Focused brief therapy

1. Introduction

Version followed: Nicholas A. Cummings's "focused, intermittent psychotherapy throughout the life cycle". The episode structure (four questions) comes from Cummings & Sayama (1995), Focused Psychotherapy. The first-session parameters come from Cummings (1986), as summarised by Dewey. The Biodyne model and group programmes come from Cummings's own interview account and from Cummings & Cummings (2013), Refocused Psychotherapy as the First-Line Intervention in Behavioral Health (contents page and chapter abstracts). The name "focused brief therapy" used for this guide is not Cummings's term. He first called it "brief, intermittent psychotherapy throughout the life cycle" and later renamed it "focused", because "brief" had become a pejorative among critics. [source: Cummings interview, psychotherapy.net; Karnac and Routledge book pages]

Status of the sources (October 2026): the onion/garlic definition rests on Cummings & Cummings's own chapter abstracts (2013); the 1986 first-session parameters, the contract examples and the "never abandon you" wording rest on Dewey's summary of Cummings (1986); the purpose of psychojudo, the list of its named manoeuvres and the "interrupted, not terminated" premise rest on the publisher preview of Cummings & Sayama (1995). Not described in the sources used [uncertain]: how each psychojudo manoeuvre is carried out, the content of the suicidality chapters, the specific novel acts Cummings used, the treatment rules for each onion/garlic cell, and a typical number of sessions per episode. The 1995 casebook's case material is not drawn on.

Focused intermittent psychotherapy is a psychodynamically informed, eclectic brief model. Cummings developed it while Chief of Mental Health at Kaiser Permanente (1959–1979), then spread it through American Biodyne, his managed behavioural-health company. [source: Wikipedia, Nicholas Cummings; Cummings interview] It is closer to a framework for organising treatment than a fixed technique set. It works like a family-physician model of psychotherapy. The patient is treated for the problem that brought them in now, not for a complete personality overhaul. Treatment is then "interrupted" rather than terminated, and the same therapist sees the patient again for later problems and developmental transitions across life. [source: Cummings interview; guidetopsychology.com]

Core idea of change: change starts in the first session. It comes from finding why the patient came now (the precipitant) and what they actually want (the implicit contract), then turning that contract into behavioural homework the patient carries out between sessions. That keeps responsibility, and therefore change, with the patient. [source: Cummings & Sayama 1995, chapter abstract (Taylor & Francis); Dewey summarising Cummings 1986]

2. Framework

The unit of treatment is the episode, not the course of therapy. A patient may have many separate episodes over a lifetime. [source: Cummings & Sayama 1995, chapter abstract] Part I of Focused Psychotherapy has three chapters: "The Developmental View", "Psychojudo" and "Structuring the Episode". [source: Karnac contents page] Only the chapter abstract and contents are drawn on here. Phase labels A–E below are this guide's organisation of the sourced elements. [synthesis]

A. First contact / first session. Goal: start therapy at once, not take a history. The therapist answers four questions for the episode:

Who is presenting? A differential diagnosis that clarifies the patient's psychodynamics and the entry points into treatment.
Why now? An operational diagnosis of the precipitating event.
What for? The patient's implicit contract, which often differs from what they explicitly ask for.
How? Homework, a behavioural task that lets change continue between sessions. In Cummings & Sayama's words, homework "operationalizes the therapeutic contract."

[source: Cummings & Sayama 1995, chapter abstract] In the 1986 version, the first session also includes "something novel" and the first homework assignment. [source: Dewey summarising Cummings 1986] Format: individual, face to face (not on the couch). The treating therapist is the first clinician the patient sees, with no separate intake interview or test battery. [source: Cummings interview]

Criterion to move on: the precipitant is named, the implicit contract has been stated back and agreed, and the patient leaves with a homework task. [synthesis, derived from the four questions]

B. Working sessions. Goal: carry out the contract through homework set every session, while anticipating and using resistance ("psychojudo"). [source: Dewey summarising Cummings 1986; chapter titles in Cummings & Sayama 1995 and Cummings & Cummings 2013] Frequency: in early Kaiser practice, at least twice weekly. [source: Cummings interview] Typical session count: no number per episode is given in the sources [uncertain]. Episodes are described as brief and patient-paced.

Criterion to move on: the patient says they feel well, or the implicit contract is met. In the 1986 parameters, patients judge when to stop better than therapists do, so following the method yields "no therapeutic dropouts". [source: Dewey summarising Cummings 1986]

C. Interruption (in place of termination). Goal: end the episode while keeping the door open. Cummings said "We never terminated a patient". When the patient felt well, the therapist interrupted treatment and invited them back for future problems. [source: Cummings interview; chapter title "Interruption Replaces Termination in Focused, Intermittent Psychotherapy throughout the Life Cycle" in O'Donohue, Cummings & Cummings 2006]

D. Return episodes across the life cycle. A new problem or life transition opens a new episode, and the four questions are asked again. Typical transitions include leaving home, job changes, marriage, children, bereavement and retirement. Patients could return years later and resume as if seen the week before. [source: chapter abstract; Cummings interview; guidetopsychology.com]

E. Parallel track: time-limited group programmes. At American Biodyne, Cummings reported 68 time-limited, manualised group programmes for specific populations. One example is a borderline-personality group of about 20 two-hour sessions, after which members moved to intermittent return. The manuals were guidelines, not scripts. [source: Cummings interview] Selection criteria and the content of most protocols were not found [uncertain].

3. Guiding principles

[source for each line in brackets; "interview" = Cummings interview, psychotherapy.net; "1986" = Dewey summarising Cummings 1986; "1995" = Cummings & Sayama chapter abstract]

Therapy begins in the first session. Do not spend session 1 on history-taking. Cummings called that practice "nonsense". [1986]
The treating therapist is the front door. No separate intake worker or routine test battery comes before you. [interview]
Treat the presenting problem, not the whole personality. Each episode has a bounded target, as a physician treats one condition and sees the patient again for the next. [interview]
Always ask "why now?" The precipitant tells you what the episode is about. [1986; 1995]
The implicit contract outranks the explicit request. Listen for what the patient actually wants from you. Therapists usually miss it. [1986; 1995]
Availability in exchange for partnership. You promise to be there as long as needed. In return, the patient works with you to make you unnecessary as soon as possible. [1986]
Responsibility stays with the patient. Homework every session, from session 1, puts the work in their hands. [1986; 1995]
Novelty breaks the "trained patient" set. Do something unexpected early to signal that this therapy acts on the problem now. [1986; chapter title "The Importance of Novelty in Psychotherapy", 2006]
The patient knows when to stop. Let the patient decide when the episode ends. If the earlier principles are followed, there are no dropouts. [1986]
Interrupt, don't terminate. End each episode with an explicit invitation to return. [interview; 2006 chapter title]
Diagnosis drives individualised treatment. A differential diagnosis of psychodynamics and personality type decides the entry point and the approach. The Biodyne "onion/garlic" typology serves this purpose: "onion patients are those who suffer, while garlic patients make others suffer". In practice, ask whose distress the problem mainly causes: the patient's own, or that of the people around them. [source: Cummings & Cummings 2013, chapter abstract on the onion–garlic conceptualization (Taylor & Francis); 1995 contents] The treatment rules for each type are not drawn on here [uncertain].
Stay one step ahead of resistance ("psychojudo"). Anticipate how the patient will resist and use that resistance in the service of change rather than fight it. [source: Cummings & Sayama 1995, Introduction and ch. 1, publisher preview; chapter titles in 1995 and 2013] [uncertain: the detailed technique of each named manoeuvre is not described in the sources used]
Manuals serve judgement. Cummings said "therapist ingenuity, insight and decision trump the manual". [interview]
Behavioural health belongs alongside medical care. Work with primary care, and recognise that distress often shows up as medical over-use. Cummings reported large falls in medical utilisation after focused psychotherapy. That is his own claim and is not verified here. [interview; Cummings & Cummings 2013 contents, chapter 4]

4. Intervention inventory

Each entry names the sourced element. Steps and wording are this guide's operationalisation unless a source is tagged. All example language is illustrative and is not Cummings's wording. [source for the set: Cummings & Sayama 1995 chapter abstract; Dewey summarising Cummings 1986; Cummings interview; book contents pages]

4.1 Therapist-first entry (no pre-treatment intake)

Purpose / when: every new episode. The patient's first contact is with the clinician who will treat them, so treatment and engagement start at once. [source: Cummings interview]
Steps:
1. Book the patient straight to the treating therapist. Do not put a separate intake worker or a routine test battery first. [interview]
2. Collect only the administrative and safety information your service legally requires, in a few minutes or on a form. Keep it out of the therapeutic hour. [synthesis]
3. Sit face to face and open on the current problem. [interview]
Example language (illustrative): "I'll be the person working with you, so let's go straight to what brought you in."
Watch for: services that legally require a formal intake or risk screen. Do these briefly, and do not let them replace the therapeutic first session [synthesis]. It is working if the patient describes the problem in their own terms within the first minutes.

4.2 Beginning treatment in the first session

Purpose / when: session 1 of every episode. History-taking alone wastes the patient's peak motivation, and Cummings called it "nonsense". [source: Dewey summarising Cummings 1986]
Steps: use the first session to work through 4.3–4.8 in order: who, why now, what for, novelty, homework. Take only the history that bears on those questions. [synthesis, organising the 1986 and 1995 elements]
Example language (illustrative): "We don't need your whole life story today. I'd rather we start making a difference this week."
Watch for: patients expecting a passive assessment. Name the difference early. It is working if the patient leaves session 1 with a stated goal and a task.

4.3 Differential diagnosis: "Who is presenting?"

Purpose / when: first session of each episode. It clarifies the patient's psychodynamics and finds entry points into treatment. [source: Cummings & Sayama 1995 chapter abstract]
Steps:
1. Form a working diagnosis of the presentation and of personality style, not just a symptom list. Cummings & Cummings (2013) frame this as "a return to psychopathology" and treating more than symptom collections. [source: Routledge contents page]
2. Place the patient in the model's onion/garlic × analyzable/non-analyzable typology. An onion patient is one who suffers: the distress lingers with the patient, as the taste of onions bothers the person who ate them. A garlic patient makes others suffer: the patient is not bothered, but partners, family or colleagues are. [source: Cummings & Cummings 2013, chapter abstract (Taylor & Francis)] The 1995 casebook chapters are Onion/Analyzable, Garlic/Analyzable, Schizophrenia, Onion/Non-Analyzable, Garlic/Non-Analyzable and Suicidality. [source: Karnac contents] The 2013 abstract on analyzable garlic patients says they may be Axis II (personality-disordered) individuals but "are still able to change". [source: Taylor & Francis chapter abstract, "Garlic that is Analyzable"] The operational meaning of "analyzable" and the treatment rules for each cell were not found [uncertain]. A practical screening question ("Who is most bothered by this problem: you, or the people around you?") is [synthesis]. Read chapters 8–11 of Cummings & Cummings (2013) before relying on the typology.
3. Screen for psychosis, substance misuse, suicidality and medical causes, and check medication. Chapter 3 of the 2013 book covers psychophysiology and psychopharmacology basics for this purpose. [source: Routledge contents; screening list is synthesis]
4. Choose the entry point (4.10).
Example language (illustrative): "Help me understand how this problem shows up between you and the people around you."
Watch for: premature closure on the stated complaint. Revise the diagnosis if homework responses don't fit it. [synthesis]

4.4 Operational diagnosis: "Why now?"

Purpose / when: first session. It finds the precipitating incident that brought the patient in today rather than at any other time. [source: Dewey summarising Cummings 1986; Cummings & Sayama 1995 abstract]
Steps:
1. Ask directly what happened recently, often days or weeks before, that made them call. Cummings's 1986 form of the question asks why the patient is here "today instead of last week or last month" (or last year, or next year). [source: Dewey quoting Cummings 1986]
2. If the answer is "it's been going on for years", ask what changed, or what made it unbearable, this week.
3. Link the precipitant to the presenting problem and state that link back to the patient. [steps 1–3 synthesis]
Example language (illustrative): "You've lived with this a long time. What happened that made you pick up the phone this week and not last year?"
Watch for: a vague answer often hides the real agenda (a partner's ultimatum, a medical scare, a legal or work threat). It is working if the precipitant explains the timing and points to the contract.

4.5 Identifying the implicit contract: "What for?"

Purpose / when: first session, and again at each new episode. Patients make an implicit contract with the therapist in session 1. It often differs from their explicit request, and therapists usually miss it. [source: Dewey summarising Cummings 1986; Cummings & Sayama 1995 abstract]
Steps: [1986 per Dewey for the sequence; wording synthesis]
1. Listen for what the patient wants from you: relief, permission, an ally, a witness, someone to fix another person, documentation, and so on.
2. Name the implied goal aloud and discuss it with the patient.
3. Agree on a goal that is achievable and within the patient's control.
Example language (illustrative): "You've asked me to help you feel less anxious. I'm also hearing that you'd like someone to tell you it's OK to leave this job. Is that part of why you're here?"
Watch for: contracts hidden in passing remarks. Cummings's 1986 examples include a patient who welcomes the comfortable chair because they will "be here for a while" (a long-term contract), and one who wants to save the marriage but expects to end up divorced anyway. [source: Dewey quoting Cummings 1986] Reading the second as a request for help through the divorce is this guide's interpretation [synthesis]. Dewey's summary calls it the "therapeutic contract"; the 1995 abstract calls it the implicit contract. Renegotiate openly any contract you cannot honour, such as changing a third party or supporting a legal claim [synthesis]. It is working if the patient corrects or confirms the statement with visible relief or engagement.

4.6 The availability-for-partnership bargain

Purpose / when: end of the contract discussion in session 1. [source: Dewey summarising Cummings 1986]
Steps: state your commitment to stay available for as long as needed. Cummings's suggested wording was "I will never abandon you as long as you need me." [source: Dewey quoting Cummings 1986] Ask in return for the patient's partnership in making you unnecessary as soon as possible. [1986]
Example language (illustrative): "I'll be here as long as you need me, now and later in life. My side of the deal is availability. Yours is working with me so you need me as little as possible."
Watch for: dependent patients who hear only the first half. Return to the partnership half when homework slips. [synthesis]

4.7 Doing something novel in the first session

Purpose / when: session 1. An unexpected act breaks the expectations of a "trained" patient (one used to passive, open-ended therapy) and signals that the problem will be addressed now. [source: Dewey summarising Cummings 1986; chapter title "The Importance of Novelty in Psychotherapy" in O'Donohue, Cummings & Cummings 2006] The 1995 casebook places "Do Something Novel in the First Session" as the first manoeuvre of its psychojudo chapter, so novelty also serves to get ahead of resistance. [source: Cummings & Sayama 1995, contents, publisher preview]
Steps: the specific novel acts Cummings used are not described in the sources used [uncertain]. Generic options [synthesis]:
1. Give an immediate, unexpected task.
2. Reframe the problem in a way the patient has not heard.
3. Change the setting or format, for example inviting the partner in or walking through the feared situation.
4. Agree to a shorter time frame than the patient expects.
Example language (illustrative): "Before you go today, I'd like you to try something you won't have expected from a therapist..."
Watch for: novelty must be respectful, consented to and clinically linked to the contract, never a gimmick or a shock tactic [synthesis]. It is working if the patient is surprised, curious and talks about it at the next session.

4.8 Homework from session 1 and every session: "How?"

Purpose / when: every session. Homework operationalises the therapeutic contract, keeps change going between sessions and keeps responsibility with the patient. [source: Cummings & Sayama 1995 abstract; Dewey summarising Cummings 1986] Refocused Psychotherapy treats homework as a core topic, and O'Donohue, Cummings & Cummings (2006) include a chapter "Designing and Assigning Effective Homework" (authorship of that chapter not checked) [uncertain on content].
Steps:
1. Derive the task directly from the implicit contract.
2. Make it behavioural, specific, small and doable before next session.
3. Have the patient restate it.
4. Open the next session by reviewing it. [steps synthesis]
Example language (illustrative): "Between now and Thursday, have one conversation with your sister where you say no to one thing. Then write down what happened."
Watch for: homework that is not done is information, not failure (see 5.4). It is working if completed tasks are producing visible change in the problem the contract names.

4.9 Psychojudo: staying one step ahead of the patient's resistance

Purpose / when: whenever resistance is expected or appears. Cummings and Sayama present psychojudo as techniques that use the patient's resistance to change in the service of healing and growth, instead of opposing it, and count these among the most creative interventions. It is a named core technique, with a chapter in both books (chapter 3 of the 1995 casebook; chapter 6 of the 2013 book, "Psychojudo: Staying One Step Ahead of the Patient's Resistance"). [source: Cummings & Sayama 1995, Introduction p. 7, ch. 1 p. 15 and contents, publisher preview; Routledge contents]
Named manoeuvres: the 1995 casebook illustrates psychojudo through named moves, each shown in a case: doing something novel in the first session (see 4.7), prescribing the resistance, humoring the resistance, mobilizing rage in the service of health, denying treatment, joining the delusion, overwhelming the resistance, and psychojudo with a family. [source: Cummings & Sayama 1995, chapter 3 contents, publisher preview] Only these headings are drawn on; how Cummings carried out each move is not described here [uncertain]. Denying treatment, joining the delusion, overwhelming the resistance and mobilizing rage are high-risk if attempted from their names alone; use them only with the casebook's case detail and clinical supervision. Related but not identical material is in the 2006 chapter "Resistance as an Ally in Psychotherapy", whose authorship is unconfirmed [uncertain]. No published step-by-step psychojudo procedure is used here; the steps below are the writer's synthesis [synthesis].
Steps (generic, [synthesis]):
1. From the diagnosis (4.3), predict how this patient is likely to resist, for example by idealising then devaluing, by missing homework, or by changing the subject to someone else's behaviour.
2. Name the likely pattern in advance, or build it into the task so that resisting still moves the patient toward the contract.
3. Side with the patient's caution rather than pushing. If the patient holds firmly to the resistant position, consider prescribing it openly as a task with a stated rationale, or meeting it with light humour rather than argument. (The casebook names "prescribing the resistance" and "humoring the resistance"; the how-to here is synthesis.)
Example language (illustrative): "You may well find you don't do this task, and that will tell us something useful too."
Watch for: anything resembling manipulation without consent. Keep the rationale explainable to the patient if they ask. [synthesis]

4.10 Choosing the entry point

Purpose / when: after 4.3–4.5. The differential diagnosis identifies "entry points" into treatment. [source: Cummings & Sayama 1995 abstract; chapter title "Enhancing Psychotherapy through Appropriate Entry Points", O'Donohue, Cummings & Cummings 2006]
Steps (generic, [synthesis]): choose the door the patient will actually walk through, in this order of preference:
1. the presenting complaint;
2. the precipitant;
3. a relationship;
4. a body symptom or medical worry;
5. a practical problem. Begin there even if the deeper dynamic lies elsewhere.
Example language (illustrative): "Let's start with the sleep, since that's what's hurting most right now."
Watch for: an entry point that the patient experiences as missing the point. Shift doors rather than argue.

4.11 Interruption in place of termination

Purpose / when: when the patient feels well or the episode's contract is met. [source: Cummings interview; Dewey summarising Cummings 1986; chapter title "Interruption Replaces Termination...", 2006]
Steps:
1. Let the patient set the stopping point. [1986]
2. Frame the ending as an interruption, not a termination. [interview]
3. Review what the patient now does differently and how to spot early signs of recurrence. [synthesis]
4. Invite them explicitly to return for this or any future problem. [interview]
5. Keep the record and the relationship available. [synthesis]
Example language (illustrative): "We're not saying goodbye, just pausing. When life throws the next thing at you, call and we'll pick up where we left off."
Watch for: this is not abandonment, and it is not open-ended maintenance. No routine follow-up appointments are implied [uncertain about Cummings's practice on booster sessions].

4.12 Return episodes across the life cycle

Purpose / when: a patient comes back after an interruption, often at a developmental transition such as leaving home, a new job, marriage, children, a death or retirement. [source: guidetopsychology.com; Cummings interview; Karnac contents "The Developmental View"]
Steps: treat each return as a new episode. Re-ask who, why now, what for and how, and set homework in the first returning session. Use earlier episodes as context, but do not assume the old contract. [source: Cummings & Sayama 1995 abstract for the per-episode questions; the rest is synthesis]
Example language (illustrative): "Good to see you again. Last time was about your work. What's brought you back now?"
Watch for: frequent returns for the same unresolved contract. This may mean the earlier episode targeted the explicit rather than the implicit contract. [synthesis]

4.13 Time-limited, manualised group programmes (Biodyne)

Purpose / when: populations who benefit from structured, peer-based work. Cummings reported 68 such programmes at American Biodyne, used as guidelines rather than rigid scripts. [source: Cummings interview]
Sourced example: a borderline-personality group of about 20 two-hour sessions, in which members reinforced limits on one another. Afterward, members moved to intermittent individual return. [source: Cummings interview] The group's informal nickname, as reported in the interview, should not be used with patients [synthesis].
Risk flag: Cummings reported that members were told they would be dropped from their health plan if they failed. Do not reproduce this. Making care or insurance depend on group performance is coercive and inconsistent with current ethics on consent and non-abandonment. Use explicit, collaboratively agreed group rules instead. [synthesis]
Steps (adapting today, [synthesis]):
1. Define the target population and the exclusion criteria.
2. Fix the number and length of sessions in advance.
3. Use a session-by-session guideline with one skill or task per session and homework.
4. Set clear group limits that members help enforce.
5. Plan the transition to intermittent individual contact.
Watch for: the other 67 protocols' contents are not described in the sources used [uncertain].

4.14 Collaboration with primary care

Purpose / when: patients presenting through physical complaints or high medical use. Cummings & Cummings (2013) devote chapter 4 to integrated behavioural/primary care, and Cummings reported reductions in medical over-use after focused psychotherapy (his own figures, not verified). [source: Routledge contents; Cummings interview]
Steps (generic, [synthesis]): with consent, agree a shared formulation with the physician. Treat the behavioural contribution while medical assessment and care continue. Never position psychotherapy as a replacement for medical treatment.
Example language (illustrative): "Your doctor and I will each keep doing our part. Mine is the stress that's making the pain harder to live with."
Watch for: missing an organic cause. Keep medical review in place.

4.15 Working with suicidal patients

Purpose / when: any episode with suicidal ideation. Both books have a chapter on suicidality ("Treating Suicidal Patients", 2013), as does the 2006 volume. [source: contents pages] Their content is not drawn on [uncertain], so nothing here is attributed to Cummings.
Steps ([synthesis], current standard practice):
1. Assess ideation, intent, plan, history, protective factors and access to means.
2. Make a collaborative safety plan.
3. Do lethal-means counselling: safe storage and removal.
4. Increase contact frequency.
5. Involve supports with consent, and use emergency services when risk is imminent.
6. Do not "interrupt" an episode while acute risk persists.
Example language (illustrative): "I'm going to ask you some direct questions about these thoughts, because keeping you safe comes first."
Watch for: brief-format pressure overriding risk management. Episode length gives way to safety.

5. Handling problems

The sources used say little about problem-handling beyond psychojudo (title only), novelty and the claim of no dropouts. Most of what follows is [synthesis] consistent with the model's principles. Sourced points are tagged.

5.1 Stuck client / no movement. Re-ask "why now?" and "what for?". The commonest cause is working on the explicit rather than the implicit contract. [source: Dewey summarising Cummings 1986, which says therapists usually miss the implicit contract; the application is synthesis] Re-state the contract, and shrink the homework to a step the patient will certainly do. Check whether the diagnosis or entry point (4.3, 4.10) needs revising.
5.2 Resistance. Use psychojudo-style anticipation: predict the pattern and side with the caution rather than pushing [concept: Cummings & Sayama 1995, Introduction and chapter 3 headings; technique content uncertain]. Practical moves [synthesis]:
- name the likely obstacle before setting the task;
- offer a choice between two tasks;
- frame non-completion as useful information.
5.3 "Trained" patients who expect long, passive therapy. Introduce something novel early and explain the partnership bargain (4.6, 4.7). [source: Dewey summarising Cummings 1986] If they still want open-ended exploratory work, discuss it honestly and refer if that is what fits their goals. [synthesis]
5.4 Homework non-adherence. Review every assignment at the next session [synthesis]. Ask what got in the way, and treat the answer as diagnostic: about motivation, about the contract, or about the task being too big. Re-negotiate a smaller task together. Do not lecture. Remind the patient of the partnership half of the bargain (4.6). [synthesis]
5.5 Overwhelm or crisis mid-episode. Shift to stabilisation and safety, and increase frequency. Twice-weekly sessions were Cummings's early default [source: Cummings interview]. Suspend novelty and challenging tasks until the crisis settles. For suicidality, follow 4.15. [synthesis]
5.6 Ruptures. Repair openly. Acknowledge any part you played, and ask whether the contract you stated back was wrong. Re-contract if needed. [synthesis] A brief, directive stance can feel dismissive, so check how the patient experiences the pace. [synthesis]
5.7 Modality-specific: the patient wants to stop "too early". The model holds that patients know when to stop. [source: Dewey summarising Cummings 1986] Respect this, frame it as an interruption with an open door (4.11), and name any early-warning signs to watch for. Exception: do not interrupt during unresolved high risk. [synthesis]
5.8 Modality-specific: dependency, or repeated returns for the same issue. Return to the partnership bargain. Make each episode's homework about self-management, and consider a time-limited group programme (4.13). [synthesis]
5.9 Modality-specific: contracts you cannot honour (changing a third party, documentation for litigation or benefits, being an ally against a spouse). Name the contract and say what you can and cannot offer. Then propose an achievable alternative contract within the patient's control. [synthesis]
5.10 Severe presentations (psychosis, severe personality disorder, active substance dependence). The model explicitly includes "non-analyzable" and schizophrenia presentations in its typology. Garlic patients (those who make others suffer) may be Axis II individuals, and the authors hold that analyzable garlic patients can still change. [source: Cummings & Cummings 2013 chapter abstracts, Taylor & Francis] The treatment guidance for non-analyzable and psychotic patients is not drawn on here [uncertain]. Coordinate with psychiatry and primary care (4.14). Check medication interactions, which are covered in the 2013 book's appendices [source: Routledge description]. Use structured group programmes where available. [synthesis]
5.11 Coercion risk in group programmes. Do not make insurance or service access depend on group performance, as was reported at Biodyne (see 4.13). Use consensual group rules and planned transitions. [source for the historical practice: Cummings interview; recommendation is synthesis]
5.12 Service pressure to cut sessions. The model was built for managed care, but its own rule is availability for as long as needed (4.6). Do not use the model to justify withholding indicated care. [source: Dewey summarising Cummings 1986 for availability; the rest is synthesis]

Sources

Sources used:

Books and articles cited (cited through the pages above):

Cummings, N. A. (1986). The dismantling of our health system: Strategies for the survival of psychological practice. American Psychologist, 41, 426–431. (via Dewey's summary)
Cummings, N. A., & Sayama, M. (1995). Focused Psychotherapy: A Casebook of Brief, Intermittent Psychotherapy Throughout the Life Cycle. New York: Brunner/Mazel (reissued by Routledge).
Cummings, N. A. (2000). The Essence of Psychotherapy. San Diego: Academic Press.
O'Donohue, W., Cummings, N. A., & Cummings, J. L. (Eds.) (2006). Clinical Strategies for Becoming a Master Psychotherapist. Amsterdam: Elsevier Academic Press.
Cummings, N. A., & Cummings, J. L. (2013). Refocused Psychotherapy as the First-Line Intervention in Behavioral Health. New York: Routledge.

Not used [uncertain]: the chapter texts on psychojudo (beyond the introduction and chapter headings), structuring the episode, novelty, homework and suicidal patients, and the treatment rules for each onion/garlic cell.

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