I am pretty sure that anyone who works with helping people change believes in the importance of the therapeutic alliance and relationship. We’ve talked about this many times before. You can see one example in the February 2010 edition of TNT.
https://changecompanies.net/tipsntopics/?p=1240

I am revisiting the topic again because recently I was consulting with two different teams both of which are the initial gateway to services. They are the “call center” for people seeking addiction and/or mental health services. So the dilemma for these clinicians is how to quickly engage the caller, assess their needs, and match them to services all in ten minutes or less. It’s all very well to talk about the therapeutic alliance, but tell me how to do that in a few minutes!

In traditional psychotherapy a therapist plans on developing a therapeutic relationship over a period of weeks and months, even years. Dr. James Mann in the 1970’s with his time-limited and brief therapy methods taught us that it is possible in certain situations to do an effective piece of work in 6 to 10 sessions. Screening and Brief Intervention (SBI) in alcohol problems is one example of how even a one time brief education and advice session can be effective in starting a change process to reduce drinking.

TIP 1
How to develop a therapeutic alliance in ten minutes or less

To make sure we are on the same page about what I mean when I say “therapeutic alliance”, I’m talking about:

1. Agreement between you and your client on goals
2. Agreement between you and your client on strategies and methods to reach those goals
3. This agreement occurs within the context of honesty, sensitivity, empathy and
understanding (an emotional bond) with the client. (Miller, Mee-Lee and Plum).

When I state you can develop a therapeutic alliance in ten minutes or less, I am being a bit provocative, but not much. I’m not diminishing the complexity of the clients who come to us, nor dismissing the work of alliance-building as a simplistic, easy-to-do, short process. But I am challenging you to not go to the other extreme, which is represented by:

–> “Oh it takes weeks, months and even years to build an alliance.”
–> “When people call who are mandated to get into treatment, you can’t build an alliance with them. They just want to stay out of jail or get probation off their back.”
–> It’s not even important to build a therapeutic alliance with them in a short phone call. All I need to do is give them a referral number to call to set up an appointment.”

In any beginning clinical exchange with a client, it is imperative to tune in quickly in the first minute or two, listen carefully for what is most important to the client prompting them to pick up the phone and call or keep an appointment to come and talk to you.

Listen into a call with a Mandated Client:

Clinician: “Thank-you for calling, what is the most important thing you want that made you decide to call today?”

Caller: “My probation officer (PO) told me to call to get an appointment with an addiction treatment program?”

Clinician: “Oh so does he think you have an addiction problem?”

Caller: “Well that’s what he thinks and what I have to do.”

Clinician: “But what do you think? I’m more interested in whether you think you have an addiction problem which needs treatment, not just what your PO thinks.”

Caller: “Well I don’t think it’s really a problem but I have to go to treatment otherwise I could go back to jail because they found something in my urine drug test.”

Clinician: “So what is most important to you – to work on an addiction problem or not go back to jail and get off probation?”

Caller: “Not go back to jail.”

Clinician: “So how about I find somewhere for you to go that will help you stay out of jail and help you prove to your PO that you don’t have an addiction problem. Or, if by chance, you do find out you have an addiction problem, demonstrate you are treating it so you won’t get arrested again?”

1. Now you have just agreed on a goal: Stay out of jail.
2. Agreed on strategies and methods: See someone who can work on that goal and prove you don’t have a problem or if you do, that you won’t get arrested again to have to go back to jail.
3. The context: A brief telephone call where you have bonded on helping the client get what is most important to him.

Whether you are working in a “call center” or seeing clients in an outpatient or residential setting, it is the same process – especially if the person is calling at the urging of a family member, a supervisor or boss or a child protective services worker. For people who voluntarily reach out, it is just as important to clarify the therapeutic alliance.

Sit in on an Initial Session with Self-Referred Client:

Clinician: “So how did you decide to come for an appointment and what is most important to you to explore together?”

Client: “I’m under a lot of stress and can’t sleep well, no energy and irritable and depressed a lot. Just not sure what to do and how to get out of this funk.”

Clinician: “So that sounds like there’s a lot going on right now. Out of all of that, is there something that is most troubling that we should start with: coping with stress; sleeping better; improving your energy level; not feeling so irritable and depressed; or figuring out what to do to get out of your funk?”

Client: “Well it’s all tied together.”

Clinician: “Well yes, but sometimes if we start with what is upsetting you most, that success helps to tackle the other things better.”

Client: “Well I’m under so much stress right now, I’m overwhelmed.”

Clinician: “So what if we focused on sorting out all the things that are stressful right now and get a handle on which things to tackle first, would that be something you would want to start with?”

Client: “Well if it would help me not feel so overwhelmed.”

Clinician: “I think it would be a great place to start and could really help you not feel so out of control. Are you willing and able to come to appointments each week to work on this?”

Client: “Yes, I’m willing to give it a try.”

1. Now you have just agreed on a goal: Sort out all the things which are stressful right now and get a handle on which things to tackle first.
2. Agreed on strategies and methods: Come to appointments each week to work on this.
3. The context: Outpatient sessions where you have bonded on helping the client cope with stress

Of course, if you and/or the client lose focus on what the goal, methods and working bond is, then you will have broken the therapeutic alliance. You might find yourself wandering all over the psychotherapy and counseling landscape. Or if there are disagreements on goals and strategies that are not attended to and resolved, then again there is no therapeutic alliance. Be ready to see the client drop out of treatment literally or functionally and just “do time”, not treatment (if mandated).

Those two scenarios took less than ten minutes.

References:
1. Miller, S.D., Mee-Lee, D., & Plum, B. (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.” In J. Lebow (ed.). Handbook of Clinical Family Therapy. New York: Wiley.
http://www.scottdmiller.com/sites/default/files/Making%20Treatment%20Count%20(Lewbow).pdf

2. Mee-Lee, David (2011): “Changing Compliance into Collaboration – Engaging Adolescents/Young Adults in Client-Directed, Accountable Treatment” Paradigm Vol. 16, No. 2. pp.6-7.
https://changecompanies.net/assets/pdfs/ChangingCompliance.pdf

Here are a few clinical vignettes to build your SKILLS on exploring the therapeutic alliance.

TIP 1
Dig below the surface assumptions to really understand the Goal of the caller or client.

The clinician at the “call center” had completed the intake call, referred the mother and her son to a clinic. She said the clinic would call them back with an appointment date and time. A couple of weeks later, the mother called back saying she still had not heard about an appointment time. The “call center” clinician braced herself, expecting angry complaints about the delay. However putting aside her own assumptions about what the caller wanted, she listened carefully for why the mother had called and what she wanted. She discovered quite a different concern and reason for the call.

The mother’s real concern was that her son not be assigned the same psychiatrist he had when he had received treatment there before. Apparently the psychiatrist had fallen asleep when treating her son. His mother wanted desperately to avoid having that same psychiatrist again. Now there was a Goal.

This opens up Methods to reach the Goal: referral to a different clinic; assistance to request a different psychiatrist; assistance to deal directly with the psychiatrist and give feedback to the clinic if no other clinic or psychiatrist was possible.

TIP 2
Be clear when the client’s Goal and/or Strategies and Methods are not possible or ethical. Work on finding mutually agreeable Goals and/or Methods.

Vignette A
The caller angrily complained she wanted the Representative Payee who was “controlling” her money to “get off my case so I can handle my own disability payments and money myself.” The caller said she owed her drug dealer money and was getting a lot of pressure to pay up. The Goal was clear: Get my drug dealer off my back. The client’s Strategies and Methods were also clear: get rid of the Representative Payee; return control of benefits to the caller; pay off the drug dealer.

Being person-centered does not mean blindly following their goals and methods if they are unethical ones. In this scenario the “call center” clinician could bond around the Goal but obviously not around the Methods. If the caller could be engaged around the Goal, alternative Methods to get rid of the drug dealer could be: budget to pay off her debt, but then to be rid of the drug dealer forever by pursuing abstinence and addiction recovery.

Vignette B
An adolescent’s Goal was to be reunified with parents, but a decision had already made by Child Protective Services to not reunify. If the young man could be engaged to explore alternate goals, these could be: To cope with the pain and loss of that non-reunification decision; find the next best possible alternative place to go; advocate for visits with his parents, initially supervised ones, with working towards unsupervised visits.

TIP 3
When family or significant others call to get a loved one into treatment, clarify and address the family’s goals.

When family members call there are at least two clients equally as important. If the identified client does not want treatment, is not in imminent danger so that they are committable against their will, then you are back to one client – the family. Since the family’s first and primary goal is not currently possible – to get their loved one into treatment – then the task now is to work with family to clarify alternative Goals: deal with the stress of an unwell loved one; examine what they can do to take care of their own stress and health; explore how to change the family dynamics and create incentives for their loved one to be open to treatment.

The San Francisco Giants won baseball’s World Series in 2010. Earlier this month on May 6 they won against the Milwaukee Brewers on a beautiful sunny day at AT&T Park in San Francisco in front of an attendance of 41,796. It was a tight game that went 11 innings when they squeaked out a 4 -3 win.

I like to think they won because of the inspiration of the National Anthem that day.

My youngest of three, Mackenzie, opened with the National Anthem for that game. If you don’t believe me, go to You Tube and search “Mackenzie Mee-Lee, Giants Game National Anthem.” It went viral. Last I checked there were 303 views! See for yourself, it might push the “views” into the 400s.

You got it that I’m the proud father. But as I write this, it’s Memorial Day weekend when the nation is supposedly honoring those who have made the ultimate sacrifice in their service to the USA. In actual fact, it is the unofficial start of the summer; a long weekend for camping or relaxing somewhere; and a good reason for retailers of every kind to lure you into buying something with no shipping charges and added free stuff, but you have to buy this weekend. I’ve already succumbed.

For many families Memorial Day, May 28 this year, is an intensely personal day for mourning their loved ones who gave their lives fighting for this country and its freedoms. I can’t imagine what it is like to lose a son or daughter in war. Well I can, but I don’t like to think about it. But I should and I will.

So as I watch Kenzie singing the National Anthem for the fifth time so far, my heart goes out to all the people who will only have videos of their loved one to watch. I will get to hug and “high five” her in the flesh next time we meet. They can only watch videos.

Take a look at the free information, articles to download, clinical practice resources and literature references on The Change Companies’ (TCC) website and at TCC’s website for consumers and clients www.ChangeU.net. Check out ChangeU for yourself and for your clients.

* On TCC’s website, www.changecompanies.net you can click on the Tips and Topics button and search 9 years of back issues. Click on Mindful Midweek and see inside the thoughts and observations of Don Kuhl, TCC founder. You’ll learn something about yourself and the world around you in these brief, but entertaining blogs.

* Then up the top of TCC Home Page, click on “Evidence” and be educated for free about the underpinnings of Interactive Journaling. Click on the “Related Articles & More” to download some articles I’ve written.

* Back to TCC Home Page and click on “What we do”. Enjoy the animation on how TCC develops Interactive Journals.

If you’d like to get selected relevant clinical and systems tips from the years of Tips and Topics all in one place, consider buying “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; Sells for $19.95)

Here are some highlights:

* Pages 93-96: Sample interaction and dialogue between therapist and client to illustrate how to engage a mandated client into collaborative treatment:
Therapist: “Thank-you for choosing to work with me. What is the most important thing you want that made you decide to meet with me?”
Client: “I didn’t choose you, they made me come.”

* Pages 114-118: Conflicts are expected and normal. If there is not conflict, someone is wimping out to speak up creatively. There’s nothing wrong with conflict. Not resolving it is the problem: “Conflict Resolution Policy and Procedure” – How to resolve conflicts in your team.

* Pages 146-148: A comprehensive chart: “Matching Stages of Change and Treatment to Treatment Goal, Intervention and Technique” – Helps individualize treatment to stage of change

* Pages 131-134: Use it NOW tools: A Client Benzodiazepine Agreement and a Client Addictive Illness Medication Agreement – Helps use Medication Assisted Treatment appropriately

* Page 72: A list of Interactive Journals you can assign to clients and matched to which ASAM Criteria Dimension they address e.g., Anger journal, Self-worth journal for Dimension 3; Into Action journal for Dimensions 4, 5 and 6

Use the material to translate theory into practice, concepts into clinical services, and be a change agent for people, programs, payers and policy makers.
FYI- Here is a preview of the chapter headings of the Tips and Topics Book:

Chapter 1: Changing a System of Care is not for the Weak
Chapter 2: Attracting People into Recovery, Even When You Don’t Feel Like It
Chapter 3: Screening and Assessment: Finding Your Audience
Chapter 4: Level of Care…or now you’ve got them…what’s next?
Chapter 5: Turning Paperwork into Peoplework
Chapter 6: Let’s Make Sure That’s What We’re Actually Doing
Chapter 7: Consolidating Systems’ Change: Celebrating Successes, Grieving Loss and Resolving Conflicts

How to buy
Call The Change Companies at (888) 889-8866. Ask for the Tips and Topics book. You can also go online and get started on ordering at www.changecompanies.net/tips-and-topics.php. It sells for $19.95.  Or grab the e-book on amazon.com by clicking here.

Thanks for reading. Join us in late June.

David