Practical Advice for Stuck Clients

Posted November 30, 2015

So many of us consult on the intervention level when a client is not making significant progress.  We offer therapists advice like, “try a cognitive reframe,” or “be mindful of the behavioral contingencies,” or offer some other “ingredient” from our preferred therapies that we think will be the catalyst for change.  And why not?  We need interventions to do therapy, and our treatment manuals are basically recipe books full of ingredients that promise results for our clients.  In fact, most seminars rally around a particular treatment manual, and some even go so far to say they have the 5 (or 10) best strategies to help even your most stuck client!

Therapy manuals and their ingredients are important, and we should learn to do our therapies well, but research shows that the interventions we use in therapy actually account for a small amount of the variance in change.

So what influences outcomes more than interventions? 

Unsurprisingly, the therapy alliance is of vital importance.  However, you may be  surprised to learn that the therapy alliance accounts for 5 to 7 times more of the variance in change than treatment manuals and techniques!

Thus, while intervention-based consultation will always have its place (again, we need interventions to do therapy), it may be more wise to consult on the how the quality of the alliance is affecting the outcome.  To this end, consider these three factors related to alliance, ALL of which research shows need to be present for a positive outcome:

1) Relationship: This is the third of alliance most obvious to therapists.  Relationship is definitely about rapport and the therapist-driven variables of authenticity, empathy, and respect.  While providing these qualities along with a nonjudgmental stance seem like common sense, it can nonetheless be difficult at times when working with a stuck client.

2) Agreement on a Goal: Having a common goal for the therapy defines the work and speaks to the active part of alliance.  Often when therapy is not working it is because there is not a shared goal to bind the alliance and create active roles in the therapy.  Ask yourself: “What does the client want?”  Without a shared goal, there is no therapy!

3) Agreement on the Therapy and its Methods as being Legitimate to Reach the Goal/Solve the Problem: This third part of alliance speaks to how successful outcomes result from an interactive connection between therapist, client, and therapy/interventions in the pursuit of the identified goal.  To be effective, agreement on the therapy and methods needs to be based in genuine belief and expectancy on the part of the client and allegiance on the part of the therapist.

Without therapy alliance, virtually no intervention will carry much success. Therefore, whenever you have a stuck client, start with making sure all three parts of the alliance are present and in play!

5 DBT Skills to Enjoy the Holidays

Posted November 18, 2015

Finding yourself or your clients stressed out and dreading the holidays? While many struggle through the holidays, that doesn’t mean we are powerless to use our skills. Building on our 5 skills to survive the holidays blog, we offer 5 more skills to actually enjoy the season. Here they are:

1. Build Positive Experience (BPE):
BPE starts with being mindful of positive events that are happening all around us. Often we miss opportunities for fun or connection because we are lost in our problems and worries. Time to awaken and take advantage of positives that are possible now. Listen to favorite holiday music, watch time-honored movies, and commit yourself to investing in the season. Make sure to schedule times to get out and about to get-togethers, community functions, services, and other events that pop up during the season. BPE takes investment, planning, follow-through, and sometimes a dose of opposite-to-emotion too!

2. Attend to Relationships (A2R):
A2R is a specialized type of BPE. Relationships are like plants in that they need to be watered or they wither. The holidays are the perfect time to send cards, pictures, or to write a meaningful note or letter. Connect by phone, Skype, or in person if possible. Take extra time to let others know that they matter to you.

3. Contributing:
Surprise a friend, loved one, or co-workers with cookies or another treat. Participate in parties and events in whatever way you can…even your presence is contributing. If you are able, consider volunteering your time with any organization that helps those less fortunate, or take time to set aside and donate items you no longer need. Support an organization like Toys for Tots or volunteer to be a Salvation Army bell ringer. Whenever you can, think about how you can give, which is a true meaning of the season.

4. Self-Soothe:
Get into your senses. The holidays are filled with sights, sounds, smells, and tastes that are pleasing to our senses. Connect mindfully to these moments, and allow yourself to relax into what the holidays have to offer.

5. Participate:
Participate is a core mindfulness skill, and it means fully immersing yourself in what you are doing in the moment. Truly inhabit each experience with your full self, gently letting go of distractions to get back to being with what you are doing and who you are with during this season. Remember that we can participate in stress and misery, or in the many opportunities for joy that the season can offer us.

5 DBT Skills for Surviving the Holidays

Posted November 10, 2015

Holidays can be a time of joy or misery. While we cannot control the world around us, or make reality unfold according to our preferences, we can practice our skills to navigate challenges and focus on what is most important to us…thereby influencing our mood for the better. Create a more stress free holiday season for yourself and others with the following skills. And stay tuned for the next email on 5 skills to not just survive, but to enjoy the holidays!

1. MINDFULNESS
Mindfulness is about paying attention to the present moment, on purpose, with an open heart and nonjudgmental stance. It is about directing what we want to focus on and when based on our wisdom and what will work. During the holidays our minds get hijacked by worries about families, get-togethers, gifts, and balancing the competing pressures of the season. The remedy is to slow down and focus on this moment, taking one thing at a time, and doing exactly what is needed (which might be just being present and not doing a thing!). We can only influence the future through this moment, so live it as effectively as you can. Also remember to take time to practice breathing, imagery, or to simply contemplate the true meaning(s) of the season.

2. OPPOSITE TO EMOTION (O2E)
The holiday season might mean that you have a lot to do. When pressure builds, procrastination and avoidance can grow. Avoidance behaviors get reinforced by what we call negative reinforcement…there is temporary relief that comes with avoiding any activity that causes stress. Step out of this trap by acting opposite to procrastination and avoidance behaviors by doing tasks and activities that need attention…take the first step and throw yourself into it. Also, don’t be afraid to balance this strategy by simplifying and letting go of task and activities that are truly non-essential.

3. PLEASED
The PLEASED skills are all about self-care. Halloween candy is still around, and more holiday goodies are on the way. Unfortunately, many of us cope with stress by indulging in the excesses of the season. It feels good in the moment, but probably works against our larger goals. This is the time to be more mindful of eating healthy, balanced food, getting more movement in our day, and improving the amount and quality of our sleep. We like to think that self-care can wait until January 1, but really the time for it is today. An increase in these skills will help make the holidays more joyful with less stress. We all do better when we feel better!

4. RADICAL ACCEPTANCE
This skill means letting go of fighting reality. When you accept and give up the fight, then you free up your mental and emotional resources to be as effective as you can. Almost by definition, needing to use acceptance means that the situation you are choosing to accept is not your preference and you do not like it. For a greater good you might need to see your in-laws (or your own family), or go to that holiday or office get-together, or make some kind of compromise. Practicing an attitude of acceptance with life’s difficulties is a nice alternative to fighting every battle and making yourself suffer over what is. That is not to say give up and give in. Sometimes we do need to set boundaries or solve a problem…but if you need to do that, you will still be more effective if you start with acceptance.

5. WILLINGNESS
This skill is the opposite of trying to control everything or take a my way or the highway approach to others and life. Being willful limits our options and forces everyone into corners. Maybe it does not have to be your way! When appropriate, learn to let go and go with the flow. Be willing to do whatever is necessary to accomplish a goal or to contribute to a get-together or another person. Let go of your preconceived notions of how you think a situation should be and practice flexibility. Holidays can make us feel out of control, which we sometimes react to by trying to control everything. People who practice willingness learn to bend so they don’t break!

MHS wishes you, your friends and family, and your clients a joyful holiday season!