DEVELOP A THERAPEUTIC ALLIANCE
– IN 10 MINUTES OR LESS
In traditional psychotherapy, a therapeutic relationship can take weeks or months to develop – but you can start building this within 10 minutes of a client’s first call for help. Dr David Mee Lee gives a step-by-step guide.
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I am revisiting the topic of therapeutic alliances and helping people to change, due to a recent consultation with two different teams, both of which are the initial gateway for people seeking addiction and/or mental-health services. The dilemma for these clinicians was how to quickly engage the caller, assess their needs, and match them to services – all in 10 minutes or less.
In traditional psychotherapy, a therapist plans on developing a therapeutic relationship over weeks and months, even years. Dr James Mann in the 1970s, with his time-limited and brief therapy methods, taught us that it is possible in certain situations to do an effective piece of work in 6-10 sessions. Screening and Brief Intervention in alcohol problems is one example of how even a one-time brief education and advice session can be effective in starting a change process to reduce drinking.
To ensure we are on the same page about what “therapeutic alliance”, I’m talking about:
1. Agreement between you and your client on goals
2. Agreement between you and your client on strategies and methods to reach those goals
3. This agreement occurs in the context of honesty, sensitivity, empathy and understanding (an emotional bond) with the client (Miller, Mee-Lee and Plum).
When I state you can develop a therapeutic alliance in 10 minutes or less, I am being a bit provocative, but not much. I am not diminishing the complexity of the clients who come to us, nor dismissing the work of alliance-building as a simplistic, easy-to-do, short process. But I am challenging you to not go to the other extreme, which is represented by:
~ “Oh it takes weeks, months and even years to build an alliance”
~ “When people call who are mandated to get into treatment, you can’t build an alliance with them. They just want to stay out of prison or get probation off their back”
~ “It’s not important to build a therapeutic alliance with them in a short phone call. All I need to do is give them a referral number to call to set up an appointment.”
In any initial clinical exchange with a client, it is imperative to tune in quickly in the first minute or two, listen carefully for what is most important to the client prompting them to call or keep an appointment to come and talk to you.
LISTEN INTO A CALL WITH A 'MANDATED' CLIENT
Clinician: “Thank you for calling. What is the most important thing you want that made you decide to call today?”
Caller: “My probation officer told me to call to get an appointment with an addiction treatment programme?”
Clinician: “Oh, so does he think you have an addiction problem?”
Caller: “Well, that’s what he thinks and what I have to do.”
Clinician: “But what do you think? I’m more interested in whether you think you have an addiction problem which needs treatment, not just what your probation officer thinks.”
Caller: “Well, I don’t think it’s really a problem but I have to go to treatment otherwise I could go back to prison because they found something in my urine drug test.”
Clinician: “So what is most important to you – to work on an addiction problem or not go back to prison and get off probation?”
Caller: “Not go back to prison.”
Clinician: “So how about I find somewhere for you to go that will help you stay out of prison and help you prove to your probation officer that you don’t have an addiction problem. Or, if by chance, you do find out you have an addiction problem, demonstrate you are treating it so you won’t get arrested again?”
1. Now you have just agreed on a goal: stay out of prison.
2. You have agreed on strategies and methods: “See someone who can work on that goal and prove you don’t have a problem or if you do, that you won’t get arrested again to have to go back to prison”.
3. The context: A brief telephone call where you have bonded on helping the client get what is most important to him.
Whether you are working in a “call centre” or seeing clients in an outpatient or residential setting, it is the same process – especially if the person is calling at the urging of a family member, a supervisor or boss or a child-protection services worker.
For people who voluntarily reach out, it is just as important to clarify the therapeutic alliance. Read our example below.
SIT IN ON AN INITIAL SESSION WITH SELF-REFERRED CLIENT
Clinician: “So how did you decide to come for an appointment and what is most important to you to explore together?”
Client: “I’m under a lot of stress and can’t sleep well, no energy and irritable and depressed a lot. Just not sure what to do and how to get out of this funk.”
Clinician: “So that sounds like there’s a lot going on right now. Out of all of that, is there something that is most troubling that we should start with: coping with stress, sleeping better, improving your energy level, not feeling so irritable and depressed – or figuring out what to do to get out of your funk?”
Client: “Well, it’s all tied together.”
Clinician: “Well yes, but sometimes if we start with what is upsetting you most, that success helps to tackle the other things better.”
Client: “Well I’m under so much stress right now, I’m overwhelmed.”
Clinician: “So what if we focused on sorting out all the things that are stressful right now and get a handle on which things to tackle first. Would that be something you would want to start with?”
Client: “Well, if it would help me not feel so overwhelmed.”
Clinician: “It would be a great place to start and could help you not feel so out of control. Are you willing and able to come to appointments each week to work on this?”
Client: “Yes, I’m willing to give it a try.”
1. Now you have just agreed on a goal: sort out all the things which are stressful right now and get a handle on which things to tackle first.
2. You have agreed on strategies and methods: “Come to appointments each week to work on this”.
3. The context: Outpatient sessions where you have bonded on helping the client to cope with stress.
Of course, if you and/or the client lose focus on what the goal, methods and working bond is, you will have broken the therapeutic alliance. You might find yourself wandering all over the psychotherapy and counselling landscape. Or if there are disagreements on goals and strategies which are not addressed and resolved, again there is no therapeutic alliance. Be ready to see the client drop out of treatment literally or functionally and just “do time” not treatment (if mandated).
YOU CAN BUILD MORE SKILLS
Dig below the surface assumptions to understand the goal of the caller/client. The clinician at the “call centre” had completed the intake call, referred the mother and her son to a clinic. She said the clinic would call them back with an appointment date and time. A couple of weeks later, the mother called saying she still had not heard about an appointment time. The clinician braced herself, expecting angry complaints about the delay.
But putting aside her own assumptions about what the caller wanted, she listened carefully for why the mother had called and what she wanted. She discovered a different concern and reason for the call. The mother’s real concern was that her son not be assigned the same psychiatrist he previously had – apparently the psychiatrist had fallen asleep when treating her son.
Now we saw a goal.
This opens up methods to reach the goal: referral to a different clinic, support to request a different psychiatrist, help to deal directly with the psychiatrist and give feedback to the clinic if no other clinic or psychiatrist was possible.
Be clear when the client’s goal and/or strategies and methods are not possible or ethical; find mutually-agreeable ones. For example, a caller angrily complained that she wanted the representative payee who was “controlling” her money to “get off my case so I can handle my own disability payments and money myself”. The caller said she owed her drug dealer money and was pressured to pay up. The goal was clear: Get my drug dealer off my back. The client’s strategies and methods were also clear: get rid of the payee, return control of benefits to the caller, pay the drug dealer.
Being person-centred does not mean blindly following goals and methods if they are unethical. In this scenario the “call centre” clinician could bond round the goal but not around the methods. If the caller could be engaged round the goal, alternative methods to get rid of the drug dealer could be: budget to pay off her debt, then be rid of the drug dealer forever by pursuing abstinence and addiction recovery.
When family or significant others call to get a loved one into treatment, clarify and address the family’s goals. When family members call, there are at least two clients equally as important. If the identified client does not want treatment, is not in imminent danger so that they are committable against their will, then you are back to one client: the family.
Since the family’s first and primary goal – to get their loved one into treatment – is not currently possible, the task now is to work with family to clarify alternative goals. These could be: deal with the stress of an unwell loved one, examine what they can do to take care of their own stress and health, explore how to change the family dynamics and create incentives for their loved one to be open to treatment.
1. Miller SD, Mee-Lee D & Plum B (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.” In J Lebow (ed) Handbook of Clinical Family Therapy; Wiley.
2. Mee-Lee D (2011): “Changing Compliance into Collaboration – Engaging Adolescents/Young Adults in Client-Directed, Accountable Treatment”. In Paradigm vol 16, no 2 pp6-7. .
DAVID MEE-LEE MD is a leading expert in co-occurring substance use and mental disorders with over 30 years’ experience in person-centred treatment and programme development. He is senior vice president of The Change Companies, is a psychiatrist certified by the American Board of Addiction Medicine, and trains and consults internationally. He is chief editor of the 2nd Edition of the ASAM Criteria and author with Jennifer Harrison of Tips and Topics: Opening the Toolbox for Transforming Services and Systems ($19.95).