Practical considerations in therapist Client interactions

Practical considerations in therapist Client interactions
Michele Aluoch 2018

FiRst impressions tell a lot
Keys To Success in Clinical Interactions: Balancing protocol, policies with flexibility and adaptability Understanding what the client is resisting Reconceptualizing resistance not as something personal but as a long term habitual pattern Reality-based thinking about your limited interactions with the client

The room Cleanliness Welcoming Assessments, exams rooms and bed room
The place of the new start What is role modeled that may be different from home Don’t model chaos and uncleanliness

Welcoming the Patient Empathy with patient’s experience: anxiety, fear, history of admissions The meaning of being here to the patient The patient’s experiencing regarding wanting to be here or not What “here” means for the patient What is comfort for the patient

The Atmosphere Find out the operational definitions of comfort, peace, safety, security, etc. for this specific patient If involuntary/mandated- what is the smallest agreed upon goal If voluntary- how can we get the process going in the right direction? What is “right” for you? Food, drink Attentiveness versus space Acknowledgement of patient’s perception

Challenging and Confronting
What can the patient legitimately understand? Stick to policy Use communication game: 3 parts: 1) You feel ________ 2) You feel this because _________. 3) You are hoping ______ will happen.

Concrete observable behavioral goals
What can I give the patient that will show I’m interested in his or her goals? I may be the only one who hears and acknowledges anything Defining and managing goals may be a new skill for the patient

Client Vs. Therapist Goals
Specific Measureable Achievable Broken down into manageable parts Concrete, behavioral Evidence based Tailored to the specific client Try camera check method to make goals concrete and behavioral. Tends to help produce operational definitions.

Preventing Escalation/seclusion
Seclusion- isolation is a private quiet room for a time with or without consent with the purpose of no contact with others E.g. Man who won’t let go of his walking stick- when pulled away becomes aggressive Woman who won’t let go of her purse- all she has- managed with flexibility.

What the client wants to know
Can this person be trusted? Do they really care about me? Is this just a job to them? Are they attentive, caring, take time to hear my story (as I see it)? What is the professionals agenda? Does the professional care about my agenda?

Different types of clients
Involuntary mandated clients Psychotic disorganized unaware clients Voluntary clients Key what can they agree to- just one thing

Cognitive Reframing Turning problems into possibilities:
Hearing them out You may be their biggest breakthrough ever Using your tone, stance, mannerisms to convincingly show that things are manageable Modeling a Solution -Focused approach

Process variables No studies have ever been found against the effectiveness of empathy. Process variables = an intimate dance between treating professional and client -Within control of the professional- empathy, positive regard, respect, sincerity= universal variables More important than how specialized and degreed a person is Specialization is at times inversely proportional to process variables and flexibility/resilience

Client’s Perceptions of What Predicts Therapeutic Alliance (Duff, C. T
Client’s Perceptions of What Predicts Therapeutic Alliance (Duff, C.T., & Bedi, R.P., 2010) Three critical factors: making encouraging statements, making positive comments about the client, greeting the client with a smile Others listed: Asked me questions Identified and reflected back feelings Was honest Validated my experience Made eye contact with me Referred to details discussed in previous sessions Sat still and did not fidget Sat facing me Told me about similar experiences he/she had Let me decide what to talk about Kept the administration outside of our sessions

The Client’s Stress

Area #1- Not Feeling Listened To
Three Common Assumptions about Listening (Barker, L., & Watson, K., 2000) Speakers control communication more than listeners. We can wait to listen well when we really have to. When someone starts talking people automatically listen.

Realities of Listening
Listeners control communication because they can open up communication by engaging or shut it down by tuning out. Listeners use their will to tune in or out to a person. The listener often is the one who puts his/her interpretation into things. Listeners evaluate whether messages are important and valuable or not. Listeners decide to follow through on what the speaker says or to not to that. Listening is not automatic. Rarely can listeners answer more than 4 details of a conversation correctly. Listening takes time and practice. Listeners only remember a small portion of what has been said- 50% immediately after talk, 10% after 1 day.

Listening Pitfalls Tuning Out or Halfheartedly Listening
Rehearsing Our Responses Assuming Meanings From What the Speaker Says Jumping to Conclusions

Four Listening Preferences
People- Oriented Action Oriented Content Oriented Time Oriented

People Oriented Listening
Other focused Demonstrates caring and warmth Nonjudgmental Clear verbal and nonverbals Relates to where the other is coming from Focuses on building relationships Notices changes in other’s moods & incongruencies in them quickly

People Oriented Listening
Problems Becomes overinvolved in other’s feelings Too empathic and may overlook faults More prone to burnout because internalizes and adopts other’s feelings Sometimes considered overly expressive by others Nondiscriminating in relationships- nice to everyone Exs: counselors, service professionals, teachers Tell stories, use illustrations. Use “we” and focus on teamwork. Be personal

Action-Oriented Listeners
Concentrate on the task at hand Frustrated with disorganized people Comes across as impatient to others Focuses on expectations Able to redirect others towards the most important points of things Identifies inconsistencies in messages where things don’t add up

Action-Oriented Listeners
Problems Impatient with people who talk too long Jumps to conclusions quickly Distracted by disorganization Too blunt- pushes people too far too fast in conversations May ask blunt questions Comes across as critical Minimizes the importance of the emotional/feelings in communication because they are too task and thing oriented Exs: Attorneys, financial analysts Keep points to 3 or less Be short and to the point. Speak quickly.

Content-Oriented Listeners
Evaluate every angle of things Likes digging below the surface to dissect problems Value technical information Wants people to back up what they say with examples and supports Values complexities

Content-Oriented Listeners
Problems Overly detailed May come across as intimidating because knows so much Asks pointed questions Devalues info. from people who don’t know their job Takes time to make decisions after studying all the angles of things Exs: scientists, mathematicians, engineers Provide the data. Quote experts and statistics. Use charts and graphs.

Time Oriented Listeners
Sets time boundaries for conversations Gives guidelines for conversation Does not want “wasted” time Tells others when they are “wasting” time

Time Oriented Listeners
Problems Impatient with time wasters as he/she see it Interrupts others Not good at concentrating and just hearing others in the moment Rushes others by watches and clocks Squelches creativity because so focused on time and clocks Go under time limits if you can. Avoid unnecessary exs. Watch their impatience level.

Top Ten Listening Hindrances (Barker, L. & Watson, K., 2000)
Interrupting the speaker. Not looking at the person who is talking. Rushing the speaker and communicating thereby that his/her message is unimportant. Not letting the speaker tell the whole thing. Showing interest in things other than the conversation at hand. Getting ahead of the speaker and finishing or concluding what he/she is saying.

Top Ten Listening Hindrances (Barker, L. & Watson, K., 2000)
Not doing what the speaker requests. Saying, “yes- BUT” which shows that the speaker doesn’t matter as much as what you want Stopping the speaker by relating things to yourself. Forgetting what the speaker talked about. Asking too many questions about details. Not doing what the speaker requests.

Nonverbal Listening Body language= up to 93%
Words can hide secrets whereas body language gives more clues 1st 10 seconds= most important Cautions: defining things by a single gesture alone without context Cultural background must be considered First obtain baseline behavior Factors to consider: Status in society fashion subculture The gaze of person- direction, length of gaze What eyebrows do Touch- spatial relations and how touch is used

Nonverbal Listening Direct look Lean slightly in Smile gently
State the person’s name and shake hand Take turns communicating Angling your body toward the speaker Use regular head nods Reflect the speaker’s emotions

Issue #2- Client’s Expectations
Advertisements/Marketing of Your practice Insurance panels Bios. Your website What they thought they gave consent for Their understanding of what therapy is/is not What they think your title or credentials are or mean What they think your certifications, licenses or certificates are for How they perceive the environment physically How they perceive you, office staff, colleagues, other clients

Issue #3- Informed Consent
Extent and nature of services Description of setting, treatment modalities, expectations/boundaries Pros and cons (counseling in general, electronic counseling, phone counseling, techniques used, setting) Limitations In clear, understandable, non-technical language Specified provider name Therapist’s responsibility to make sure the client understands (e.g. if cannot read, blind, etc.) Defines role of counselor (versus mediator, court guardian, expert witness) Expectations of both therapist and client behaviors Risks/benefits of therapy Qualifications of the therapist Financial considerations and responsibilities

Issue #4- Assessment/Diagnosis
Why we ask the questions we do What the diagnosis means Who knows what Unethical- therapist as moral agent, client no longer autonomous person coming for help Ethical- based on observation of concrete, observable or clients self reported behaviors compared to “norms” and researched and studies standards with respect to client perspectives and worldview with full information and informed consent under a specific “contract” outlining terms of the clinical relationship

Issue #5- Treatment Planning
What goals the client will by into Client desires What client perceives to have worked/not worked so far How involved client wants to get in the therapeutic process How goals are measured Operational definitions of measurable goals How achievable goals are Competing demands therapist’s hopes, clients’ hopes. Referring agency, insurance company, family/friends, employers/schools/physicians

Issue #6- Client’s Perceptions of your Competency
How the client defines competency: certification/licensure, your job title, where you are from, how you look, if you have been through the same life experiences as them. , etc. Board requirements regarding licensure, certifications, and disclosure statements in office Client’s assumptions about your title and ability to clarify or correct these Techniques used

Issue #7- Readiness or Resistance
Common Defense Mechanisms (Clark, A.J., 1991) Outside awareness initially Habitual Useful (in client’s perception) Denial- rejecting responsibility “I don’t have a problem.” “Nobody ever told me.” “I didn’t know.”

Readiness or Resistance
Displacement- shifting responsibility to a vulnerable substitute “I couldn’t control my behavior because of that stupid overbearing teacher.” “A few drinks just cause me to do things I don’t expect.” Identification- acting like someone he/she admires “I have a good heart just like my brother.” “My family may have it’s flaws but we all are hard working.” “I can be just as competitive as the next guy when things comes down to it.”

Undoing- Trying to reverse an unhealthy behavior by doing something opposite “I drank all weekend but when I came to my senses I realized this isn’t me so I threw all the liquor in the house down the drain.” “I know I mouth off and get out of control but I am the most gentle and apologetic person afterwards.”

Intellectualization- avoiding unpleasant feelings which are perceived as “negative” and make someone feel vulnerable “Drinking on occasions is not like getting drunk, you know.” “I just have a different way of getting things done than what my boss wants.” Projection-attributing unacceptable behaviors to others that are really characteristic of self “It seems like you don’t want this counseling to help me. You disagree with me.” “They said I didn’t perform on my job.” “If that fool would have gotten out of the way I wouldn’t have hit him in the drunk driving incident anyway.

Rationalization-Justifying one’s behaviors “Everyone lies to their parents.” “All people steal some of the extra supplies on the job that aren’t being used.” “Most parents get frustrated with their kids and lose control at times.” Reaction formation- Exaggerating claims of highly moral actions and attitudes “I would never get tempted to do anything like that.” “I organized the community fair against that kind of behavior.”

Regression-returning to an earlier stage of maturation and development “I had these kids young. It is my time to live . What’s wrong with dressing in their clothes and going to clubs. I missed out.” Repression-Resisting discussing or approaching topics or barring self or others from certain topics “I don’t recall anything like that.” “I don’t ever remember disobeying my parents.”

Mattering To Others (Rayle, A.D., 2006)
Internal need to feel significant: A) general mattering B) interpersonal mattering Why do I exist? What difference do I make? Do others notice me? Are my interactions with others different because of me? Do I have the social supports I desire? *** Counselors can have a significant role in shaping mattering.***

Therapist Openness/Disclosure
Fostering therapeutic alliance Modeling freedom for clients to disclose Reducing client’s sense of being alone in his/her problems Increasing sense of realness in the counselor Sidney Jourard’s idea of “dyadic effect”: “disclosure begets disclosure”- people are more likely to be open with interviewers who themselves are open than with interviewers who express little or nothing of themselves”

What Clients Said Was Helpful Disclosure
Acceptance and Encouraging Ensuring Attention Body Language Silence (Listening) Open and Closed Ended Questions Reflection of the Content of Sessions Disclosure of Feelings Reflection of Feelings Self Disclosure Confrontation Key- developing an understanding of what each operationally means to a given client

Questions to Consider Regarding Disclosure
Have I paused to evaluate this potential disclose beforehand? Why am I disclosing? How will this help the client’s goals in counseling? Are there conditions which necessitate this disclosure? If so, what? Are there other ways of approaching the client’s issue that may be as effective as disclosure? Is there any potential harm or danger to the client from this potential disclosure? Does the client have the ego strength for this disclosure? Will this disclosure blur professional boundaries? How will this disclosure help the client emotionally (instilling hope, moving toward counseling goals, feeling less alone)? Could the client end up feeling demoralized by my disclosure? Will this disclosure help with reality check? Possibly test out a lower level disclosure first (e.. an obvious topic the client may be wondering about) versus a more detailed deliberate disclosure

Solution Focused approach
Help them see something is manageable in the midst of chaos Focus on client strengths A success driven model Solution building Focus on the desired outcome Uses success language: How have your managed?... All clients have resource already.

No problem happens all the time. Solutions are there already but just aren’t implemented enough. 1) When you do not have the problem? 2) When the situation is “less bad?” We can plan for alternatives to the presenting problem.

There are no problems... Only opportunities. There are no failures.. Only learnings. There are thousands of solutions. There are no uncooperative people but only people with unique ways of cooperating.

Therapist Expectations
What I Expect of The Mental Health Field What I Believe Is Expected of Me In My Job Setting My Company Should My Company Actually

The Interpersonal Cycle of Burnout ( Geurts, S. ,Schaufeli, W
The Interpersonal Cycle of Burnout ( Geurts, S.,Schaufeli, W., & DeJonge, J., 1998) Cognitive thoughts regarding injustice Social comparison Communication with colleagues Reactions to ambiguous criteria for success EQUITY EXPECTED CONTRIBUTIONS EXPECTED BENEFITS Sense of negative norms in the setting Discrepancies between investments and outcomes Availability of positive alternatives Discrepancies between “shoulds” and actualities

Issues in Burnout: Healthy Unhealthy
Strong commitment of employees Weak commitment of counselors Strong availability/support from staff Isolation, weak involvement of staff Co-worker relationships- encouraged Minimal opportunities for rel. Support supervision Low collegial support Specific, concrete expectations Ambiguous/changing expectations Freedom for some autonomy Discouraging new ideas/creativity Reasonable deadlines Excessive unrealistic time pressure Some staff retention High turnover of staff Sense of purpose/fulfillment Doubt as to meaning/purpose Clients who want help Mandated clients Realistic specific goals Goals which cannot be achieved Solid clinical identity Need to be liked by clients Facilitator, counselor Responsible for change Separation self/client Self tied to client outcomes Setbacks are one part Setbacks as personal

Maintaining Counselor Wellness
Defining Counselor Wellness Both an outcome and a process Involves several dimensions

Empathy Without Loss of Self
The Most Important Factor: Social Support Systems Personal life/family/friends Community involvement Colleagues What social supports do that helps: Facilitating compassion Focusing on similar elements among all people- normalizing feelings Reducing self blame Facilitating realistic self acceptance

EXERCISE: PLANNING FOR WELLNESS
Word Associations: Health- Healing- Replenish/renewal- Escape- Coping- Fulfillment- Satisfaction-

Compassion Fatigue Examples: Dreaming the client’s dreams
Experiencing intrusive thoughts and images Hyperarousal Sleep problems Difficulty concentrating Being easily startled Sense that no one understands my distress NOTE: May also extend to family of the counselor and support systems of the counselor

Vicarious Traumatization
Reactions to cases of those abused or in trauma not a pathological reaction based on empathic reactions to trauma survivors triggered by our own application of our counseling skills “empathy at full throttle”, “exaggerated empathy” (Rothchild, B., 2002) Less than 10% in most cases Examples: Child abuse, terrorism victims, physical or emotional abuse victims, natural disaster victims, violent crime victims, people with sudden violent deaths

Exercise: What Do I Want To Be Remembered For?
Plan a eulogy for yourself. Write at least 3-5 important variables that you want memorialized about yourself. What are you doing to pursue these now?

Exercise: Create a Self Pledge
Balance of time. Responding to client demands Setting boundaries professionally and personally. Re-assessing my goals. Doing one thing just for myself. Allowing leisure for some time every day.

Examples for discussion

#1 Patrick, a person who was brought in by police starts screaming during his assessment: “I don’t need to be here. All you fools are the ones ruining my life.” The police had given you a report that they found Patrick in his truck deep in the woods at a local park holding a loaded gun. Beside him was a handwritten suicide note about ending his life and things being meaningless and hopeless. When a search of his home was done it uncovered a note left there with instructions for family members about how to divide up his goods after he is gone. Boxes of packed goods were stacked near the note. Patrick acts irate and uncooperative stating that he is just “at his wit’s end. Everyone gets there at some point in time.” He is argumentative about why he is “being singled out” and “forced into treatment he doesn’t agree with.” He keeps repeating, “I did not ask for this.”

#2 Diane, an obese female, comes in for a psychosocial assessment. Weighing over 400 pounds you realize the assessment chairs are too narrow and have arms on them. You are not sure how Diane can get assessed in the traditional assessment chairs.

#3 When you are trying to conduct therapy Maria (the client) begins yawning and only gives minimal responses to your questions and probes. She is respectful and attentive but does not offer many examples or elaboration on things.

#4 Mark, a client you are working with, is rather restless and shifts in his chair quite a bit. In fact, often throughout your session he even stands up and paces throughout the room, changes positions in seating or talks while standing above you.

#5 Amy, a teenager, crosses her arms during a therapy session. She remarks, “I didn’t ask for this. Of course my mom thinks I’m the problem but did you even ever witness how she treats me? She screams at me, throws endless questions at me, and never praises me for my efforts at doing anything right. She’s trying to paint a picture that I’m a troublemaker but really she’s just not wanting anyone to know how she treats me. I wish you could be in our house even one day to see how painful it is to be me.”

#6 Amelia, a disoriented woman, becomes argumentative throwing objects around the room- not understanding who you are, where she is, or how she ended up here. She talks rapidly and exhibits a great deal of behavioral agitation. It is near impossible to get any informed consent, demographic, or basic treatment paperwork done.

#7 A homeless, unkempt gentleman named Carl came in after a direct referral from a nearby hospital. He is polite and not argumentative in any way but his body odor makes it hard for you to breathe. You notice he has bedbug marks on him and some bugs are in his belongings. He seems oblivious to the body odor and have lived like this for so long it does not seem to bother him as it does you. He is able to keep talking throughout though you are having trouble breathing or interacting due to your health concerns.

#8 A female patient named Clara has her own problems about not wanting to be treated by a tall, dark skinned man because it reminds her of when she was raped. She has gotten to the point where she is yelling loud, derogatory generalized comments about all men being perverts and untrustworthy. She insists that she only wants treatment by females. She also yells against foreigners because the person who raped her had more than colored skin than her so she assumes they are “from somewhere else.” When she sees on her paperwork that the doctor is a male name and appears to be another foreigner she says she will only deal with females here or she wants to be transferred to another facility.

#9 Gloria, a severely depressed woman states that she hasn’t eaten or slept in three days. She is very hungry for a good, hot meal and some sleep. She is resistant about answering questioning stating, “you have enough information already. You can get what you need from my other doctors and family members. I’m not answering any more questions!”

#10 Dan, a man referred for assessment and admission to your facility states that you don’t realize how it really is. His family members who are his guardians and power of attorneys only want to control his living arrangements, take all his money, and take away his life. “I have no rights.” He maintains he is not impaired in any way.

#11 Bertha, a middle aged woman states, “I just don’t want to feel this (bad) way anymore.” She explains how pervasive her hopelessness and helpless feelings have become. She eventually asks, “what can you even do for me anyway?”

#12 Richard, a young adult male is a polysubstance user suing significantly more amounts of his drugs daily. He says he has been to multiple programs only to leave AMA (against medical advice). Before the rehab has been completed because he can’t stand being away from the people, places, and situations associated with using. You know he is never complaint with treatment for more than a few days and deep down you are fairly sure that again he is coming in now because he is feeling physically at his worst and his support systems are low but you are unsure he will stick with treatment for long again. Deep down you think about all the time and process you are putting into things for him with him likely still to leave.

#13 Sandra, a single mom, becomes defensive in her assessment and leans in physically toward your face stating, “what can you do for me? I’m sure you live in a good neighborhood and have it made- no real struggles of any kind. Here I am stuck. You can’t possibly understand my life struggling to put food on the table. It is just about a miracle to survive one day to the next- prostitutes, guns, physical fighting, drugs. No safe streets for my kids to kick a ball around. You gonna get me outa that? You gonna promise me my babies wont get shot while they are walking to the bus stop or to play? You gonna get someone to help me so I can rest at all?”

#14 (In an inpatient setting): Garth, a patient who is agitated, states, “if you don’t give me my belongings or try and ask me another question I will pound my fist through your face. I have every right to my own belongings. You can’t keep them from me!”

#15 Marilyn states, “I have no one. No support systems anywhere. You’d be a first person to give me the time of day. But why do you care so much? I’m sure this is just a job to you- they must pay real good! I’ve seen so many therapists in the past 5 years I cannot even count them. One problem after another. Most of them do not stay on the job long enough. Just about the time they get to know me they leave. They switch jobs, stop taking my insurance, or for some reason become a problem too. I’ve had a few fall asleep on me, not pay attention to me, reschedule me so many times that I could not get in for a while. How do I know you won’t leave me too?”

#16 Nathaniel, an older adult male, angrily states, “You’re really trying to get me to sign my life away on these papers, aren’t you? Don’t even give me a chance to read them- just sign here and there on the ‘x’. I’m supposed to not question anything or you will tell someone I’m noncompliant and I’ll be put in a program for longer- that is how it works? Just sign away or else!”

#17 (In a crisis center setting): “What’s taking so long? I’ve been waiting for hours now and have not been seen. If I wasn’t suicidal by now I am! You guys sure don’t care about compassionate care just keeping people waiting so long so long. You think a few chips to snack on and a small plastic cup of water are supposed to make me feel better? You people seem like the most uncaring group I have ever seen- just leaving people sitting for hours with nothing!”

#18 A client tells you he is in physical pain and has not received his meds in hours/is greatly overdue. You are not a doctor/nurse but realize that the client is becoming increasingly agitated because of reported physical discomfort.

#19 A person you are assessing /treating seems to struggle to comprehend paperwork and concepts related to consent. Eventually you realize he is illiterate and cannot read the paperwork but you would not want to admit this “shortcoming.” How do you obtain informed consent?

#20 A client begins screaming because she says a therapist told her “she is Bipolar.” She states she “knows of relatives of hers who are Bipolar and she is nothing like them.” She believes people have criticized her and passed judgment on her because she was stressed over severe life events. She continues, “How dare people describe me like that! I’m not gonna be treated like a mentally ill person!”

#21 You recommend to a client that’s he needs to come at least weekly for outpatient counseling. However, the client states that “is not possible.” She can only afford 1-2 times monthly because of the specialist copay. She also states that the out of network deductible is too high so it is unreasonable to come to you with the frequency you are suggesting.

#22 A young adult client from a rural Appalachian community sees you dressed in your professional attire. “I know you are trying to be helpful but you’re just not from around here, are you? He comments on your clothing, mannerisms, and how educated and refined you are. “You must be from the big city for sure.”

#23 A dual diagnosis client states, “of course I know why I drink. I have just had too many life stressors lately. I could stop if I wanted to.” As you assess usage and frequency the client seems tp have a comeback and rationalization and intellectualization for everything. Despite meeting DSM criteria for severe alcohol use including tolerance and withdrawal the client seems to be making excuses. He even has a BAL of .3 at the time of the assessment. How do you handle this?

#24 “I’m sure no one would care if I died,” stated an adult female. They don’t care while I’m alive. They never have. Every time I say I need help and someone to talk no one takes it seriously. Why would you even care about me, a stranger? I appreciate your comments of encouragement and empathy but you have to do that.”

#25 Sara is feeling stressed and overwhelmed. She has daily depressive episodes and panic attacks. After you ask her what a better life would look like she was able to tell you about a few years ago when she used to be able to handle stress more easily. Though unable to see that there is anything at all positive in her life now, you hear as the client’s narrative is shared that there was indeed a time when the client implemented resources inside herself that she does not appear to be drawing on now.

#26 As a therapist some of the cases you have had lately are extremely difficult to get out of your mind. You have images of certain challenging clients you have assessed and treated. You have difficulty sleeping when you question how you dealt with some cases and if you should have handled them differently. Even when you are at home your family has noticed that at times (the every times you are thinking about the most challenging cases) you seem different.

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