How to Connect With Patients Who Hold You at Arm’s Length

How to Connect With Patients Who Hold You at Arm’s Length

IN THIS VIDEO:

Jill Levitt: So, hi everyone and welcome to our one-hour webinar today on working with Alliance Resistance using TEAM-CBT to form an authentic and productive relationship with patients who hold us at arm's length with Heather Clague and Daniel Mintie. My name is Jill Levitt and I am a clinical psychologist and also the director of training at the Feeling Good Institute in Mountain View, California. I'm going to be introducing today's topic and speakers in just a moment, but first I want to guide you to a few aspects of the RingCentral Technology so that you can get the most out of the webinar.

First, I'll let you know that you all are muted and we'll keep you muted throughout, but the best way for you to interact with us today would be if you have questions at the bottom of your screen you should see a Q&A box and you can enter questions there and we'll be trying to answer your questions throughout the webinar. We'll also save some of your questions for a Q&A time where we will interact with your questions and Heather and Daniel will attempt to answer some of them. Also, Heather and Daniel will ask you some questions throughout about yourself and your practice and things like that and during that time you can answer those questions using the chat box. So, if you look at the bottom of your screen, you should have two different places to interact with us. One is Q&A for specific questions and one is chat box for answering our questions. Please remember that we'll be taking attendance electronically throughout and you are required to attend the entire webinar in order to be eligible for CE credit. You will receive an email from admin@feelinggoodinstitute.com within about 24 hours with the CE survey. So, if you don't get that, please check your spam box. You should receive that survey within about 24 hours and after you complete the survey within a week, you'll get a CE certificate also via email from admin@feelinggoodinstitute.com. If you have any questions about the survey or the certificate, first check your spam folder and then you can always send an email to us at admin@feelinggoodinstitute.com. So, now for the more interesting part, which is our presentation, let me introduce to you Heather and Daniel. So, Daniel Mintie is a licensed social worker based in Taos, New Mexico. He teaches TEAM CBT at the Feeling Good Institute and at universities and training centers worldwide. His most recent book is Dharma Wheels, then Motorcycling and Cognitive Behavioral Therapy and Heather Clague is a psychiatrist who specializes in TEAM CBT and she sees patients in her office in Oakland, California as well as via online video therapy for anyone in all of California. A graduate of Yale University and the University of California, San Francisco, she has continued her training with Dr. David Burns and the Feeling Good Institute and Heather is a level 4 TEAM CBT certified therapist and trainer. And so, I will turn it over to Heather and Daniel. Thanks.

Daniel Mintie: Thank you, Jill, for hosting us here this morning and thanks to everyone who's signed up. See, we're over a hundred here on our class. Heather and I are quite excited about sharing some work that Dr. Burns and others have been doing in the direction of what we're calling Alliance Resistance. So, we can identify at least three forms of resistance and one of these would be outcome resistance which would be a patient's ambivalence about making some life change, perhaps letting go of depression, depressionogenic thinking and behavior. We can also identify something we call process resistance which would be ambivalence about working towards making a particular change. So, if someone came to us and wanted help with a phobia, say, we would be telling them that doing exposure exercises would be an essential part of that treatment and most patients and therapists, myself included, have some ambivalence about doing exposure, turning towards what we've been avoiding instead of, again, turning away from it. So, alliance resistance is a term that was coined by our colleague Daniele Levy and this expresses an ambivalence about forging a warm and open therapeutic alliance with us. So, I think that all of these forms of resistance we could understand as being co-created by the action and the inactions of both the patients and the therapists. We'd want to avoid the error of saying patients are reluctant to align with us and instead formulate this as ambivalence that both parties would feel about forming a working therapeutic alliance. The other thing that I've noticed is that while we would talk about outcome process and alliance resistance as though they're separate things, I think oftentimes they're simply separate lenses through which we could look at the same thing. So, a person who is somewhat ambivalent about letting go of depression, say, will also probably be ambivalent about putting in the work that we would be asking them to do if they were to get better and then perhaps also somewhat ambivalent about connecting with us in a vital way.

Heather Clague: Great. Thanks, Daniel, and thank you, Jill. So, how might you know that you're having a problem, that there is alliance or some of these other kinds of resistance? Obviously, the therapy might be failing to make progress. The patient's symptoms might not be improving. There might be treatment-interfering behavior which, when I say this at the moment, I'm thinking of the patients, but the therapist may also be engaging in treatment-interfering behavior. But if the patient's not doing homework, the patient is having a hard time articulating their feelings or responding to our inquiry about their feelings, saying they don't know what they feel. The patient might be very angry and blaming the therapist for a lack of progress. There may be kind of endless venting or lots of intellectualizing and lots of talking, but never quite getting to the invitation and getting down to work. Another important clue that we'll be talking about today is our own negative thoughts and feelings about the treatment of the patient. That's usually a sign that something's going on that we probably want to attend to. So, these would all be signs that something is up in the room that probably needs to be taken a look at.

Daniel Mintie: There are probably dozens of different forms of alliance resistance. In the class that we'll be offering next month, we're going to be focusing on four distinct kinds, and we could call one of those a fight response. So, this would be a patient who argues with us or expresses outright hostility towards the form of therapy that we're offering. Another would be what we call the flight response, and this could be a patient who is careful to avoid certain topics and to evade responding in a direct way to questions we might ask them about those topics. The flight could also be expressed behaviorally by rescheduling sessions a lot or missing sessions or just not showing up in the consistent way we would need them to show up to successfully work together. We could also identify a response that we call freeze, which would be common, say, with trauma patients who would simply dissociate when there's a difficult topic that's coming up or there's a conflict that's emerging in our relationship with them. They would just stay in the room physically but go away emotionally or cognitively. Another form of freeze that we see rather common with adolescent patients is the patient would just clam up and sit silently and not engage in conversation with us. And then there's a kind of resistance we call the con, and in our class we're going to be going into this in some depth because I think it's somewhat common. And the con can take different forms. One would be the patients presenting for treatment to placate a third party. Say there's a wife who's threatening divorce unless her husband gets help with his drinking or something like that. And so we'd be invited into this sham therapy relationship with someone, not because the person actually wants help with changing their relationship to alcohol, but they're fearing the consequences of not showing up and having a therapist that they're working with. So in the con dimension, we're always looking at some form of lying that's happening. And the lying can be either active, that we ask a question and the patient would lie to us, or it could happen in a passive way that the patient just omits essential information from the work that we're doing. When that lying by omission is going on, we found that it's oftentimes being driven by projecting a very harsh inner critic that the patient's been hearing around onto the therapist, and then being frightened about being forthright with the therapist because of fearsome judgments. I'd sent out a study that had been done at Columbia University that asked patients, that there were 500 or so patients who either were in therapy or had been in therapy recently. And 84% of them reported lying to their therapist about something at some point. And the most common topic area for lying was sexuality. The second most common was suicidality. And the third most common was just the transference that the feelings that the patient had towards the therapist. So we'd like to run a little poll here and see what our numbers might look like as a community this morning. Heather, can you bring that up for us? So you can simply type in here your response to this question. So we can gauge how often do you experience one of these forms of alliance resistance that we're discussing?

Heather Clague: Great, and we're getting your responses now. I'll give people just another few moments here to enter their responses. We've got about 80% of people responding, so I'll go ahead and share these results with you.

Daniel Mintie: Okay, so in our community then, we're, looks like somewhere between 60% saying, well, that happens only now and then, and 44% saying, well, that happens quite a bit. And that's about what I would expect that we would see there. Our population might be somewhat different than the population that was polled at the Columbia study, but I think what we're seeing is that this is a very common occurrence for some of us more so than others.

Heather Clague: Great. So there's our poll. So another way to talk about alliance resistance is that it's an unhelpful enactment. So the word enactment comes from the psychodynamic tradition and refers to the idea of the unconscious playing out of roles by patient and therapist, which is something we're always doing. And it can be helpful if, for example, the roles are hardworking patients and helpful therapists, but it could be unhelpful if the roles were something like helpless victim and virtuous rescuer. But the idea here is that it's always a two-person interaction. This is always something actively shaped and created by both the patient and the therapist. And that's what will lead us to having it be something that can be incredibly useful because it's a way for us to engage actually more deeply with a patient and then help them shift the patterns of relating to something that may work better for them, more in line with what their goals are.

Daniel Mintie: So when we're talking about alliance resistance, we're talking about something that is present in the here and now, moment to moment in the room. This is not something that would come and go. It's something that's a kind of context for our connection with each other. And so we could take any snippet of interaction between the therapist and the patient and see how alliance resistance was being co-created in that moment by the actions of the patient or inaction and the action or inaction of the therapist. What we can also see is that this dynamic is directly related to any presenting problem. I'll say that again. Alliance resistance is hardwired to any presenting problem. So let's just look at three common examples. One would be anxiety. What we see happening very, very often with the anxiety disorders is that there's an overly nice presentation on the part of the patient. And that over-niceness is directly related to the anxiety. With depression, there'd be a presentation of helplessness or hopelessness, which are obviously core components of depression itself. But those are going to appear in the relationship with the therapist. And the patient and therapist both might start feeling the undercurrents of feeling, gee, there's just no hope for this person, or I just don't know what to do here. With PTSD, there are very often conscious or unconscious strategies to hold other people at arm's length. If someone has hurt me, I've been a victim of, say, childhood sexual abuse. Without realizing it, I may set things up to keep other people, my therapist included, from getting too close to me. So when we're looking at the therapeutic alliance, we're looking at the relationship with the patient as a venue in which to experience and surface and observe the self-defeating beliefs and the maladaptive behaviors that create and maintain any illness. We're also seeing that alliance as the platform upon which we can address those very beliefs and behaviors. And in our class next month, we're going to be looking at tools like the interpersonal downward arrow, which we find is oftentimes a wonderful mechanism to get at what's going on in our relationship with the patient. And then what are the opportunities right there to address those self-defeating beliefs and maladaptive behaviors.

Heather Clague: Great. So as Daniel's laying out, alliance resistance can be an obstacle to therapy, and if we don't address it, it will sabotage the therapy, because without a working alliance, the work will not get done. It's also an opportunity. Sorry, my screen is being a little funny here. So by addressing it, we may then have the royal road to actually addressing the patients presenting complaints. And I would say there's a side benefit, which is that we both have to rise to the occasion, but we get to rise to the occasion. So it's an opportunity for the therapist to change and grow as well, because we're human beings in the room, and and all of our parts will be there exerting their own influence. So we'll be growing and shifting towards an increased capacity for connection as well. So we wanted to talk about a couple of cases with you. So I saw a man we'll call Jeremy, and he came to see me for help with self-esteem and anxiety, and a tremendous sadness that he did not have the kind of intimate relationships in his life that he would have wanted to have at this point. And he'd had symptoms for many years. He'd done quite a bit of therapy, and come to understand himself, and I think had a pretty good sense of his the story, you know, of his experience, but he hadn't really gotten much symptom change. And very, very bright guy. I was kind of intimidated by him. He's a very powerful intellect. And we'd been working together for several sessions, and I'd been getting empathy scores consistently about 15 out of 20. And when I would attempt to address that with him at the beginning of our sessions and inquire what might be missing, how I might be off track, he tended to push that aside and tell me it's fine, and he wouldn't really expect anything different. And he was fairly resistant to wanting to talk about that more. And during our sessions, he was speaking in a very pressured way, and it was a lot about his intellectual understanding of cognitive behavioral therapy and reasons why it might or it might not work for him. And in addition to telling me about many different problems in his life, but there was a tremendous pressure in the way he was speaking. And it was very hard for me to get a word in edgewise. And actually when I would try to talk, he would raise his voice and talk over me. And so I noticed what had happened was that I was falling silent, and I just let him continue talking. So we'd like to do another poll. This time you can enter your answer into the chat box. I'm wondering what you might be feeling if you were sitting with a patient like the one I'm describing. And let's see. I'm exploring the. I'm going to open up the chat box here, which I think will let everyone see it. Sorry, you don't need to see that. Jill, maybe you can help us here. I'm not seeing the results of the chat box.

Jill Levitt: Yeah, so Heather, everyone can. On the bottom of your screen, there's a little thing that says chat, and it's got kind of like a little circle with dots in it. And everyone can open their own chat box, but you would need to open yours in order to see what everyone's writing. So I can see what everyone's writing.

Heather Clague: Okay, I'm clicking on chat, but it's not.

Jill Levitt: It's not opening it for you?

Heather Clague: No.

Jill Levitt: Let me just to save time right now, say we've got someone saying, I would feel blocked and pushed away, frustrated, sad, irritated, anxious, and pressured, and nervous, frustrated, and helpless, powerless. I'm going to read the unique ones, insecure, intimidated, irritated, disinterested, defeated. So many awesome feeling words here.

Heather Clague: Yeah, great. All right. Well, that's awesome. And I'm glad to see that I am in good company. So let's look at my role in the dynamic. Let's see here. So exactly, you guys were right on track with my feelings. I was feeling irritated, and frustrated, and defeated, and shut down, and inadequate, and hopeless, and kind of pitying. That's sort of a direction that I tend to take things. And I was telling myself that I shouldn't be irritated with him. I should always be patient and compassionate, that the fact that I was irritated with him meant that I was not a good and kind enough therapist. And then I could hear myself saying, well, this guy's going to need years of therapy, and sort of starting to withdraw and anticipate that we're not going to go anywhere fast. And then my behavior was to withdraw into superficially polite distance, and to avoid offering any kind of invitation to him while I kind of sat in silence. Um, so that's what I'm doing. So what do we imagine he's feeling? And if that's how I'm behaving? And Jill, maybe you can share with us a sampling of.

Jill Levitt: Sure. So please enter in your chat box what how you imagine he might be feeling, right? Okay. So we've got blocked, and challenged, upset that nothing is happening, alone, stuck, powerful, angry, unheard, dismissed, absent, rejected. We've got a lot of angry, afraid, distant, nervous, ignored. We've got a thought like he would think you were artificial. Confused, angry, hopeless, alone.

Heather Clague: Yeah, great. So, so you can see that, that this patient and I are off to the races, in terms of us failing to form a working alliance. And it's, it's no wonder that we haven't made any progress yet, and that he hasn't gotten any symptom relief. So, um, so how did we, so I, being the therapist and the trained professional in the room, it was incumbent upon me to be noticing this dynamic and taking steps to shift it. And because we're a two body interaction, if I start to change, he will then also have to change. Um, so I'll show you the sampling of TEAM CBT techniques that I used in this case. This is not meant to be a formula. It's more to show you, you know, the way that we can, you know, hopefully artfully put together, different TEAM CBT techniques to, um, identify and, and, um, shift a dynamic like this. So the first thing I did was I shifted myself into a more assertive role and out of just listening, I kind of woke myself up out of the trance. I think I probably even changed my body posture, um, to kind of enliven myself. Um, and then I used, changing the focus, um, to bring attention to the dynamic between us using a positive reframe. And whereas before, when I had tried to speak up, I did it a little bit timidly. This time I did it more assertively. I think I used my hands and I caught his attention. Um, and I said to him, you know, Jeremy, we've been seeing each other for a number of sessions now, and so far your symptoms scores haven't improved. I've noticed that. And the other thing I was doing was, um, using, I feel statements to acknowledge my negative feelings and then some inquiry. So, and I said, you know, I noticed that I've been starting to feel a little stuck and I'm worried that we aren't connecting in a way, um, that's going to help you make progress. And I was wondering if you've noticed this too, and how you're feeling about how things are going between us. And he responded at first, the way he had, when I would bring up the evaluation of therapy sessions kind of dismissively and saying, you know, he wouldn't expect more and he knew his problems were longstanding. Um, and, and that he said, don't take it personally, but our connection is good enough. I pressed a little more with inquiry and I asked him to give me a grade for empathy. Um, and, uh, again, he, he was sort of with, with saying it's fine, it's not a problem. He gave me a grade of B plus. Seeing what I felt here now was a tension that I was wanting to press him to tell me why I wasn't getting an A and he didn't really want to go there and do that. So, um, I shifted to, um, exploring some outcome resistance. Um, would he actually want to have a, you know, a close, warm, you know, relationship with me where he felt completely understood. So I framed that using the magic button that if he could press the magic button, would he want that to feel completely understood by me and feel that I was completely warm and caring. And he really responded to that, uh, and said no. Uh, and in answering that question, we started to informally elucidate the roles in our relationship and he related this to experiences with his mom who was quite troubled and, um, who he experienced as being very intrusive and she would press him to tell him about how he was feeling. And if he brought up any negative feelings, she would get upset and kind of dysregulated and then start yelling at him and get angry at him. Um, and so then that let me use the five secrets and especially disarming technique to say, I understood now why he said when it was good enough, what he meant that he wouldn't actually want me to be closer, getting that close to him, he would associate with then something bad happening, the person getting upset and starting to criticize him. And I, and I think I phrased it, you know, it sounds like if, if it felt like we were too close, that might feel intrusive to you. And he agreed, he agreed with that.

And so then I, I again, decided to take, to accept what he was saying as, as the truth and that, and except his holding me at arm's length to my experience was actually a wise thing for him to be doing in his experience. And then if I accepted that and stopped pressuring him to be closer than he felt comfortable being, maybe we were actually at a good point and I could just go ahead and offer an invitation, which is what I did. I offered a very open-handed invitation and noted that we had been talking a lot about CBT, but we weren't really using any of the methods yet. And I'm wondering if he wanted to shift to do that, or if there was more that he wanted to tell me. And to my surprise, he eagerly accepted the invitation and we got rolling and, and finished a mood log that session. And my empathy scores went up significantly. At the end of that session, he gave me a 19 out of 20 on empathy and a seven out of eight on helpfulness and satisfaction. And his feedback for me was that he was very grateful that we had gotten to work. And I'm happy to say that since then, our sessions have been moving forward very productively. So by recognizing that I was having negative feelings and identifying my thoughts and behaviors that were contributing to my own resistance of a helpful alliance to him, that let us then talk about that openly and make a shift and have the therapy move forward in a way that was helpful to him.

Daniel Mintie: Thanks Heather. You're describing some wonderful work you did with this patient. And what we'll be doing in our class next month is inviting students to bring these cases in so that we can process those together, see what might be going on, both on the therapist side and on the patient side, that's contributing to this disconnection and inability to move forward with the work. And I love looking at this consultation with folks, and we'll look forward to doing that with those of you who will be signing on for our four-week class. We'd also like to follow Heather's lead here and talk for a few minutes about a patient that I was in a somewhat similar dynamic with. We could call this patient Mary. And Mary is a brilliant person, a medical provider, very well trained, who experienced some early sexual abuse in her family of origin. So when she reached out to me, I immediately liked her and thought, oh, this is gonna be a great therapy. This person sounds highly motivated. They really understand how therapy works. We're gonna do some great work together. So in our second session, I noticed that the first maybe 20, 25 minutes or so was this kind of question and answer thing happening around trauma. And Mary would ask me about PTSD and TEAM CBT, how those worked. I would answer those questions. And then a couple of times she said to me, I have this kind of crazy thought that keeps coming around that maybe I'm able to trick Daniel. I mean, it's ridiculous. Of course, I don't want to do that. And the conversation stayed at that level. And like Heather, I noticed I started to feel a bit uneasy with what wasn't happening in that conversation and in the therapy. So I asked Mary if I could share a bit of what I was feeling. She said, of course. So I told her, you know, I've noticed we've been having this back and forth and a kind of abstract conversation with each other about trauma treatment. And on the one hand, I'm very happy to answer questions that you would have for me. And on the other, I noticed I was feeling a little sad and a bit frustrated. It's like, I want you to come outside and play. And that hasn't been happening here today. And then I checked in with her and said, how has this been feeling to you? We've been together for 20, 25 minutes. What's happening over there on your side? So as did Heather, you notice that I started by changing the focus, moving from the content stream of my colleague to colleague conversation about trauma treatments to what's happening emotionally in the room. I brought forward a couple of I feel statements to give her information that she could not have had, had I not done that. And then did some inquiry and invited her to dialogue with me. So immediately the tone in the room shifted and Mary said to me, well, that's how I do all conversations. But nobody's ever called me on it before. So as soon as she said that, I said, you just came outside. I love this. And I'd love to hear more about how you do all conversation.

And immediately this opened up into something that felt very real to both of us. And Mary talked about having a need, in her words, to control the narrative. And she said that she felt this pressure to do that because she had this deep fear of rejection if someone were really to see me. So instead of talking with, as it turned out, not just me, but pretty much everyone in her life in an open and authentic and real way, she would use her formidable intellect to kind of set the game pieces out to make sure conversation stayed in a certain zone and didn't get too close to home. And then she also said to me, you know, this is both an effective and an exhausting strategy. And I felt now we were in a position to actually get to know each other and to do some work together if that's what she chose to do. Afterwards, she gave me very good ratings on empathy and helpfulness and then wrote in a couple of comments, one was I’m just reading these verbatim, this was an interesting and important experience largely because of my getting to hear your feelings and your concern that there was some overmentalizing of things or avoidance in some way. This is, of course, possible and has been a very effective defense mechanism for me. The other thing she wrote in was, I'm glad we got to the similarities in our interaction with each other and my interactions with others. I always try to control the narrative. And even when I do share something vulnerable, I'm still careful to keep the other person at arm's length. So a bit earlier in our time together, I had mentioned how our alliance with the patient will contain all of the ingredients of their emotional suffering. And what I was able to see as a result of our breaking through that defense that she had was that there was this self-defeating belief that had come out of her experience of her abuse as a young girl, which was that she was bad. So she was in a place of self-rejection of herself, judgment of herself. That was that harsh inner critic. It's my fault. I'm damaged goods, that kind of thing. And then that inner critic projected that fear into other people so that she would be afraid that others would take that same position.

And to avoid running into that rejection externally, she would make sure that people didn't really get in to see what was going on in her own heart and mind. I also noticed that her mention of that irrational fear of tricking Daniel, we talked about that a bit more after the log jam broke. And the fear was that she would trick Daniel into seeing that she was, quotes, better put together than she was, close quotes. And it occurred to me that that wasn't so irrational, that on some level she was testing to see could Daniel be tricked into colluding with her agenda for that business as usual kind of relationship. And she was actually showing me her hands there saying, you know, I have this fear, of course I wouldn't.

Jill Levitt: Heather, Daniel froze on my screen.

Heather Clague: Okay, good. Well, not good. Daniel froze for me too.

Jill Levitt: There he is. Now he's back. Daniel, you froze on our screen for a moment. We heard you say through about colluding and then and then lost you.

Daniel Mintie: Ah, okay. So, what we realized downstream was that this concern about tricking Daniel wasn't, at least wasn't only an OCD kind of thought, oh, I'm doing something wrong here. It was also a way of her hinting that there might be some dissembling taking place here and giving me the opportunity, which in hindsight, I decided to take to find out would I go down the usual relational path with her or would I notice that that was feeling somewhat uncomfortable for me and invite her to talk about what it is that we were doing with each other. So, I think it's an example of the way in which oftentimes the form of alliance resistance is a finger pointing at the solution, at the alternative. And in our class next month, I'll look forward to taking up your cases with you and seeing how that might be going on in the work that you're doing.

Heather Clague: Great. Well, thank you, Daniel. That's really inspiring. I just love, again, how the problem and the solution are just two different sides of the same phenomenon. So, at this point, we'll stop and take some questions. I think Jill will maybe let us know some questions.

Q&A Session