challenging issues in clinical practice

1. Challenging Issues in Clinical Practice From Andrew Page and Werner Stritzke (in preparation) Handbook for Clinical Psychology Trainees. New York: Cambridge University Press.

2. Introduction Psychologist: How have things been going this past week? Client: Pretty good. I�ve been doing what you asked me and I�ve noticed that the anxiety is a lot less than it was. P: In terms of the �fear thermometer� that you were using each day to rate your anxiety as homework, what sort of ratings did you get? C: Well I didn�t put them in my diary, but I thought about it each day and I�ve remembered my ratings. P: That�s OK. I don�t actually need you to do the homework, but it would be really good if did it next week instead because it might show something useful. C: Yeah, no worries at all.

4. A Model of Resistance and Non-compliance

5. Managing Homework Compliance Not an insignificant problem because homework assignments play an important role in outcome (Burns & Auerbach, 1992), such that clients who are less reliable demonstrate worse outcomes Kazantzis, Deane, & Ronan (2000) found that setting homework accounted for 13% of the variance in outcomes (r = .36) and homework compliance accounted for 5% (r = .22) in therapeutic outcomes. important and worthwhile to encourage clients to conduct homework assignments, especially given that this is a factor that is potentially under therapist control to some degree (Bryant, Simons, & Thase, 1999). amount of time allocated to homework, given that these activities can predict 13% of the outcome. Do they occupy 13% of therapy time (i.e., about 8 mins per hour)? the amount of variance in outcomes explained by homework is significant, it remains low. Therefore, if compliance is becoming contentious, perhaps it is better to build upon the client�s strengths?

6. Managing Homework Compliance (Birchler, 1988) First, he suggests that the psychologist should only provide homework assignments once a satisfactory level of rapport has been established. Second, any homework that is prescribed corresponds to the therapeutic goals. Accordingly, the psychologist needs to create an expectation that completing homework will alleviate presenting problems. Third, he encourages the psychologist to involve the client in planning homework; be the task one of assessment or treatment. By maximising the perception of control and willing participation, the likelihood of compliance will increase.

7. Managing Homework Compliance (Birchler, 1988) Fourth, the psychologist must check that any assignment does not exceed the client�s present motivational levels - consider factors such as time, energy, and cost. Sixth, reduce any threatening or anxiety-provoking aspects of homework. Seven, make sure that any tasks are specific and clear. Asking a client to repeat or to paraphrase instructions can assist this process. Giving written assignments and reminder notes can also help. Consider any possible secondary gain if the client does not comply. Finally, he recommends that the psychologist reviews homework assignments. During the review the therapist should provide support for the client, help to shape early attempts into correct behaviour, and to acknowledge positive efforts.

8. Managing Homework Compliance Thus, when giving homework it is important to allocate time to the process. Prescription of homework assignments will involve (i) explaining why you are asking the client to do the homework, (ii) getting the client�s involvement and commitment, (iii) describing the homework in details, (iv) requesting that the client paraphrase and then practice the exercise. In addition, homework must be essential to therapy. If the assessment or the task is not essential to the process and progress of therapy, then why are you wasting the client�s time with it? If the homework is essential, then it follows that you will review the homework exercise at the start of the next session. Some have even suggested that if homework is not completed, then consider cutting session short (Jacobson) and postponing the sections of the sessions that required the homework until the following week

9. Example (OCD) Ground Rules Keep looking Don�t put knife away or hide it Keep concentrating on the knife Goal and Steps Sit alone with a picture of a vegetable knife for 2 minutes (6 times per day; until 75% sure of being able to do next step) Sit alone with a picture of a vegetable knife for 5 minutes Sit alone holding a plastic knife for 5 minutes Sit alone holding a plastic knife for 10 minutes Sit alone holding a bread & butter knife for 2 minutes Sit alone holding a vegetable knife for 5 minutes Sit alone holding a vegetable knife for 7 minutes Sit alone holding a vegetable knife for 8 minutes Sit alone holding a vegetable knife for 10 minutes Sit alone holding a vegetable knife for 15 minutes

10. Example (Cont)

11. What is therapeutic resistance? �the most elaborate rationalisation that therapists employ to explain their treatment failures� (Lazarus & Fay, 1982) �rejection of the client�s goals by the therapist.� (Stewart, 1983) �the sincere desire to change confronts the fears, misconceptions, and prior adaptive strategies that make change difficult� (Wachtel, 1982) �basic reluctance to explore, to understand, to grow and change� (Blatt & Erlich, 1982) �a bad fit between the therapist and the family� (Heyman & Abrams, 1982) �patterns and transactions in family therapy that prevent change� (Glick & Kessler, 1980). major ingredient for therapy or problem that must be dealt with so that therapy can return to its objectives?

12. What is therapeutic resistance? We suggest that the psychologist should take responsibility for dealing with resistance (without taking inappropriate blame for poor therapeutic outcomes). (e.g., teachers with problem children) View therapeutic resistance as issue to be addressed in the overall plan of therapy, not a reason or an explanation for therapeutic failure. problem-focused approach to resistance adopt a transtheoretical approach to resistance and non-compliance - the goal is the amelioration of the client�s problems, and the clinician�s job is to help the client achieve this goal. Resistance and non-compliance can be used as a treatment target or addressed as a problem, depending upon the psychologist�s judgment about the best way to achieve the goal of treatment.

13. Identifying Resistance

14. Ways to Manage Resistance During the Therapeutic Process Contacting client before first session will increase probability client will attend Establish credibility as a competent professional who can create the context for change Begin treatment by establishing rapport Model good listening behaviour Provide a clear rationale for the tests and give strong encouragement about completing the testing. Provide the client with clear and informative feedback on the testing. Employ strategies that increase the engagement of the client in therapy. Reinforce completion of homework assignments

15. Ways to Manage Resistance During the Therapeutic Process Provide clear problem formulation and explicit rationale for treatment Convey optimism about change and establish a collaborative set. Predict possible obstacles to treatment that flow from formulation. When resistance or non-compliance occurs identify it as resistance (use a less judgmental description, such as �problem in therapy� or �we seem to be encountering some difficulties�), make explicit what the issue is, work with the client to identify the meaning and function of the resistance, and then respond accordingly Why?

16. Ways to Manage Resistance During the Therapeutic Process Psychologist miscommunicated or client has difficulty comprehending. unmotivated due to a lack of expectation of success slow or erratic therapeutic progress so review the case to ensure that all the problems have been identified, the treatment is appropriate for the problem and the particular type of client. client will present with a meaningful behavioural pattern or sequence that is a manifestation of the problem, or part thereof. challenges of the psychologist - wise not to be defensive, but make concern explicit, and to deal with challenge by addressing it. Sometime the situation can be defused through humour (although this has the potential to backfire if the client interprets a humorous retort as belittling them or the concern). At other times the concern can be dealt with by citing appropriate data or it might be appropriate to refer the client to another therapist.

17. Ways to Manage Resistance During the Therapeutic Process Addressing termination in an explicit manner in important. This allows the client to plan for termination, to deal with any grief and loss which may be experienced, and to raise any further matters which should be dealt with before termination is complete. Phasing treatment sessions so that they are spaced a greater distances can be beneficial, as can setting a formal follow-up session (so that the client does not feel abandoned at the end of treatment). It is also useful during the latter phases of treatment and into termination to reinforce independence. Cognitive behaviour therapists have suggested that the clinician can engage in a �search & destroy� (Epstein, 1985; Jacobson, 1984) approach. Can treat resistance by reframing the attitudes & actions. Psychologist can train client in skills that will not only be useful in addressing problems, but can be used in therapy to discuss and resolve resistance in ways that do not involve non-compliance and passive resistance

18. Ways to Manage Resistance During the Therapeutic Process �symptom prescription.� In this circumstance, the problem behaviour (or symptom) is actually given to the client as an instruction (or prescription).

19. Consider? Ways to Handle Blocks to Progress in Therapy: A Client Guide

20. Train Client in Problem Solving 1: Identify the Problem Realising that you have a problem is one thing, correctly identifying it is another. You may know that something is wrong with your car because it makes strange noises, but knowing what part to replace requires careful thought and diagnosis. 2: Brainstorm Solutions Write down as many solutions as possible. Do not try to keep them in your head because this causes confusion. 3: Chose One Solution Weigh up the positive and negative aspects of each solution. Choose the one most likely to succeed. 4: Implement One Solution Think how you are going to put your chosen solution into practice and then do it. 5: Evaluate the Outcome Later, check if your chosen solution worked. If unsuccessful, go back and implement the second best solution. Keep working until you solve the problem or decide to brainstorm new solutions.

21. Motivational Interviewing (Miller & Rollnick, 1991)

22. Expressing Empathy. An accurately empathic response responds to the meaning and emotion expressed in a communication, all the time accepting the validity of the person's experience.

23. Expressing Empathy CLIENT: Panics are the most terrifying experience I have ever had. Have you ever had a panic attack? PSYCHOLOGIST 1. Yes, I think I have. It was during the war when we were under enemy fire ... PSYCHOLOGIST 2: Although I've been anxious, it sounds as if you have found panic attacks to be quite different from the anxiety that you used to feel.

24. Expressing Empathy CLIENT: When I'm having a panic all my rational thoughts go out the window and I think I AM going to die of a heart attack. PSYCHOLOGIST 1: But you have had many clean ECGs, your cholesterol is low, and you are young. Everything points against you actually dying of a heart attack. PSYCHOLOGIST 2: It makes it difficult to stop the panic when the worry about dying becomes so overpowering.

25. Expressing Empathy CLIENT: I've had this problem with my husband for ten years, I've been to so many different psychologists it is not funny, and I haven't got better so far. PSYCHOLOGIST 1: Well, we use a cognitive-behavioural programme which is very successful and I'm very experienced in delivering the technique. You should improve quickly. PSYCHOLOGIST 2: Having failed before it must have been hard to bring yourself along to the clinic. How did you motivate yourself?

26. Developing Discrepancies Accepting the validity of a person's experiences does not necessarily involve accepting that clients stay as they are. Purpose of offering empirically validated treatments is to modify maladaptive cognitions and behaviour. Miller and Rollnick (1991) Vigorous confrontation leads to alienation of the client Developing a discrepancy between the person's current behaviour (and its consequences) and future goals. Every client presents to treatment with some degree of ambivalence. The task is to ensure that the rewards of recovery outweigh the benefits associated with the absence of change. By drawing attention to where one is, in relation to where one wants to be, it is possible to increase awareness of the costs of a maladaptive behavioural pattern. Focus upon costs that are seen as relevant to the client rather than the psychologist. One satisfactory way to develop discrepancies between current behaviour and future goals is to enquire about what the person would most enjoy doing when unshackled from their panic disorder or agoraphobic avoidance.

27. Avoiding Argumentation Once a person initiates treatment and begins to comply with the components of the programme setbacks invariably occur. An unsatisfactory way for a psychologist to respond is to harass the person to complete the exercise or berate their non-compliance Miller and Rollnick (1991): it is more profitable to avoid argumentation. They encourage the perception that therapeutic resistance is a signal of psychologist, rather than client, failure. When a person refuses to complete an assignment it is time to stop forcing the point and shift strategy. The psychologist has a problem which they must take the responsibility to solve. The shift towards problem solving enables the psychologist and client to avoid argumentation, overcome the difficulty, and is a critical part of rolling with resistance.

28. Rolling With Resistance Therapeutic resistance may signal a lack of understanding of the purpose of part of the programme or it may indicate a lack of success with one of the treatment components. Resistance may also indicate a weakening of resolve, indicating the need to develop a discrepancy to once again enhance motivation. Whatever the case, the psychologist must back-track and solve the problem. Rather than pushing against the resistance, the therapist can extract from the complaint or refusal a foundation of motivation upon which to re-build the treatment.

29. Rolling With Resistance CLIENT: I'm having a bad day with my agoraphobia. I don't think that I can do today's assignment. PSYCHOLOGIST 1: You have to face your fears. Remember, avoidance makes fears worse. You will just have to go out and catch the bus. PSYCHOLOGIST 2: When we agreed to the assignment yesterday you felt that it was achievable, how are you going to get yourself to be able to achieve the task?

30. Rolling With Resistance CLIENT: I did everything right, but I had a panic anyway. Your treatment just isn't working. PSYCHOLOGIST l: We know the treatments are effective, what do you think you did wrong? PSYCHOLOGIST 2: Even though you battled hard to manage the mood, the depression broke through. Are there any lessons that you can learn to help you have greater success next time?

31. Supporting Self-Efficacy Resistance in therapy can often follow a setback. At such times self-efficacy decreases as the person feels that successful mastery of their problem is no longer an achievable goal. In working with a client to overcome many disorders (e.g., mood, anxiety, substance use) it is particularly important to reverse decreases in self-efficacy. Central to supporting self-efficacy is conveying the principle that change is possible

32. Supporting SE at Start of Rx �We have seen how fearful avoidance is driven by panic attacks and we have discussed how life would be different if you could be free from panic attacks. We know from past groups that around nine in ten people, just like you, become free from panic attacks. Free from panics not only in the short term, but we have followed these people for up to two years after treatment and they remain panic free. Although you may find this difficult to believe, our results are no different from other similar centres around the world. However, I suspect that even though I have told you that people can learn to master panics you are thinking, "I bet I'm the one in ten who doesn't get better." Therefore, the more important question is not how many people are panic free, but how do you move from being the one in ten, to being one of the nine in ten? The simple answer is, you will need to work hard. The techniques that we will teach you are effective and this is demonstrated by the high success rates. Our experience has shown us that those people who do not improve (i) do not put in the effort necessary to learn the techniques, (ii) do not practise the techniques, or (iii) give up and go back to using the strategies which they have used before to partially manage anxiety and panics. We will teach you new techniques which will enable you to control you panics. It is up to you to learn and practice the techniques, working hard to conquer the panics, because when you do, you can be free of panic.�

33. Supporting SE Later in Rx The second time when self-efficacy must be supported is during setbacks. client is demoralised and possibly resistant to therapeutic interventions, it is necessary to solve any problems while conveying the belief that change is still possible. The third, time when self-efficacy must be particularly supported is at the termination of treatment. clients are often worried how they will fare without the support of the psychologist and if treatment has been in a group context, without the support and encouragement of other group members. This difficulty can be tackled by reminding clients that the gains during treatment were due to their efforts. In addition, it can be helpful to offer ongoing regular follow-up sessions.

34. References Anderson, C. M., & Stewart, S. (1983). Mastering resistance: A practical guide to family therapy. New York: Guilford Press. Birchler, G. R. (1988). Handling resistance to change. In I. R. H. Falloon (Ed.), Handbook of behavioural marital therapy. London: Hutchinson. Burns, D. D., & Auerbach, A. H. (1992). Does homework compliance enhance recovery from depression? Psychiatric Annals, 22, 464-469. Bryant, M. J., Simons, A. D., & Thase, M. E. (1999). Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome. Cognitive Therapy and Research, 23, 381-399. Jacobson, N. S., & Margolin, G. (1979). Marital therapy: Strategies based on social and behavior exchange principles. New York: Brunner/Mazel. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioural therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7, 189-202. Linehan, M. M. (1993). Skill training manual for treating borderline personality disorder. New York: Guilford Press. Martin, G. A., & Worthington, E. L. (1982). Behavioral homework. In M. Hersen, R. M., Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 13, pp 197-226). Orlando: Academic Press. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: Guilford Press. Openshaw, D. K. (1998). Increasing homework compliance: The SEA method. Journal of Family Psychotherapy, 9, 21-29. Shelton, J. L., & Levy, R. L. (1979). Home practice activities and compliance: Two sources of eror variance in behavioral research. Journal of Applied Behavior Analysis, 12, 324. Shelton, J. L., & Levy, R. L. (1981a). A survey of reported use of assigned homework activities in contemporary behavior therapy literature. The Behavior Therapist, 4, 13-14. Shelton, J. L., & Levy, R. L. (1981b). Behavioral assignments and treatment compliance: A handbook of clinical strategies. Champaign: Research Press. Spinks, S. H., & Birchler, G. R. (1982). Behavioral-systems marital therapy: Dealing with resistance. Family Process, 21, 169-185. Wachtel, P. (1982). Resistance: Psychodynamic and behavioral approaches. New York: Plenum. Weiss, R. L. (1979). Resistance in behavioral marriage therapy. American Journal of Family Therapy, 7, 3-6.