Some time ago, I was consulting with two teams, both of which are the initial gateway or “call centre” for people seeking addiction and/or mental-health services. The dilemma for these clinicians is 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. So when I say you can develop a therapeutic alliance in 10 minutes or less, it is a bit provocative – but not much.
To make sure we are on the same page, when I say “therapeutic alliance”, I’m talking about:
- agreement between you and your client on goals
- agreement between you and your client on strategies & methods to reach the goals
- this agreement occurs in the context of honesty, sensitivity, empathy and understanding (an emotional bond) with the client (Miller, Mee-Lee and Plum).
This does not diminish the complexity of the clients who come to us, nor dismiss the work of alliance-building as simplistic. But you are challenged not go to the other extreme, and think, as is all too common: “It’s not important to build a therapeutic alliance in a short phone call. All I need to do is give them a referral number to call to set up an appointment”.
Tune in quickly in the first 1-2 minutes. Listen carefully for what is most important in prompting the client to telephone you or keep their appointment to come and talk with you.
Listen into a call with a reluctant 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/family told me to call to get an appointment with an addiction treatment programme?”
Clinician: “Oh, so do they think you have an addiction problem?”
Caller: “Yes, and it’s 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 others think.”
Caller: “Well I don’t think it’s really a problem but I have to go to treatment otherwise I could face consequences 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 jail/face the family/other consequences?”
Caller: “Not go back to jail.”
Clinician: “So how about I find somewhere for you to go that will help you stay out of jail and help you prove 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?”
Now you have just agreed on a goal: stay out of jail. You 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. You agreed on the context: a brief telephone call where you bonded on helping the client get what is most important to him/her.
No matter what your work setting is, it is the same process – especially if the person is calling at the urging of a family member, a supervisor or boss or child protective services.
For people who voluntarily reach out, it is just as important to clarify the therapeutic alliance…
Listen into a call with a self-referred client…
Clinician: “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, irritable and depressed. 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: “Agreed, but sometimes if we start with what is upsetting you most, that success helps to tackle the other things better.”
Client: “I’m under so much stress, I’m overwhelmed.”
Clinician: “So what if we focus 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 want to start with?”
Client: “Yes, if it would help me not feel so overwhelmed.”
Clinician: “I think it would be a great place to start and could really 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.”
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. You agreed on strategies and methods: come to weekly appointments to work on this. You agreed the context: outpatient sessions. You bonded on helping the client cope with stress.
Of course, if you and/or the client lose focus on what the goal, methods and working bond is, then the therapeutic alliance is broken. Or if there are disagreements on goals and strategies that are not attended to and resolved, again there is no therapeutic alliance. Be ready to see the client drop out of treatment.
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