[acb-hsp] Quickly Building a Therapeutic Alliance

Wed Jan 30 13:21:09 EST 2013

FYI!

Please see below I copied and pasted.  The reference source for me is a
newsletter I receive from "internationally known,  trauma-informed
techniques" speaker and researcher for providers, especially
mental/behavioral health provider.  The sources for information itself
is included in what I copied and pasted at the bottom.  Hope it is
helpful.

SAVVY  

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.

http://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 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%20Cou
nt%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. 

http://changecompanies.net/assets/pdfs/ChangingCompliance.pdf

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