Treatment Interfering Behaviours

Treatment Interfering Behaviours

Treatment interfering behaviours (TIBs) refer to any client or clinician behaviours that interfere with a client’s potential to benefit from treatment. Research has found that TIBs are present in more than 50% of AOD clients (Beatson, Rao & Watson, 2010). These behaviours are typically repetitive, ongoing behaviours that prevent effective recovery.

Identifying and addressing TIBs increase the likelihood of achieving better outcomes for client recovery. Recognition of TIB warning signs can assist in early identification and management of these behaviours (e.g. history of self-harm/violence, history of repeated treatment drop out, disruptive psychosocial factors).

Common TIBs include:

• Non-attendance or late arrival
• Dramatic behaviour or extreme emotion
• Splitting
• Threats of harm (self and others)
• Critical or dismissive of response to therapist’s approach
• Presenting substance affected
• Repeatedly presenting “in crisis” (Crisis orientation)
• Deliberate disruption of therapeutic relationship
• Attempts to change the focus of sessions
• Unhelpful responses (“Dunno” or “I can’t remember” or “I’m not sure”)
• Aggression
• Providing inaccurate/misleading information
• Not identifying clear goals for treatment
• Denying problems or refusing treatment

When these signs are identified, it is important to discuss these issues in supervision and develop a plan to effectively address and reduce the presence of these behaviours.

Splitting

Splitting is a conscious tactic frequently employed by forensic clients to pit one entity against another (e.g., CCS case manager vs clinician). This behaviour can be used to help a client get what they want and manipulate those around them. Splitting is particularly harmful to therapeutic outcomes, so it should be addressed promptly at both an organisational and therapeutic level.

Some ways to manage splitting behaviours include:

• Where possible, ensure client’s interactions are with only one staff member
• Always be supportive of other staff members – never speak negatively about other staff to the client
• Communicate clearly and consistently with the client and CCS
• Communicate clearly (and unapologetically) that you are unable to get directly involved or ‘take sides’
• Ensure that everyone dealing with the client responds in a similar manner
• Be clear with the client about the best person to meet their particular needs and that it isn’t appropriate for the client to go to various people for the same thing
• Seek supervision if the client makes unambiguous claims of abuse or unprofessional behaviours

Crisis Orientation

Forensic clients often present themselves in a constant state of crisis and drama and likely have done so for some time. Clients may present in this manner for a number of reasons including avoiding underlying problems, to satisfy a need for excitement/shock, avoid negative feelings or to feel ‘alive’ rather than depressed or worthless etc.

In these cases, it is important openly discuss how the client’s behaviour is impacting their potential for recovery, and develop a collaborative plan for addressing both crises and treatment needs.  For example, you may agree to spend 10-15 minutes at the start of the session to discuss the “crisis,” and to spend the remainder of the session on broader treatment goals.

It is important not to become desensitised to client crises and recognise when these crises could lead to harm to the client or others. Appropriate risk assessment for suicidal or para suicidal behaviours/ideations should always been undertaken.

General strategies for managing TIBs:

• Provide a balanced response where the client is not invalidated, and you are not placed in an untenable situation
• Discuss the impact the client’s actions may be having on treatment
• Be clear from the beginning about your reporting requirements
• Establish expectations early (through group agreement or treatment contract)
• Identify the specific treatment-interfering behaviour and explore the possible reasons for this behaviour (e.g. avoidance, cognitive deficits etc)
• Advise the client of the consequences of continued behaviour
• Gently encourage client reflection on their interpretations of other people’s actions / motivations
• Seek supervision
• Identify strategies that could assist with the reasons for this behaviour
• Document actions
• Consider holding a case conference with the CCS case manager to discuss issues together
• Don’t buy into the behaviour!

Clinician TIBs:

Clinicians can have a range of responses to the TIBs or general behaviour of a client, some of which interfere with treatment outcomes. It is important to address both client and clinician TIBs to prevention deterioration of the therapeutic alliance and ensure effective treatment. Clinician TIB’s may include:

• Ignoring/avoiding addressing client TIBs
• Responding aggressively to the client
• Failing to recognise a client TIB
• Feeling frustrated/discouraged/hopeless
• Stereotyping clients who engage in certain behaviours
• Stigmatising clients with certain diagnoses (e.g., ASPD)
• Negative countertransference (responding or thinking in a judgmental manner due to own “stuff”)
• Positive countertransference (“I’m the only one who can help this client”)
• Avoiding challenging clients

How you can address your own TIBs:

• Avoid judgement of the client
• Monitor your level of involvement with the client (e.g. over or under-involvement)
• Seek supervision
• Recognise how your own TIBs might provide information about the client’s presentation (which can also inform treatment)
• Practice reflectively (e.g., be aware of your own vulnerabilities and negative responses and what might be driving them)
• Practice self-care regularly

For more information regarding managing TIBs, have a look at the following publications:

Clarke, M., Fardouly, P., & McMurran, M. (2013). A survey of how clinicians in forensic personality disorder services engage their service users in treatment. The journal of forensic psychiatry & psychology, 24(6), 772-787.

Wyse, K. (2016) Treatment engagement of people in forensic personality disorder services. DForenPsy thesis, University of Nottingham.