BookREVIEW: The Heat of the Moment in Treatment
Mindful Management of Difficult Clients
Norton & Co, New York & London 2013
(Previously published in 2012 as: Dropping the Rope: A Clinician’s Skill-Building Workbook)
.This book takes clinician-readers on an exploratory journey to uncover their own contribution to heated exchanges with clients. Part one invites readers to challenge their own perceptions and assumptions and to employ mindfulness in managing reactions to difficult situations with the aim of moving from ‘reactivity’ to ‘connectivity’. Part two focuses on practising the “moment to moment interactions of the work in order to enhance the alliance and the therapeutic impact of our interventions”.
The book is packed with opportunities to ‘Lean in’, experiential learning tasks, progressively developing the skills of mindfulness. These are further developed in the context of a challenging client chosen by the clinician-reader. At the end of each chapter, readers are invited to ‘Map check’ and consider which aspects of the material presented has resonated most with them, the value and importance of this in their work and to think of a specific action that they can take within the next 24 hours “which has the potential to move you forward in the direction of what matters”. The author suggests going through the workbook in a systematic way.
Here is a brief overview of the content. Part one:
Chapter 1: By describing the ‘Seven Brain Related Habits of Effective (Psychotherapeutic) Self-Managers’, Abblett gives a useful, if basic, summary of the neuroscience of affect arousal and calming.
Chapter 2 introduces the four quadrants of the ‘Interpersonal Process Grid, which has two axes, ‘connect-disconnect from other’ and ‘internalising-externalising’. Experiential learning allows readers to identify ‘knee jerk reactions’ and to begin looking at their own values. Further case examples ask readers to consider in which quadrant a given behaviour lies.
Chapter 3 helps readers explore their beliefs, assumptions and what Abblett calls ‘Fusion’, “the human tendency to snag ourselves in our thoughts, useful or not” and how to bring about ‘defusion’, through observing our thoughts using mindfulness.
Chapter 4 focuses on opening self to emotional experience in the here and now, using more mindfulness techniques.
Chapter 5 guides readers into a state of mindfulness in which to explore scripts and beliefs learnt in childhood.
Chapter 6 takes the learning from the previous chapter and considers how feelings and thinking from the past impact on the present. Many of the experiential exercises invite an exploration and development of compassion.
Chapter 7 brings all the learning from previous chapters together and explores how to apply it when faced with strong feelings of rage and disgust, fear and avoidance, desire, attraction, shame, apathy and gratitude. In order to manage these responses, Abblett proposes the acronym APPALL, to describe a process of: Awareness, Pausing for Perspective, Acceptance, Looking at your values, and Leaping into action.
Now that reader-clinicians have knowledge of their emotional triggers, scripts, habitual thoughts and behaviours, have developed compassion for both self and others and an ability to respond from a position of in-the-moment mindfulness, part 2 moves into practice.
Chapter 8 looks at the importance of timing in making an intervention and at a variety of obstacles to good timing.
Chapter 9, the first of two chapters on ‘Relational Leadership’, begins the difficult task of exploring and practising authenticity in the moment-to-moment interaction (or what I know as ‘immediacy’), through the medium of a book. To be fair, he strongly suggests practising with colleagues and using supervision. Abblett further discusses the value and place of self-disclosure and humour.
Chapter 10 suggests a simple formula, STEPS, for managing very challenging clients: Say the problem, Think of solutions, Evaluate the solutions, Pick one, See if it works. This is explored in the context of all previous learning and the importance of boundary setting.
Chapter 11 looks at using mindfulness in extreme situations with clients, managing the unexpected and stresses the importance of self-care and how you might get it.
Finally chapter 12 explores how to maintain the practice of mindfulness in clinical work, with reference to how mindfulness practice can become a state of mind, a way of being, and not just limited to clinical practice.
Reading this book, I wondered who the target audience might be. Any self-respecting training institution of counsellors and psychotherapists would surely ensure that students have ample opportunity to explore the material presented in this book and to practice immediacy skills. In addition, self-respecting training institutions require their students to be in personal therapy for the duration of the course to deepen their self-awareness. As a skills trainer myself I am constantly reminded of the importance of personal therapy as an essential component of training; a place where issues arising for the student, not least in the classroom, can be explored by the individual in depth at his own pace. I think that BACP made a mistake when they decided that individual, personal therapy would no longer be required as an essential component of a counsellor’s experience prior to accreditation. After all, it is the most usual way in which counselling is delivered.
Unfortunately, many mental health practitioners do not go through rigorous training with a personal therapy component. More recently in the UK, as IAPT has been rolled out in the NHS, psychologists trained briefly in CBT and Person Centred approaches with relatively few training opportunities for self-reflection have frequently ousted long established, experienced and well trained counsellors from their posts. These psychologists are the practitioners who will benefit most from this book alongside almost anybody, whether in mental health or not, who is curious about their own contribution to heated and apparently stuck relationships. The presentation of material, such as in the ‘Interpersonal Process Grid’ and some of the experiential exercises are a useful resource to the skills trainer.
The author is American and his style is an extremely informal, rather chatty affair with numerous asides. This may initially irritate British readers, be warned! However, taking up the challenge to employ mindfulness, readers can manage any unhelpful feelings and appreciate the material presented in this workbook.
Karin Parkinson works as an integrative therapist, hypnotherapist and clinical supervisor in north London and teaches counselling skills at the Minster Center.