Working More Effectively with Difficult Clients

1. Working More Effectively with Difficult Clients University of Nevada, Reno

2. Logistics • NIDA funded study • Audio taping info. • Cell phones • Meals • Bathroom breaks • Participant packets • Any logistical questions?

3. Schedule Today 9:45-12:00 Workshop 12:00-1:00 Lunch 1:00-4:45 Workshop 4:45-5:00 Post Assessment Tomorrow: Working with culturally different clients

4. Purposes of the Workshop • To help you to work more effectively with difficult and different clients • To reduce/prevent burnout and bring more vitality to your work • The bottom line: To help make a difference in your lives and the lives of your clients Based on the principles of: Acceptance and Commitment Therapy (ACT)

5. Guidelines • At times this will be experiential - may stir a few things up • We want to create a safe place • You are invited to take some risks during the exercises and discussion and push your growth edges out a bit, but do only what you are ready to do • Confidentiality is essential • No rescuing

6. A request • Intend for this workshop to make a difference • What if stepping up to our work challenges required that WE step forward and look within ourselves? • My commitment: • To stay present • To step forward myself • To serve you in this joint effort

7. mindfulness exercise

8. Introductions In a minute or less: • Your name • What you want to get out of this workshop. • What is one way that you might get in your own way in terms of having that happen here?

9. Burnout: Contributors • Burnout is widespread in the addictions treatment field. • What is going on? • Some evidence that difficult clients are actually increasing in rate. • Addictions treatment services in many places are getting more limited. • And yet addictions counselors are being asked to do more.

10. Burnout: Contributors • The research suggests that the two biggest predictors of burnout in the addictions field are: • dealing with difficult clients • …especially in the context of chaotic organizational environments and low institutional support.

11. Difficult Clients? • What are difficult clients like? • What makes them difficult?

12. Notice What Just Happened • As we entered into this, what happened in this room? • Sometimes we can be disempowered before we even go into the session, as soon as we realize that that’s what we’re facing (i.e., the difficult client). • Does anybody have this experience? • You look on the list for who you are going to see this day, and its like “oh no,” not xx; or “whew,” glad he’s not there today? • A client cancels and you feel relieved?

13. When we are with difficult clients, two things happen 1) There’s a stream of judgments and evaluations that come up when we are with difficult clients -- towards the other person and towards ourselves. 2) There are feelings and reactions associated with this that are not easy to sit with. • Examples?

14. Struggling with Experience • Struggling with these reactions is associated with burnout. • We start to objectify our situations, our clients, and even ourselves. • We need room for our thoughts and feelings when we climb in the room with a difficult client. • Otherwise we lose our vitality and connection to work (and even the rest of our lives).

15. Bottom Line • Some of the stuff we will do here might be helpful with difficult clients directly, but mostly we want to start with ourselves.

16. Exercise • I need 3 volunteers who are willing to answer a few personal questions

17. Classification, judgment, and evaluation happen inside each of us • We can’t escape them as they are essential to adaptation. Get out of room? • On the other hand, there may be times when they are over-extended • Example: object exercise

18. The problem isn’t the judgments, stereotypes, or evaluations themselves, but when they structure our world without our noticing this process.

19. Our culture doesn’t give us many tools • Terrifying images on TV constantly • Less and less training on how to be with our own distress in a way that is softer, kinder, more compassionate. • Our culture is massively promoting the “feel good” message.

21. We are Feeding This Process: Sleeping Medications 3 2 Billion Projected: 2010 - $9B 1 2000 2003 2005

22. Suffering is Normal • High lifetime incidence of major DSM disorders (~50%, doesn’t include addiction or psychosis) • Year incidence around 26% + ~5% addicted • High treatment demand from other persons • High rates of divorce, sexual concerns, abuse, violence, prejudice, loneliness • Some extremely destructive behaviors are both common and non-syndromal, e.g., suicide

23. Suicide as an Example • Unknown in nonhumans but universal in human society (in U.S. ~1.3% of us die by suicide) • Over a lifetime: • About 10% of people attempt suicide • About 20% have serious struggles including a plan • About 20% have serious struggles without a plan

24. So what’s the alternative? • We’ll be walking through one in rest of workshop

25. Psychological Flexibility Acceptance and Commitment Therapy

26. Psychological Flexibility Psychological flexibility is contacting the present moment fully as a conscious human being, as it is, not as what it says it is, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.

27. These processes are anti-burnout

28. Helping Counselors • Approximately 90 Drug and Alcohol Counselors • Randomly assigned to three groups: • ACT • Multicultural training • Content contact control • Day-long workshop • 3 Month Follow-up

29. Change in Burnout Education ACT Multicultural 4 0 -4 Pre- Post Pre- F-up Pre- Post Pre- F-up Pre- Post Pre- F-up

30. Effects on Judgmental Thinking Control Multicultural ACT

31. And it May Help Your Clients: Severe Substance Abuse • 124 abusing multiple drugs within the last 30 days while on methadone maintenance • Three conditions (RCT) • ACT + methadone maintenance • ITSF + methadone maintenance • Methadone maintenance

32. Treatment • ACT and ITSF Plus Methadone • 16 weeks • 3 sessions per week (one group, two individual) • Methadone (supplied) and monthly drug counseling • 6 month follow-up • Methadone Alone • Methadone (supplied) and monthly drug counseling

33. 65 ACT 55 ITSF 45 35 MM 25 Objectively Assessed Opiates Percentage Negative UAs Pre Post 6 Mo Follow Up Phase

34. 3 randomized trials are now done: ACT versus Nicotine Replacement (Gifford et al., Behavior Therapy, 2004; N = 76) ACT + FAP + Zyban versus Zyban (Gifford et al., soon to be under review; N = 303) ACT versus CBT (Hernandez-Lopez, Roales-Nieto, & Luciano, Universidad de Almería, Spain; under review; N = 81) Details vary: group, individual, length but all have one year follow-up and the major empirically supported approaches are there as comparisons Smoking

35. Smoke Free at One Year Follow-Ups (all included) Nicotine Patch ACT Zyban Overall effect size d = .34 ACT + FAP + Zyban CBT ACT 5 10 15 20 25 30 35 Percentage Not Smoking

36. The Bottom Line` • You may be a better clinician overall if you learn ACT • If you apply these methods to your own day to day work life you likely be less stressed, more empowered to alter your work environment, less burned out, more engaged, and more effective.

37. Most of What is in this Workshop You Can Take Home • Was a best seller last year • You will get a free copy to use as a follow up on the workshop • We have evidence that using it helps

38. Acceptance of Where We Start • 4 questions: • Things you might share • Thing you don’t • What you like least about yourself • What stands between you and what you most want • Hands up

39. Acceptance of Where We Start • Judgments are historical and often painful • Yet we don’t have the information • And they are easily programmed

40. Stevie Has Already Started

41. The mind • Much of thinking is quick, reflexive, automatic • Mental content is programmed into us, much like a computer is programmed • We work by addition, not subtraction

42. What if control is the problem? • 95% solutions • If you are not willing to have it, you will • Polygraph • Pain and suffering

43. Cognitive Fusion • We tend to live in a world excessively structured by literal language • Verbal constructions of life can even become a veritable substitute for life itself • People cannot distinguish a verbally-based and evaluated world from the world as directly experienced through the senses. • The two become fused into one world.

44. See, that’s what I’m talking about!

45. Let’s jump out of the water • Milk exercise

46. 3 groups of cognitive defusion (mindfulness) methods: • Introduce to the concept that language may not hold all the answers • Create distance between thought and thinker • Help people detect verbal entanglement (when you do, you step out of it for a moment): differentiate “buying a thought” from “having a thought”

47. Language may not hold all the answers • "Verbal knowing rests atop non-verbal knowing so completely that an illusion is created that all knowledge is verbal" (Hayes et al., 1999). Exercises/metaphors • Learning a skill • Tell me how to walk

48. Create distance between thought and thinker • “the mind” as an object (take your mind for a walk) • Thoughts on cards • Bus metaphor

49. Name badges: Letting go of attachment • Write a negative self-evaluation on the badge • Put something on there that you are willing to let go of attachment to • Something most others don’t know about you • One possibility: Think of what’s the worst thing that anyone could call you, something that you would work really hard to not be called. • Rules: • No talking about content of name tags for 30 minutes • See if you can let go of being right • Just sit there and see how it feels to be wearing that badge

50. Taking Your Mind for a Walk • Groups of three: One is a person, two are minds. • Person goes where he/she chooses; Minds must follow. • Persons: this is your job • Notice your breath as you walk • Feel your feet, leg, torso, hands as you walk – go wherever you choose to go • See, hear, smell, feel –slow down and note what is happening around you and in you • See if you can notice things you normally would not • Smile • And gently listen to your mind …