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.

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Introduction

• Psychologist How have things been going this
  past week?
• Client Pretty good. Ive been doing what you
  asked me and Ive 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 didnt put them in my diary, but I
  thought about it each day and Ive remembered my
  ratings.
• P Thats OK. I dont 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.

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A Model of Resistance and Non-compliance
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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 clients
  strengths?

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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.

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Managing Homework Compliance (Birchler, 1988)

• Fourth, the psychologist must check that any
  assignment does not exceed the clients 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.

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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 clients 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 clients 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

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Example (OCD)

• Ground Rules
• Keep looking
• Dont 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

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Example (Cont)
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What is therapeutic resistance?

• the most elaborate rationalisation that
  therapists employ to explain their treatment
  failures (Lazarus Fay, 1982)
• rejection of the clients 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?

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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 clients problems, and the clinicians 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 psychologists judgment about
  the best way to achieve the goal of treatment.

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Identifying Resistance
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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

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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?

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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.

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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

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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).

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Consider?

• Ways to Handle Blocks to Progress in Therapy A
  Client Guide

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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.

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Motivational Interviewing

• (Miller Rollnick, 1991)

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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.

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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.

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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-behaviour
  al 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?

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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.

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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.

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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.

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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?

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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?

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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

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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.

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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.

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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.