Working More Effectively with Difficult Clients

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(No Transcript)
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Working More Effectively with Difficult Clients

• Jason Luoma
• University of Nevada, Reno

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Logistics

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

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Schedule

• Today
• 945-1200 Workshop
• 1200-100 Lunch
• 100-445 Workshop
• 445-500 Post Assessment
• Tomorrow Working with culturally different
  clients

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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

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Predictions

• Some of you
• (1) Will agree with what I have to say
• (2) Will find it intriguing, different
• (3) Wont like it, see how Im doing it wrong,
  want to debate.

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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

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A request

• A request
• Intend for this workshop to make a difference
• This is your time, I invite you to make it worth
  something
• This is about your life, creating one that is
  important and vital
• 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

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• mindfulness exercise

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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?

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Burnout Contributors

• Burnout is widespread in the addictions treatment
  field.
• We know that burnout is not good for us
  (psychologically or physically) or for our
  clients.
• 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.

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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.
• Were mainly going to focus on difficult clients,
  but some of what you learn here may also be
  useful in responding to organization issues.

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What is Difficult About Difficult Clients?

• What are difficult clients like?
• What makes them difficult?

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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
  thats what were 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 hes not there today?
• A client cancels and you feel relieved?

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When we are with difficult clients, two things
happen

• 1) Theres 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?

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• Some of the stuff we will do here might be
  helpful with difficult clients directly, but
  mostly we want to start with ourselves.
• "Therapy is a discussion between two people, one
  of whom is more anxious than the other, and it's
  not always clear who that is." Harry Stack
  Sullivan

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We can get stuck when

• We try to push away from things that are
  psychologically difficult for us as a way of
  doing our work.
• The problem is that as we try to push these
  things away, they tend to become stickier.
• If difficult thoughts and feelings need to be
  pushed away, it produces a kind of hardening in
  us.

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Struggling with Your Own Experience

• Our research suggests that struggling with and
  trying to change the largely automatic and
  programmed reactions that occur when we are with
  difficult clients is associated with burnout.
• In burnout, we also start to objectify and
  demonize our situations, our clients, and even
  ourselves.
• Its like its not OK to think, feel, see, or
  sense whatever it is there when we climb in the
  room with a difficult client.
• This has a cost in terms of vitality and
  connection at work (and even the rest of our
  lives).

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The Target Psychological Flexibility

• Our culture teaches us little about how to sit
  with hard things in a compassionate way.
• What were are going to do in here is to attempt
  to find a way that is more flexible, so that we
  can carry those parts of us that are difficult
  and be present with and engaged with our clients.

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Exercise

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

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Classification, judgment, and evaluation happen
inside each of us

• We cant escape them as they are essential to
  social adaptation.
• On the other hand, there may be times when they
  are problematic
• Example object exercise

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• The problem isnt the judgments, stereotypes, or
  evaluations themselves, but when they structure
  our world without our noticing this process.

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Our culture doesnt give us many tools

• We are increasingly barraged with scary, even
  terrifying images in our daily lives (think TV
  news) and given little in the way of how to sit
  with all this difficult stuff.
• We are getting less and less training on how to
  be with our own distress in a way that is softer,
  kinder, more compassionate.
• And our culture is massively promoting the feel
  good message. Examples-- drug advertisement,
  pathologizing of everything, extreme makeover
  TV shows.

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We are Feeding This Process Sleeping Medications
3
2
Billion
Projected 2010 - 9B
1
2005
2003
2000
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Obesity Among U.S. Adults 1985
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
26
Obesity Among U.S. Adults 1986
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
27
Obesity Among U.S. Adults 1987
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
28
Obesity Among U.S. Adults 1988
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
29
Obesity Among U.S. Adults 1989
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
30
Obesity Among U.S. Adults 1990
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
31
Obesity Among U.S. Adults 1991
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
32
Obesity Among U.S. Adults 1992
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
33
Obesity Among U.S. Adults 1993
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
34
Obesity Among U.S. Adults 1994
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
35
Obesity Among U.S. Adults 1995
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
36
Obesity Among U.S. Adults 1996
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
37
Obesity Among U.S. Adults 1997
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
38
Obesity Among U.S. Adults 1998
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
39
Obesity Among U.S. Adults 1999
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
40
Obesity Among U.S. Adults 2000
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
41
Obesity Among U.S. Adults 2001
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
42
Obesity Among U.S. Adults 2002
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
43
Obesity Among U.S. Adults 2003
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
44
Obesity Among U.S. Adults 2004
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
45
Obesity Among U.S. Adults 2005
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610.
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Suffering is Normal

• High lifetime incidence of major DSM disorders
  (in the new NCSR 50, doesnt 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

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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

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• The daily round has become frantic, for workers
  and homemakers alike - we need Day Runners just
  to keep track of what were supposed to do! Each
  task interrupts the last, nothing one does ever
  feels fully completed, and many live their lives
  always a little panicky, as thought late for an
  appointment. (The appointment theyre really late
  for is an appointment with themselves.)
• -Michael Ventura (2006)
• From Appointments with Ourselves

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• So what are we proposing? Whats the model?
• Well be walking through this in rest of workshop

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Acceptance and Commitment Therapy
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Instead of running away from your emotions ---
Acceptance
Contact with the Present Moment
Values
Defusion
Committed Action
Self-as-context
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Contact with the Present Moment
Values
Acceptance
Instead of arguing with your mind--- mindfulness.
We call it defusion.
Committed Action
Self-as-context
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Contact with the present moment slowing down
and showing up to the moment
Values
Acceptance
Defusion
Committed Action
Self-as-context
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Contact with the Present Moment
Values
Acceptance
Defusion
Committed Action
Self as context --- Consciousness. Being present
as a conscious human, intentional person
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Contact with the Present Moment
Values what do you want to be about?
Acceptance
Defusion
Committed Action
Self-as-context
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Contact with the Present Moment
Values
Acceptance
Commitment and how to do you get your feet
moving in the direction of what matters to you?
Defusion
Self-as-context
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Acceptance and Commitment Therapy
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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.

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• The enemy of health is rigidity.
• The proponent of health is flexibility.
• The enemy of burnout is flexibility its
  painful to sit with people who are difficult, in
  pain. Its hard to sit with this and show up and
  work for our clients.

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Why Are Difficult Clients a Source of Stress and
Burnout?

• Recent data correlational data from our lab
• Measure clinician burnout, then measure
• stress and mental health,
• job variables,
• stigma, and
• ACT related variables acceptance, defusion, and
  values

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Stress, ACT, and Burnout
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Now Reverse It
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Work Effectiveness and Burnout

• Thats correlational can we DO anything about
  it
• Weve begun to look at this

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Study 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

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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

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Objectively Assessed Opiates
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
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Subjectively Assessed Total Drug
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
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Smoking

• 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

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Smoke Free at One Year Follow-Ups (all included)
Nicotine Patch
ACT
Zyban
Overall effect size d .34
ACT FAP Zyban
CBT
ACT
30
25
5
20
15
10
35
Percentage Not Smoking
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Is it helpful for counselors? Glad you asked.
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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

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Effects on negative judgmental thoughts
Control
Multicultural
ACT
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Change in Burnout
Education
ACT
Multicultural
4
0
-4
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
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Effects on Judgmental Thinking
Control
Multicultural
ACT
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The mind

• Much of thinking is quick, reflexive, automatic
• Were constantly living in a world structured by
  language, and usually arent aware of this (e.g.,
  watch your minds right now)
• Mental content is programmed into us, much like a
  computer is programmed
• We work by addition, not subtraction

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Eye to Eye

• Sit in pairs, knees between knees
• Look at the other person
• Notice the chatter
• Let go and be present to being with another person

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What if control is the problem?

• 95 solutions
• If you are not willing to have it, you will
• Polygraph
• Pain and suffering

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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.

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• Example Read the following to yourself while
  simultaneously being aware of how your feet feel

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• Little Jack Horner
• Sat in the corner,
• Eating a Christmas pie
• He put in his thumb,
• And pulled out a plum,
• And said,
• What a good boy am I!

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Lets jump out of the water

• Milk exercise

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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 dont know about you
• One possibility Think of whats 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

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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

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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
• Describing a chair
• Tell me how to walk

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Create distance between thought and thinker

• the mind as an object (take your mind for a
  walk)
• Thoughts on cards
• Bus metaphor

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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

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Minds this is your job

• Get close to your person and communicate nearly
  constantly describe, analyze, encourage,
  evaluate, compare, predict, summarize, warn,
  cajole, evaluate, and so on.
• Persons cannot communicate with his or her mind.
  The mind must monitor this, and stop the person
  ("Never mind your mind") if the rule is violated.
• Persons should listen to their minds without
  minding back and go where you choose to go.
• Include work-related content brainstorm

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The task

• Do this for four minutes. Then switch, person
  become a mind and one of the minds become the
  person (minds watch the time).
• After four more minutes, switch again.
• After four more minutes, split up and walk
  quietly by yourself for four minutes.
• While you are walking, walk mindfully and
  notice that you are still taking your mind for a
  walk. Persons should follow the same rules as
  before during this time.

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Buying a thought vs. having a thought

• Buying a thought looking at the world as
  structured by that thought or from the vantage
  point of the thought
• Having a thought Looking at the thought as a
  thought
• Exercise Leaves on the stream

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Values

• Goals vs. values
• process vs. outcome
• Distinguish goals and values
• Chosen, cannot be evaluated, rather are what
  enables evaluation

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The Life Question

• Given a distinction between you and the things
  you are struggling with and trying to change, are
  you willing to experience those things, fully and
  without defense, as it is and not as it says it
  is, and do what takes you in the direction of
  your chosen values in this time and situation?

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Values Statements

• What I value is __________________
• What I have been doing is (that has not been
  working in terms of my values) ____________
• What thats cost me is__________________
• What I will do from here is _______________

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Most of What is in this Workshop You Can Take
Home

• This is your free copy to use as a follow up on
  the workshop
• Main place to learn more about ACT is
  www.contextualpsychology.org
• A listserv that goes with this book can be found
  at www.yahoogroups.com and is called ACT for the
  Public.

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Basic Assumptions of ACT

• Suffering is basic fact of life for humans.
• Its not just that humans have pain suffering
  is much more than that.
• People struggle with the forms of psychological
  pain they have their difficult emotions, painful
  memories, self-evaluative thoughts, their
  uncomfortable urges or sensations.
• They think about them, they worry about them,
  resent them, anticipate them, and hate them.

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ACT Assumptions

• People are capable of great commitment,
  incredible courage, and deep compassion.
• Knowing they will die, humans invest in the
  future. Knowing they will be hurt, they still
  love. Facing meaninglessness, humans still strive
  for ideals.
• At times, humans are fully present, alive,
  committed.
• One might say that these are the moments that
  make us most fully human.