bring in critical participants
 Demonstrate: how to push for the pain, -the worry, the guilt and shame, the anger, the sorrow
 Demonstrate: how to button-up after each hard push and then at the end of a session
33
Advanced Methods of Practice requires the facilitator or lead clinician to exercise greater mastery and control of the instructional experience.
Live Supervision and Tasks Common to the Lead Supervisor
AP

34
Alfred Adler pioneered the “Open Forum”, a venue for inviting volunteers to engage in one-session problem-solving therapy in front of a live audience. Audience
members are invited to step onto the stage to discuss their situation and obtain help from the therapist and others.
The format was heavily replicated by others, including talk show hosts beginning in the 1980’s.
- modeled by Dr. Robert Sherman, Author, Senior Fellow at the Adler Institute of NYC, and Chair of the Queens College Graduate Programs in Marriage & Family Therapy.
AP

35
Lead Therapist (s)
Client (s)
Th
Th
Th
Th
Th
The advanced Live Supervision format invites seasoned clinicians to join willing clients in the therapy process under the auspices of a Lead Practitioner.
The Lead Practitioner structures session so as to draw on participating members individually or as a group (“Greek Chorus”).
The format encourages broad experimentation across gender, age, racial and cultural lines, “tag team therapy”, and structured realignments, coalitions, and collusions.
- modeled by Dr. Richard Belson, Director of the Family Therapy Institute of Long Island and long-time collaborator with Jay Haley.
Greek Chorus:
May be Active or
Silent observers;
Lead Therapist may
defer to Greek Chorus
members as a sounding
board, for opposing
opinions, for emphasis,
or to echo disparate
voices. Members may
also be called to step-in
as Co-therapists or
provide “Tag Team”
therapy support.
Unlike a 2-Way Mirror
Therapy Room the
Treatment Team, Lead
Clinician(s) and
Client(s) are all in the
same room, sitting
audience-style.
The session may be
highly choreographed
or free-floating
depending on its
purpose, the approach,
and the interests of the
client(s).
AP

Multiple Family Therapy (Multi-family Therapy/Multi-Family Group Therapy) brings several families together,
usually four to seven, who are struggling with a similar problem, condition or pathology such as Addiction, Eating Disorders, or Psychosis.
Families work together and as separate units along, and across, generational, gender, and subsystem lines.
It was first pioneered by H. Peter Laqueur, MD, at Creedmoor State Hospital, in NYC, in the early 1950’s.
36
AP

For additional information or assistance contact:
Demetrios N Peratsakis, MSEd, SDSAS, LPC, ACS, CCTP, WTCSB Executive Director
7025 Harbour View Blvd, Suite 119, Suffolk VA 23435;
dperatsakis@wtcsb.org; dperatsakis@gmail.com Cell: (757) 377-2397
Recent e-Publications (control + right click to view):
Advanced Methods in Counseling & Psychotherapy Training Modules August 2023.pptx
37
Socratic Method of Teaching & Learning Psychotherapy 12_8_2023.pptx

Foundation Skills for Seasoned Case Managers, Residents, and Licensed Professionals
39

Differentiating Neurobiomedical from Psychological Symptoms

41
Ruling out the possibility of an underlying medical condition is a critical part of the initial consultation. It should also be
prioritized whenever such a concern arises. When indicated, psychological testing and/or medical diagnostics should be
employed. Therapists should note that 1) physiological symptoms can emerge from psychological distress and that 2)
neurobiomedical conditions may express as anxiety or depression or other psychosocial impairments. Whether psychological or
somatic in nature symptoms may be used by the individual or the relationship system to gain or regain control, mediate stress,
avoid responsibility, or influence power and control. –see also section on Brain Injury and Post Trauma Distress.
STEP 1: Global Assessment
Standard instrument (ie DLA-20) or core realms of functioning, including orientation, SUD,
depression/suicidality and unresolved conflicts, trauma, and points of anger. Ideally, a cursory review of the
intrapsychic and interpersonal domains should be taken.
STEP 2: Rule Out
Exclude the possibility of a neurobiomedical condition (this Section)
STEP 3: Challenge the Meaning and Purpose of the Symptom or Presenting Problem
1) Track the beliefs and interpersonal transactions surrounding the Presenting Problem (PP), Identified
Patient (IP) or Symptom(s);
2) Test the rigidity of the belief system, unbalance existing convictions and introduce new possibilities.
3) Return to the Presenting Problem (amplify if necessary), refocus on the goal of treatment and solidify
agreement to work (Contracting). If commitment seems tenuous, seek agreement to return for “just one
more session”, using it to shore up investment.
STEP 4: Contracting
Agreement on the preliminary goal of treatment, membership, frequency/cadence, importance of the
therapeutic alliance, homework, and expectations surrounding work and pushing/encouraging change.

Constructionism & Systems Perspective on Symptoms
Origination and formation of enduring patterns of
behavior, structures or syndromes that organize social
interaction, mediate stress and provide adaptive response
to change. When biomedical conditions acquire social
significance, their expression may also emerge into
psychological symptoms or tactics.
1. Symptoms are hardened patterns of interaction around
which individuals express power and control.
2. Symptoms acquire history as they organize social
behavior including how roles and rules of behavior
become defined and how love, hate, need and want
are communicated and shared.
3. Symptoms acquire Purpose, Meaning and Power
Biomedical conditions may acquire psychosocial purpose.
Prolonged Duress and Trauma -from disaster, loss, or
betrayal, as well as from conflict and power struggles
that result in misbehavior and victimization, result in
psychological injury. Unresolved, this invariably leads to
depression and anxiety which are fueled by Guilt, Anger,
and Shame (GASh). The “injury” is to self-worth, to trust
and intimacy; to one’s willingness to be vulnerable.
42
Symptoms
1. Biomedical Condition
(CBD, ABI, TBI)
2. Prolonged Duress
(Conflict/Power Struggle)
3. Trauma
(Psychological Injury to Worth)
Source or Cause
Demetrios Peratsakis, LPC, ACS © 2018

43
This simple C.A.T. Rule-of-Thumb Rule-Out should be a matter of course during the initial consultation for hormonal, neurochemical, structural injuries or
irregularities of the body and brain. Additional concerns should be referred for psychological or neuro-medical diagnostic testing: “When in doubt, check it out!”
1. Congenital Brain Damage (CBD): genetic (pre-birth) or birth trauma
2. Acquired Brain Injury (ABI)/Neurological and Medical Illnesses: i.e.. stroke, tumors, aneurysms, thyroid disease, cancer, vitamin D
deficiency, poisoning, exposure to toxic substances, infection, choking, complications due to alcoholism, substance misuse or medications.
3. Traumatic Brain Injury (TBI): head/skull injury to brain (accidents, sports injuries, falls, violence)
What to look for:
 Evidence of Progressive Decline in Cognitive Performance
 Selectivity of the Impairment
 Attitude toward Impairment by Caregivers
 “The Miracle Question”
Things to Consider
 Formal Testing; Coordination with PCP or other primary healthcare providers
 “Can Do” vs “Can’t Do” ; “Can’t Do” vs “Won’t Do”
 Institutional Behavior
 Chronic Duress/Severe Emotional Distress
 Symptom Purpose and Intent* The idea that Psychological Symptom have purpose and meaning in social relationships is explored in the
next several slides.

Underlying medical conditions may express as psychological symptoms. The clinician must screen for disorders associated with injury or irregularities of the body and brain due to medical,
hormonal, neurological/neurochemical, structural, congenital or brain injury conditions (C-A-T) and be prepared to recommend or require additional testing. “When in doubt, check it out!”
1) Look for Symptoms which make a Medical Illness more likely:
 a change in headache pattern
 visual disturbances, either double vision or partial visual loss
 speech deficits, either dysarthrias (problems with the mechanical production of speech sounds) or aphasias (difficulty with word comprehension or word usage).
 abnormal autonomic signs (blood pressure, pulse, temperature)
 disorientation and/or memory impairment
 fluctuating or impaired level of consciousness
 abnormal body movements
 frequent urination, increased thirst (possible symptoms of diabetes) or significant weight change
 sudden onset of delusions or hallucinations not associated with delirium or dementia
 allergic reaction or influence of alcohol, prescription/street drugs, poisoning or other substances and toxins
2) Look for Evidence of Progressive Decline in Cognitive Performance from a Previous Level: impairment to complex attention, executive function, learning and
memory, language, perceptual-motor, or social cognition, as documented by self-report, the expressed concern of a knowledgeable informant or observer, and supported by
a) Mental Status Exam (MSE) or standardized neuropsychological testing for detecting cognitive impairment, i.e. https://www.alz.org/media/documents/cognitive-
assessment-toolkit.pdf
b) Medical examination (i.e.. blood test, cat scan, MRI, MRSI, MEG or diffuse tensor imaging) or
c) Testing: https://www.ncbi.nlm.nih.gov/books/NBK64110/ and https://www.ncbi.nlm.nih.gov/books/NBK64105/
3) Selectivity of the Impairment: Is performance relatively consistent across similar tasks, functions or activities or does it appear to vary depending on interest, surroundings
or participants?
4) Attitude toward Impairment by Caregivers: Does the behavior elicit compassion or anger? Do others view the actions as manipulative, belligerent or vengeful? Would
caregivers agree that the individual “Can’t/Can Not” control their behavior or do they believe they simply “Won’t” for some reason?
5) “The Miracle Question” This was first employed by Alfred Adler as a method to distinguish between psychological and somatic conditions: “If I were to waive a magic
wand and it got rid of this symptom you’re experiencing forever, what would be different?” If, as an example, the complaint was chronic back-pain and the response was “I
would get a good night’s sleep”, it points to the possibility of a medical condition. If, on the other hand, the response appeared associated with some task in life, such as
“I’d finally go back to school and finish my degree”, we might suspect a psychological purpose as the foundation. –See Related Screening Factors, next 2 slides
44

1. “Can Do” vs “Can’t Do”
It is important to distinguish between three, related terms to better assess the expectations we should hold of our clients as well as ourselves:
Ability, one’s actual mental or physical skill; Capacity, one’s potential to develop or acquire a skill; and Capability, one’s unique fitness for
a defined end or purpose. While there are rule-of-thumb ways to rule-out underlying medical conditions, a more precise assessment of
complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition is difficult to ascertain without
more comprehensive testing. Typically, the need to do so is expressed by family, friends and caretakers or more readily apparent during the
course of treatment. The simple rule: so long as the individual retains capacity to learn, they can benefit from counseling.
2. “Can’t Do” vs “Won’t Do”
Ambivalence, due to fear and apprehension, is not the same as unwillingness disguised as inadequacy, failure or sabotage. Can’t Do vs
Won’t Do may initially be difficult to discern as the second often masquerades as the first. Many feign helplessness and despondency in
order to place others in their service, escape responsibility, or burden then as an act of punishment and revenge. This is a passive-aggressive
power-struggle for control. It does not mean the individual’s suffering is not genuine; simply that the guilt and shame bring a sense of
legitimacy to the “nobility” inherent in the experience. When others feel manipulated and resentful, instead of compassion for the
individual, it’s likely that “refusal” rather than “inability”, is at play. The power-play must be disengaged and redirected in order for
treatment to proceed.
45

3. Institutional Behavior
To what extent has the individual been conditioned by their history with institutional care from hospitals, emergency departments,
day support programs, social services departments, counselors and even jails? For many, the behavioral healthcare system has
become their default social network, within which they have learned to accommodate their behaviors and beliefs in order to more
effectively navigate their needed social supports. Is the behavior a learned response to the therapeutic context? It should also be
noted that long-term institutional care, as well as chronic addiction problems, may adversely impact maturation and more age-
appropriate social adjustment.
4. Symptom Purpose and Intent
Symptoms are socially organized transactional patterns that acquire meaning, power and purpose. To understand their purpose, one
need examine the outcome of the behavior and its social implications. What the symptom “accomplishes” is it’s intended outcome.
This, rather radical perspective can provide great insight as to the reason for one’s actions and the goal of the behavior. Where the
behavior has volition and intent, their exists a psychological component. Even symptoms of an underlying bioneuromedical
condition can acquire social purpose and meaning. Where they compromise the individual or family’s ability to more effectively
manage life’s tasks or adapt to change, counseling may be indicated. –see slides on Psychological Symptoms and their Purpose
5. Chronic Distress
Physiological symptoms of chronic tension, violence or distress, may present as psychological problems, including disorganized
thoughts, difficulty concentrating, irritability, fatigue, headaches, difficulty sleeping, digestive problems or changes in appetite,
feeling helpless or a perceived loss of control, low self-esteem, loss of sexual desire, anxiety, frequent infections or illnesses.
46

A. General Assessment: Interpersonal, Relational Factors
1. Global Functioning (instrument or Hx); history of the Presenting Problem (PP) and/or Identified Patient (IP)
2. Relationships, Intimacy and Love Supports: partnership(s), current support system, Family of Origin, Family Constellation and Family
Atmosphere (Genogram). Three-generational assessment, including historic artifacts, characteristics and sociodemographics.
3. Maturation/Life Tasks: general adjustment and adaptation to the developmental, Life-Cycle processes and the demands of the Tasks of
Adulthood. Approach and attitude to life’s challenges, hardships and disappointments; ability to effectively resolve conflict, cooperate, and
problem solving with others; movement toward the constructive, nonconstructive and destructive.
4. Open Discord, Conflict and Power Struggles (ie. detouring, coalitions and collusions; passive-aggression and temper tantrums)
5. Unresolved Trauma, especially Interpersonal Violence and Betrayals (ie. cut-offs, expulsions, abuse, rejection, affairs and abandonment)
6. Therapeutic Alliance: continuous monitoring of trust and collaboration within the therapeutic relationship.
B. Specific Assessment: Intrapsychic, Internal Processes
1. The Self Concept: the combination of characteristic beliefs, values, moral convictions, and attitude toward Self, Others and the World that
form the individual's distinctive perspective; understood through themes and patterns.
2. The Self Ideal: the fictitious goal or imagined state of excellence; “self-actualization” or striving for ‘superiority’, purpose and meaning.
3. The Self Ideal vs the Self Concept
 the difference between the Self Ideal and the Self Concept may be viewed as a gauge or barometer of Self Worth and Self Esteem
 this difference points to the likelihood of over-reliance on avoidance and self-protection tendencies (Safeguarding)
49
A comprehensive psychological assessment should evaluate both Interpersonal (General) and Intrapsychic (Specific) factors.
Neurobiomedical causes should have been “ruled out” and the Presenting Problem deemed psychological in nature.

50
1. Need to Avoid Blame & Shame
 Problem accepting criticism and the risk of failure
 Problem with responsibility and the risk of judgement by others
2. Problems with Empathy and Intimacy
 Co-dependency; giving up the self as a method of pleasing others
 Hypervigilance to critique and the opinion of others
 Difficulty with trust, communicating and speaking true feelings, beliefs, and needs
3. Poor Self-esteem & Self-worth
 Struggles with feelings of shame, inadequacy and worthlessness
 Continual need for validation from others
 Constant bouts of Guilt and Shame, which fuel depression and anxiety
 Difficulty with appropriate assertiveness; having weak and/or inflexible boundaries
 Self Concept continuously falls short of the Self Ideal
4. Problems with Anger & Aggression
 Misuse of Anger, Power and Control to feel superior or more worthy than others
 Passive-aggressive displays of revenge and blame to inflate false sense of vanity
5. Difficulty Adjusting to the Demands of Life and Life Events
 Difficulty coping with pain or adequately reconciling adjustment to significant normative and paranormative
changes associated with 1) the Life Cycle and 2) the Adult Life Tasks of Work, Friendship, and Love.
 Overreliance on avoidance strategies to blunt, mitigate or avoid pain.
Adulting requires successful reconciliation of the challenges that accompany Life’s demands.
Problematic psychosocial dynamics, as well as unresolved trauma, can impede the maturation process and the individual’s ability to thrive.

Trauma
Life
Cycle
Life
Tasks
3) Trauma
Psychological injuries due to significant hardship, conflict,
loss, natural and manmade disasters, or human tragedies.
Trauma may be cumulative; it diminishes our willingness to
risk re-injury and adversely impacts our desire for intimacy
and trust. Betrayal is the most insidious form of trauma.
Unresolved, trauma results in depression and anxiety.
2) Life Tasks
Core developmental domains of maturation and adulthood,
including a) Work; b) Friendship/Community; and c) Love (Alfred
Adler; Dreikurs/Mosak added d) “Self” and e) “Spirituality”).
These are critical to self-identity and belonging as a social being.
Details on next slide.
1) Life-Cycle Changes
Normative and para-normative developmental
stages or changes that occur across the life-span.
Each involves series of relatively universal
processes and tasks, such as young adults
preparing to leave home, the birth of a first
child, marriage, separation, divorce, and so on.
(see Monica McGoldrick and Elizabeth Carter)
Adulthood & Maturation: 1) reconciliation and adjustment to the significant changes created by Life Cycle events and processes;
2) relative success in negotiating the Tasks of Life and acceptance of the injuries and hardships imparted by others as well as Life’s misfortunes.
Clinical Review: given the circumstances (age, type of and scope of injury, opportunity to remedy, et al), how well is one doing or should be doing?
Problems arise when individuals are unable to cope or adequately adjust to significant events in one of the three (3) main domains of life.

The Adult Tasks of Life are the Goals & Developmental Context of Socialization.
“The human community sets three tasks for every individual. These three tasks embrace the whole of human life with all its desires and activities.
All human suffering originates from the difficulties which complicate the tasks” - Rudolf Dreikurs, 1953
1. Work: contributing to the welfare of others; the need to cooperate and build community, to belong and to share, for comfort, protection, resource development, and a
means of pooling information and innovation (culture). –evolutionary advantage. This includes Occupational Choice (who we are moves what we choose to do or to be
known by others); Occupational Preparation (being trained and training others builds worth and confidence); Satisfaction (daily and career goals that shape movement
toward our final goal or self-ideal); Leadership; Leisure; and Socio-vocational (relationships with colleagues is an important part of community).
2. Friendship/Community: building social relationships with friends and relatives; Cohesion, attachment and bonding. The creation and expansion of culture (innovation,
information) -evolutionary advantage. It includes Belonging, the sense of being accepted and cared for by others, of being valued, is the fundamental driving force of
humankind, and Transactions, how we interact with others. These are directly responsible for the abatement of one’s sense of vulnerability and inferiority.
3. Love: Intimacy, bonding, establishing (sexual) intimacy with a partner and the foundation of procreation and parenting. This is the most demanding and rewarding of
adult relationships. It includes Sexual Sex Role Definition (What is Man? A Woman?); Sexual Sex Role Identification (Masculinity; Femininity); Sexual Development
(puberty, secondary sexual characteristics, menstruation, masturbation, et al); and Sexual Behavior.
4. The Self Task: Survival; Body Image; Opinion; and Evaluation (added to Adler’s original three, above)
5. The Spiritual Task: Relationship to God; Religion; Relationship to the Universe; Metaphysical Issues; and Meaning of Life (added to Adler’s original three, above)
The Tasks of Life provide opportunity for socialization and the development of meaningful, intimate relationships.
Intimacy, an agreement to risk hurt in exchange for trust and acceptance, and love require Empathy the driving conviction of Social Interest.
Improving Empathy, will improve the development of meaningful relationships and, in turn, success in the Tasks of Life.
52
“Nobody adopts antisocial behavior unless they fear that they
will fail if they remain on the social side of life.”
― Alfred Adler

3. Trauma
(Failure, Tragedy, Loss, Betrayal)
1. Difficulty Adjusting to
Life Cycle Changes
2. Interpersonal Conflict
(Overt/Covert Power-Plays; Interpersonal
Violence and Acts of Betrayal)
Depression
and
Anxiety
Presenting Problems fall into one
of three categories, often triggering
one or both of the others
Psychological
Problem
Psychological problems arise due to difficulties adjusting to significant events in one of three (3) main domains of life
*While any physical infirmity, medical condition, or brain injury (Congenital Brain Damage; Acquired Brain Injury; and Traumatic Brain Injury (TBI)
can acquire functional value, their origins are deemed non-psychological and should be ruled out as primary targets for psychotherapy. Significant change,
conflict, and trauma, require adjustment in role, function, identity and interpersonal relations which may be difficult to navigate or reconcile. Unresolved,
this invariably leads to depression and anxiety, fueled by Guilt, Anger, and Shame (GASh). Symptoms arise as a means of regaining or obtaining control.

3. Trauma
(Failure, Tragedy, Loss, Betrayal)
1. Difficulty Adjusting to
Life Cycle Changes
2. Interpersonal Conflict
(Overt/Covert Power-Plays; Interpersonal
Violence and Acts of Betrayal)
Depression
and
Anxiety
Presenting Problems fall into one
of three categories, often triggering
one or both of the others
Psychological
Problem
Psychological problems arise due to difficulties adjusting to significant events in one of three (3) main domains of life
Relational Perspective on Symptoms
Origination and formation of enduring
patterns of behavior, structures or
syndromes that organize social interaction,
mediate stress and provide adaptive
response to change.
1. Symptoms are hardened patterns of
interaction, or “structures”, around
which individuals express power and
control.
2. Symptoms acquire history, as they
organize social interaction, including
how roles, rules, boundaries,
expectations and functions are
defined and how love, hate, need and
want are communicated and shared;
often, over generations.
3. Symptoms acquire Purpose,
Meaning and Power.
*While any physical infirmity, medical condition, or brain injury (Congenital Brain Damage; Acquired Brain Injury; and Traumatic Brain Injury (TBI)
can acquire functional value, their origins are deemed non-psychological and should be ruled out as primary targets for psychotherapy. Significant change,
conflict, and trauma, require adjustment in role, function, identity and interpersonal relations which may be difficult to navigate or reconcile. Unresolved,
this invariably leads to depression and anxiety, fueled by Guilt, Anger, and Shame (GASh). Symptoms arise as a means of regaining or obtaining control.
Symptoms

Poor
Adjustment
to Change
Conflict Trauma
Depression
& Anxiety

Unattached
Young Adult
Newly Partnered/
Married Couple
Family with
Young Children
Family with
Adolescents
Launching
Family
Family in
Later Years
Family Life Cycle The Unattached Young Adult
 Differentiation of Self in Relation to the Family of Origin
 Leaving Home
 Tasks of Life:
1. Work/Career;
2. Friendship;
3. Love
Newly Partnered/”Married” Couple
 Developing the Couple Relationship:
1. Strengthening the Relationship Against
Others;
2. Negotiating Power, Rules and Roles;
3. Building Vulnerability, Trust and Intimacy
Family with Young Children
 Establishing the Executive Subsystem
1. Strengthening the Relationship Against Others;
2. Negotiating Parenting Styles
 Sibling/Ordinal Positions:
1.Personality growth
2.Demarcation of roles
Families with Adolescents
 Individuation creates transition of Power
 Preparing Child for Adulthood
 Building Parents’ careers
Launching Family
 Separation and Loss
 Making room for new additions
 Reaffirming/renegotiating Couple
Families in Later Years
 Retirement
 Loss of friends and loved ones
 Existential angst/death and non-
beingness
Common periods of emotional and intellectual relationship adjustments across the life-span (Monica McGoldrick).
Each necessitates significant adjustment to change in existing emotional processes, relationships, beliefs, and identities.
56
NOTE:
Families and relationship
systems are enormously
complex and varied.
The “Life-Cycle Stages”
depicted here are a gross
oversimplification of the
developmental social
changes of life. Within
each significant “phase”
or “stage” there are
specific emotional and
social processes that
change and that we must
adapt to and reconcile.
Read Monica McGoldrick
and Elizabeth Carter’s
groundbreaking work on
life-cycle processes.

Breaking the impasse
by undermining or
overpowering others
Conflict
creates Anxiety
Common
Problem-solving Remedies
1. Collaboration/Alliance
(win/win)
2. Compromise
(I bend/you bend)
3. Accommodation
(I lose/you win)
4. Competition
(I win/you lose)
5. Avoidance
(no win/no lose)
6. Triangulation
(win/win/lose)
Conflict
Anxiety builds
until resolved
Unresolved,
conflict results in
Power-struggles
Common Outcomes*
1. Open Discord
a. Stable, unsatisfying
b. Unstable (unsatisfying)
2. Impairment in a Child
a. Attention Seeking
b. Power Seeking
c. Revenge Seeking
d. Displays of Inadequacy
3. Impairment in a Partner
a. Failure
b. Depression
c. Illness
4. Emotional Cut-off (escape,
expulsion, abandonment)
* Bowen (1-4); Adler (2. a,b,c,d)
Power
Struggle
Tension solidifies
into long-term
discord
Power Play
Anger and hurt
result in dire
attempts to break
the impasse
Demetrios Peratsakis, LPC, ACS, CCTP © 2014
Common Threats
Treachery or Betrayal
 theft, disloyalty, sabotage, incest,
abandonment, infidelity
Revenge
 punishment, suicide, crime,
depression, addiction, eating
disorders, failure or acts of
inadequacy
Violence
 warfare, bullying, threats, rage,
domestic violence, abuse
Scapegoating
 Severe triangulation,
victimization or bullying
A
The Good
B
The Bad
C
The Ugly
Where there’s a “Will” -there’s a “Won’t!”
Unresolved, conflict leads to power struggles and “stalemates” often “broken” by undermining or overpowering the partner or significant others.
Severe
Trauma
Trauma
Intensifies
57

Tragedy or Hardship
Victimization by a manmade or natural disaster,
hazard or catastrophe causing great suffering,
hardship, destruction or distress, such as a serious
accident, threat of harm or crime.
Loss
Ambiguous loss; loss of a loved one; loss of
prestige, a prized possession, a familiar way of
being, one’s health, or one’s goal.
Conflict or Betrayal
A breach of the trust agreement among friends,
family or lovers, including abuse, neglect, incest,
back-stabbing, infidelity and sexual affairs.
Emotional experience: Fear (Dread)
Impact: sense of Vulnerability
Preoccupation: Avoidance (Safety-Needs)
 Emotional experience: Sorrow (Grief)
 Impact: sense of Emptiness
 Preoccupation: Replacement
Emotional experience: Anger (Rage)
Impact: sense of Treachery
Preoccupation: Revenge
Often
Overlap
Source of Distress (Injury) Psychological Impact
Trauma is distress (extreme anxiety, sorrow or pain) fueled by Guilt, Anger and Shame (GASh).
1. The injury diminishes one’s sense of Worth, which is inextricably tied to others.
2. Unresolved, we seek remedies that circumvent the pain but do not reconcile the injury (Avoidance Strategies)
3. The greatest injury is borne by the trauma of betrayal of a sacred trust
4. Injury is expressed in symptoms we call Anxiety and Depression, whose purpose is to avoid the potential for re-injury

Triangles: Problem Solvers and Creators
Triangle Theory
1. Conflict is a continuous condition of human interaction
2. Triangulation is a pattern of interaction that reduces conflict and distress; it is a process whereby anxiety is decreased, and
tension dissipated through emotional interaction with others
“The (Bowen) theory states that the triangle, a three-person emotional configuration, is the molecule or the basic building block of
any emotional system, whether it is in the family or any other group. The triangle is the smallest stable relationship system. A two-
person system may be stable as long as it is calm, but when anxiety increases, it immediately involves the most vulnerable other
person to become a triangle. When tension in the triangle is too great for the threesome, it involves others to become a series of
interlocking triangles.” M. Bowen. “Family Therapy in Clinical Practice.” Aronson New York. 1976. P373
3. Unmediated, conflict results in chronic tension expressed as “physiological symptoms, emotional dysfunction, social illness
or social misbehavior” - M. Bowen
4. According to Bowen, the resulting conditions are characterized by
a) marital (or partner) discord;
b) dysfunction in a partner;
c) impairment in one or more of the children; or
d) severe emotional “cut-off”, including isolation, abandonment, betrayal, or expulsion
5. Triangulation may also result in preferred patterns of interaction that avoid responsibility for change –Alfred Adler
60

- dyad
-third person or subject of mutual, concern or interest
anxiety
closeness may increase as
anxiety is reduced
61
 Two members (or all three) are drawn closer in alliance or support.
For example:
 Separated or divorced husband and wife come together as parents for
their child in need
 sisters share greater intimacy after one has been the victim of a crime
(the triangulated my be a person or an issue, such as “work”, the
“neighbors” or in this example, the “crime”)
 A third party helps mediate conflict or remedy problem
in the two-person relationship (dyad).
For example:
 siblings cease their disagreement over chores to actively
chide their younger brother
 co-workers are unclear on best approach to an issue and
seek guidance from their supervisor
- dyad

Conflict in the dyad goes
unresolved as attention is drawn
away from important issues
Adult
Adult
child
# 2. Collusion and Cross-generational Coalitions (problem avoidance)
# 1. Detouring or “Scapegoating”
(problem avoidance)
 Collusion: Two members ally against a third, such as when a friend serves as a
confidant with one of the partners during couple discord or siblings ally against
another. The third member feels pressured or manipulated or gets isolated, feels
ignored, excluded, or rejected as a result of being brought into the conflict
 Cross-generational Coalition: The third party is a child pulled into an
inappropriate role (cross-generational coalition) such as mediator in the conflict
between two parents. This could include parent-child-parent and parent-child-
grandparent triangles.
62
# 1
# 2

Conflict in the dyad goes
unresolved as attention is drawn
away from important issues
Adult
Adult
child
# 2. Therapist Unwittingly Colludes with a Member (problem avoidance)
# 1. Collusion against the Therapist
(problem avoidance)
 Collusion: Two members ally against a third, such as when a therapist serves as a
confidant with one of the partners during couple discord or agrees with someone’s
opinion that another member is the Identified Patient. The targeted member feels
pressured or manipulated or gets isolated, feels ignored, excluded, or rejected.
63
# 1
# 2
T
T
Therapist

 Triangulation begins as a normative response due to stress or anxiety
caused by developmental transition, change or conflict
 The pattern habituates, then rigidifies as a preferred transactional
pattern for avoiding stress in the dyad
 The IP (Identified Patient) begins to actively participate in maintaining
the role due to primary and secondary gains (ie. distratction, attention)
 The “problem”, which then serves the purpose of refocusing attention
onto the IP and away from tension within the dyad, becomes an
organizational node around which behaviors repeat, thereby governing
some part of the couple or family system’s communication and function
 Over time, this interactional sequence acquires identity, history and
functional value (Power), much like any role, and we call it a
“symptom” and the symptom-bearer, “dysfunctional”
 A key component in symptom development is that the evolving pattern
of interaction avoids more painful conflict
 This places the IP at risk of remaining the “lightning rod” and
accelerating behaviors in order to maintain the same net effect
 When this occurs, it negates the need to achieve a more effective
solution to some other important change (adaptive response) and
growth is thwarted. The ensuing condition is unhealthy as it stifles
maturity and social adulting.
Over time
64

Research suggests that people develop Cognitive Distortions as a way of coping with adverse life events. In theory, the more prolonged and severe
those adverse events, the more likely it is that one or more cognitive distortions will form. In this regard, Cognitive Distortions, or Mistaken
Beliefs, also serve a means of safeguarding the individual and relationship systems sense of worth and self-esteem. This was first described by
Alfred Adler as erroneous or problematic schema by which we make judgements as to who we are and how we should behave. In truth, Cognitive
Distortions, or Mistaken Beliefs, constitute the predominant accumulation of core tenets and values that comprise personality and individual
interpretation. Subjectivity is, by definition, one’s impressions of the world based on or influenced by personal feelings, tastes, or opinions. The
more erroneous, the more “mistaken” or “distorted” and the more askew the conclusions and outcomes drawn from them:
These core judgements shape
a) How we belong with others, family and community
b) Our feelings of worth and interpersonal significance
c) Our sense of safety and feelings of security
1. These perceptions develop early in childhood and surround such core conceptualizations as Self-concept, Self-ideal and Self-esteem. They
are fueled by intergenerational narratives, including myths, legends and legacies. Typically, especially with religious or local customs,
there exists a moral imperative attached to the belief. Implied, is that to breach or violate the “rule” is tantamount to disloyalty or sin.
2. In great part, these same beliefs can become fundamental impediments to change. They can restrict our social sphere, prejudice our
narratives, and thwart the inner imperative toward Social Interest and our investment in the welfare of the community and others.
3. These ideas also drive our sense of protection, the degree to which we must ensure safety and security in the world around us. When
threatened, they become progressively more rigid and antisocial, often compartmentalizing the world and dividing allegiances and trust.
4. The purpose of therapy, therefore, is to challenge or unbalance the power, meaning or purpose of the existing belief in order to introduce
new possibilities. This expands the potential for more adaptive problem-solving, remedial change, and more enduring growth.
66

67
Several theoreticians have catalogued common Mistaken Belief and Cognitive Distortion patterns, including the Neo-Freudians Aaron Beck and
David Burns (Cognitive Distortions), the Adlerians Harold Mosak and Richard Dreikurs (Mistaken Beliefs), the Neo-Adlerians Karen Horney and
Albert Ellis (REBT Irrational Beliefs) and the Family Therapists like Vimala Pillari and his Family Myths of shared cognitive distortions.
Of all, Bernard Shulman, MD (1973) categorized 6 “mistaken” beliefs, based on Alfred Adler’s work, work exceedingly well:
1. Distorted attitudes about the Self (“I am less capable than others”)
2. Distorted attitudes about the World and People (“People are hurtful”; “Men will always let you down”)
3. Distorted Goals (“I must be perfect”; “I must win at all cost”)
4. Distorted Methods of Operation (ie. excessive competition; procrastination; avoidance)
5. Distorted Ideals (“ a real man…..”; “women should always…”)
6. Distorted Conclusions (“Life is…”; “I am a Failure/Victim…”)
“Each . . . (individual) organizes himself according to his personal view of things, and some views are more sound, some less sound. We must always
reckon with these individual mistakes and failures in the development of the human being. Especially must we reckon with the misinterpretations made
in early childhood, for these dominate the subsequent course of our existence.” -from The Individual Psychology of Alfred Adler: A systematic presentation in
selections from his writings. (H. L. and R. R. Ansbacher, Eds.). © 1964, Harper & Row, Publishers, Inc; page 183:

Problem Interpretations Originate and Reinforce Psychopathology
1. Look for rigidity and inflexibility in rules, expectations, and outlook
2. Look for conflict (guilt and shame) created between ideal vs actual performance
3. Look for extremes such as “Must” and “Should”, “Never” and “Always”
 Trace it in the family lineage (genogram); ie “Whose rule is that?”
 Examine Pluses and Minuses to broaden narrow perspectives
 Examine how it is used to reaffirm convictions that preserve one’s sense of self, self-esteem or loyalty to family
 Examine what “breaking” the rule means and how that justifies retaining the conviction
 Examine the purpose of the conviction or the benefit its conflict, shame or guilt provides. Often, while negative, suffering
can entail a sense of “nobility”. It can be a powerful way to punish others or excuse oneself from challenges and change
4. Challenge the Meaning and Rigidity of the Symptom -introduce doubt and then substitute alternative possibilities
 Track the beliefs and interpersonal transactions surrounding the Presenting Problem (PP), Identified Patient (IP) or
Symptom(s);
 Test the rigidity of the belief system, unbalance existing convictions and introduce new possibilities;
 Return to the Presenting Problem, refocus on the goal of treatment and solidify agreement to work (Contracting)
5. Determine the Purpose of the Symptom
Problems and symptoms are social constructs. It’s important therefore to understand how others are affected by them and
how their involvement or responses reinforce the problem transactions (dysfunctional interactional pattern)
 Determine the Line of Movement of the Symptom/Behavior (see next slide)
 Answer: “Who is most affected by your symptoms or this problem -and how?”
 Answer: “What/How would things be different in your life if you didn’t have this problem or these symptoms?”
(“The” Question; Adler, 1929. Often incorrectly credited to deShazer; used for differential dx also).
68

When examining symptoms, problem behaviors or severe avoidance strategies (Safeguarding) it is important to determine
the Line of Movement, the specific purpose and intent of the action, behavior, feeling, activity or transaction.
The Line of Movement will always be consistent with the person’s striving toward a means of remaining safe while contending with the social demands of life.
69
Symptom or
Problem Behavior
(ie. odd behavior)
Outcome/Goal
What does the behavior,
feeling or action
accomplish?!
Clue: Look at the reaction of
others, how they respond or
behave; that is the likely
intent of the Symptom or
Problem Behavior!
A B
Q: What is the Purpose of the Symptom, Action, Feeling, or Behavior?
A: Work backwards from the Outcome to discern its Intent or Purpose!
Narratives, trends, symbols, patterns and other similar forms of social and intrapsychic communication are not aimless or without intent.
Called the “Golden Thread”, by noted Adlerian Robert Sherman, tracing the goal or outcome back to the onset of the action will unveil its intent.
The intent, is the true purpose or motivation of one’s actions.

Disrupt beliefs about the Symptom,
the Presenting Problem or the
Identified Patient. Modify its meaning.
Disrupt the sequence of events,
behaviors and interactions that surround
the Symptom’s expression or aftermath;
Disrupt the social structures (shared beliefs)
that reaffirm the symptom and its expression,
including roles, rules, functions, expectations
and ways of being organized
1. Use Cognitive Restructuring and Critical Reasoning
techniques to sow doubt, blur or soften the belief or
conviction. Related techniques include Motivational
Interviewing, the “Columbo” technique, Socratic
Questioning, and Confrontation techniques that “soften
the beach”.
2. Introduce alternative explanations or imaginings. Use
terms like “What if…?”; “Is it possible that….?”; “Can
you picture…?”; “Some people…”; “if it was somehow
different, how would that be?”; “If you could do that,
what would that be like?”
3. Trial new possibilities. Predict discomfort or
backsliding to older habits. Be on the alert for sabotage.
The counselor must “unbalance” this rigid pattern of ideation by introducing doubt through alternative explanations, gaining insight and then practice with
new possibilities. The most common method is to use Critical Reasoning, or a process known as Cognitive Restructuring (Doyle, 1998; Hope, 2010) to
shift the client’s belief or have them behave in a different way. Alternatively, the counselor can ask “How does that make you feel?” and proceed to
examine the thoughts and beliefs that underly and support the feelings. It will always be about hurt, even when anger is the prevailing emotion expressed.
34

1. Create a new symptom (ie. “I am also concerned about
________; when did you first start noticing it?”)
2. Move to a more manageable symptom (one that is
behavioral and can be scaled; ie. chores vs attitude)
3. I.P. another family member (create a new symptom-bearer or
sub-group; ie. “the kids”, “the boys”)
4. I.P. a relationship (“the relationship makes her depressed”)
5. Push for recoil through paradoxical intention (caution!)
6. “Spitting in the Soup” –make the covert intent, overt
7. Add, remove or reverse the order of the steps (having the
symptom come first)
8. Remove or add a new member to the loop
9. Inflate/deflate the intensity of the symptom or pattern
10. Change the frequency or rate of the symptom or pattern
11. Change the duration of the symptom or pattern
12. Change the time (hour/time of day/week/month/year) of
the symptom or pattern
13. Change the location (in the world or body) of the
symptom/pattern
14. Change some quality of the symptom or pattern
15. Perform the symptom without the pattern/short-circuiting
16. Change the sequence of the elements in the pattern
17. Interrupt or otherwise prevent the pattern from occurring
18. Add (at least) one new element to the pattern
19. Break up any whole elements into smaller elements
20. Link the symptoms or pattern to another pattern or goal
21. Reframe or re-label the meaning of the symptom
22. Point to disparities and create cognitive dissonance
23. Rewrite the narrative without the symptom
24. Externalize and exorcise the “voices” in the narrative
25. Manipulate the emotion associated with the symptom
Rule # 1: Narrow broad perspectives
Rule # 2: Broaden narrow perspectives
1) Caution client to go slow; predict little or no change
2) Predict that the desire to return may wane
3) Predict residual anger at therapist for being “pushy”
4) Recommend at least 1 more meeting
Note: 1-4, Minuchin/Fishman; 5-6, 21, 22, 23, Adler; 7-20, O’Hanlon; 23, 24,
White; 25, Peratsakis. Pattern/Action may represent a concrete behavior,
emotion, or family member
Manipulating symptoms as a method of introducing doubt, alternative views and new possibilities
71

Explore the PP
Hardened (rigid)
beliefs about who
and what is the
problem
Challenge Beliefs
(Unbalancing)
Therapist explores &
challenges belief system;
softens rigidity
Return/
Reaffirm PP
Therapist
continuously returns
to PP/IP; amplifies
concern if necessary
72
Home Base = Safe Territory
Returning to the Presenting
Problem helps ensure the
client understands the
departure was temporary
(exploratory) and reaffirms the
initial purpose of meeting and
their Mistaken Belief That is
reassurance is necessary until
eh therapist has successfully
unbalanced the world-view
1
2
3
Exploring & Challenging, and then Returning
Probing & Confrontation:
It’s important to question and challenge
presuppositions as a means of unbalancing
their rigidity and introducing new
possibilities, new meanings.
The therapist must return to the reason for
seeking therapy; that is the client’s current
view of the problem, regardless of how true
that may be. The shuffle dance looks like
this: push, retreat to PP; push a bit harder,
return to the PP; push a bit harder and hold,
then retreat if necessary. If you have pushed
too hard, then apologize, reaffirm the
importance of the PP and go a step further,
if necessary, by amplifying the concern.

1. Give Task
 Assume Authority & Expertise
 All Clients are a “Forced Referral”: therapy must assure safety while pushing for experimentation and change
 Normalize Experience: “…we see this all the time”; “Most kids…”
 Never Ask Permission!
 Direct with Simple Commands
 Keep Directives Behavioral; ie “Talk to her”; “Get up and go sit next to him”; “Get them to behave”
 Use Simple Intros to more complex tasks: “Let’s try something…”; “Most/Some people find this helpful…”; “Let’s do an
experiment”; “I’m going to have you try something that may be very difficult.. ”
 Homework is Failure Prone: script it; make behavior independent of others; predict difficulty or failure
2. Stay on Task
 Never Rescue! -Always redirect back to task
 ALWAYS Interrupt When Work is NOT Being Done!
 NEVER Interrupt When Work IS Being Done!
 Push-back is to be expected, but NOT accepted
74

3. Button-Up, 1, 2, 3
1) Stop: “Let’s stop” or “Hold up, that’s enough hard work for now…”;
add hand gestures as signals
2) Explore:
 “Was that worse than you thought it would be?”
 “That was tough work, what should we do different next time?”
 If the task was not completed
o “That was very hard; what was going on for you while you were trying it?”
o “That was very hard; tell me, what do you think would have happened if you could have done it?” “What’s
the worse thing that might have happened?”
3) Do a Temperature Check
 Examine therapeutic alliance for possible back-lash, anger, resentment or fear: “I pushed you pretty hard, how
upset with me are you?”
 Predict residual anger; “If it turns out that feel angry with me, would you be willing to come back just for 1 more
session, even to tell me you never want to see me again!?”
 Predict “relapse” or back-sliding due to difficulty of change
 Poor contracting is the #1 reason for therapist burnout
 Anger at the therapist is the #1 reason for clients leaving therapy or refusing to change
 Optional: Assign homework
 Must be “safe” and do-able in behavioral terms
 Must anticipate failure or sabotage; exaggerate its difficulty and predict what could go wrong
75
Button Up !

“Client Expressions of Power in the Therapeutic Alliance” -by Ofer Zur, Ph.D.
1. Not talking
2. Not following advice or suggestions
3. Non-disclosure [Selective disclosure] or not answering questions
4. Taking notes or recording sessions
5. Coming late or leaving sessions early
6. Non-payment or refusal to agree to terms of service
7. Stalking
8. Change seating or other office arrangements
9. Provocative or threatening clothing
10. Use of violent, vulgar, threatening or provocative language
11. Use of anger, aggression or rage
12. Dominating the conversation
13. Inappropriate touch
14. Inappropriate gifts
15. Offering incentives
16. Acting coy or seductively
Note:
These represent direct
challenges to the therapeutic
alliance and should be
confronted right away.
The simplest method is to
discuss them as a barrier to
help and a “mixed message” :
“I want counseling but I don’t
want to change!”
The client is then encouraged
to make a choice and decide
how, if at all, to proceed with
counseling.
Power, is influence and control within the relationship system. It is the ability to influence outcome, the manifest expression of
our will. In this regard, it is never random but purposive and consistent with our self-concept and worldview. It colors our
beliefs, opinions, interests and desires and can best be understood through our behavior and the intended goal of our action.
“Ready or not, here it comes!”

Couple or Family Expressions of Power in Therapeutic Alliances - Demetrios Peratsakis
1. Shot-gunning/Carpet-bombing: overwhelming the therapist with too many issues, Presenting Problems or Identified Patients
2. Fugue: confusion or ambivalence over selecting Presenting Problem or Goal
3. Erratic attendance: sets appointment, cancels/no-shows; sets appointment, cancels/no-shows
4. Referral Agent, Family Member, Spouse or Partner sets appointment, partner/client refuses to attend
5. One sets appointment, then sabotages the client’s/partner’s participation
6. Both attend, one sees a problem, one does not
7. Both attend, both agree that one partner is the problem (identified patient/I.P.)
8. Both attend, agenda moves to Individual Counseling (I/C) or child focus (F/C)
9. Both attend, one begins to No-show (leaving therapist with partner/spouse)
10. Both attend, one drops a “bomb” (ie. sexual affair, drug abuse, major illness)
11. Both attend, one discloses their desire to separate or divorce
12. Both attend, one or both unclear on commitment (separate or remaining together)
13. Both attend, one or both continually triangulate the therapist
14. Both attend, the agenda and goal of therapy continually changes/new crises or goals arise
Power, the ability to influence and control, is a driving force in all social interactions. The therapist must gain mastery over
the ability to “disengage and redirect the Power Play” (Sherman).
78

Understanding the nature of power and its integral relation to our social interactions is the key to mediating power-plays and
remedying conflict.
Power, is influence and control within the relationship system. It is the ability to influence outcome, the manifest expression of our
will. In this regard, it is never random but purposive and consistent with our self-concept and worldview. It colors our beliefs,
opinions, interests and desires and can best be understood through our behavior and the intended goal of our action.
Examine the Intent of the Power Struggle
 Does the client need to control others in order to feel more worthwhile or superior?
 Is the client angry or upset with the therapist?
 Is the client second-guessing the utility or effectiveness of treatment?
 Has the therapist behaved in a manner that is suspect or that has damaged the trust?
 Does the therapist misuse their power and belittle, shame, or induce guilt in the client, especially by moralizing, lecturing or assuming a
haughty or “parental” attitude?
 Is the client frightened, contending with mistrust from prior emotional trauma and psychological injury?
 Is the client worried or freighted about the potential consequences of change?
Disengaging and Redirecting
 Stop the process and ask directly about the issue. “I think I may have stepped on your toes a bit, are we going to be okay?……..”
 Take a 1-down: “I’m not sure where we are; how should we proceed?”; “I’m a bit lost, where should we go from here?”
 Point to the ambivalence: “I’m getting some mixed messages; should we move forward or not; is this worth trying to change?”
 Seek permission to power-play: “My role is to push you in ways that will be uncomfortable. That may be more than you bargained for but
otherwise we may waste a lot of time and not get as much done. Would you rather I annoy you or waste your time?”
79

Hardships and disappointments are a natural part of life. When gauged as deeply distressing or disturbing experiences we refer to them as psychological injury or trauma.
The actual injury is damage to one’s sense of self-worth, an estimation of trust in one’s own capabilities as well as in the safety and security of one’s relationships.
Trauma fosters guilt, anger and shame, and because of its social implications may harbor blame and resentment toward others.
Its results are cumulative; unresolved, it results in depression and anxiety.
Symptoms often emerge as protective, safe-guarding behavior that help reassert control and
safe-guard or shield the individual and their relationship system from further injury or harm.
Accidents, Natural Disaster, Illness, Injury
1. Accidental Physical Injury
2. Fire
3. Industrial Accident
4. Work Accident
5. Invasive Medical Procedures
6. Injury or Illness
7. Motor Vehicle Accident
8. Natural Disaster
9. Property Loss
Threat or Harm to Others
1. Death of a Loved One
2. Injury or Illness of a Loved One
3. Threat to a Loved One
4. Witness to Violence
5. Suicide of a loved one
Threat or Harm to Self
1. Adult Sexual Assault
2. Captivity
3. Childhood Sexual Abuse
4. Combat & Military Sexual Trauma
5. Communal Rejection (Scapegoating, Shunning)
6. Cults and Entrapment
7. Domestic Violence
8. Physical Assault
9. Rape
10. Robbery
11. Sexual Harassment
12. Threat of Physical Violence
13. Torture
14. Victim of Crime
15. Victim of Violence
16. Witnessing Traumatic Event
81

A Simpler Model for Understanding Psychological Injury

83
General Overview
1. Unresolved trauma and emotional pain creates psychological injury
2. Psychological injury results from damage to one’s sense of self-worth
3. Psychological injury results in depression and anxiety.
4. Depression and anxiety are in a direct relationship to one another. They are the same
safe-guarding behavior; what differs is their temporal phase.
5. Depression and anxiety are fueled by guilt, anger and shame (GASh)
All trauma results in emotional pain. The source of the injury greatly affects the type of psychological damage that occurs. The death of a
loved one, devastation through flood or accident, and infidelity or abuse, all differ greatly because of the nature of the injury and its
associated meaning. While there may be other ways to group the causes of trauma, doing so based on the source of the injury helps the
clinician to better understand the kind of injury that has occurred as well as the most likely path for clinical intervention (see next slide)

Socratic Method of Teaching & Learning Psychotherapy 12_8_2023.pptx

Socratic Method of Teaching & Learning Psychotherapy 12_8_2023.pptx

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