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Working with the resistant client and their family


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Dr. Louise Stanger of All About Interventions describes SFT, motivational interviewing and parallel processes to help addiction professionals integrate these transformational processes into practice.

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Working with the resistant client and their family

  1. 1. In and Out: Working with the Resistant Client and Their Family  Dr Louise A. Stanger Ed.D , LCSW, BRI II, CIP  MINT Trainer of Trainers  Faculty SDSU  Director All About Interventions
  2. 2. Objectives:  Identify Who is the Resistant Client and Family ?  To Introduce SFT and MI and Parallel Processess  To Demonstrate how they differ from other processes  To teach how professionals may integrate these transformational processes into practice.  Identify Who is the Resistant Client and Family ?  To Introduce SFT and MI and Parallel Processess  To Demonstrate how they differ from other processes  To teach how professionals may integrate these transformational processes into practice. 2
  3. 3. How do our Families Arrive ? Substance Abuse Mental Health Other –Legal, Physical, Family History
  4. 4. Family History
  5. 5. Attributes of Healthy Families ( McMannis PHD & McMannis MSW) Talking & Loving Expressing Language Adapting to Change Sharing Time Together Who’s in Charge Balancing Closeness & Difference Accepting Difference Seeing The Positive Effective Problem Solving Parenting Together
  6. 6. Family Strengths ( Lamm, 2009) Communication Caring Health Commitment Resilience Spirituality
  7. 7. Family Systems Minuchin Parent SiblingCouple
  8. 8. Families that have Substance Abuse and Mental health  Are behavioral systems in which SA and MH-related behaviors have become the central organizing structure  An identity is forged around this, family accommodates to the special needs of the person with SA or MH behavior  Daily rituals reflect this new identity and can alter the balance that exists between growth and regulation in the family  Families begin to count on a conscious or unconscious way of this new identity and are somewhat resistant to change in other words SA is actually maintained by the family  Hence the introduction of change most often appears as emphasis on short tem stability at the expense of long term growth.  Family distortions
  9. 9. Good - Not So Good
  10. 10. Portlandia
  11. 11. Family Fusion & Lack of Boundaries Lack of personal space Taking over-controlling Blurred lines Blaming Power Denying Rescuing faulty reasoning Lack of boundaries
  12. 12. Before Treatment Families Confused Bewildered Attached to The Problem Deny Minimize
  13. 13. Feelings Families Have Confusion Anger Sadness Love
  14. 14. So, What Type of Families Do You Encounter? Agreeable Family –Does everything you ask The Invisible Family-Always in the background The Questioner- Calls all the time and emails … The Know it all-Knows everything about everything The Talker – Talks –Talks and Talks The Complainer- Nothing is ever good enough The Worrier The Micro-Manager
  15. 15. What’s your Attitude ?
  16. 16. Families are hurting experts (SFT) 1.Client is the expert about their own life 2. Professionals adopt posture of not knowing (easier said then done)! 20
  17. 17. 21 Families/Clients are experts 3. Counselor expertise is called along the way. 4. Remember this is not about you 5. Avoid one upmanship
  18. 18. Assumption is they are motivated  Probability of behavior change or movement toward or against goal  Extrinsic…….  Intrinsic ……  What are they motivated to do?
  19. 19. Parallel Processes Families must have opportunities to grow alongside their loved one that is in treatment. Krissy Pozatek, LICSW
  20. 20. Parallel Processes Letting go of Reins Emotional Attunement Listening Reflectively Shifting Responsibility
  21. 21. Multidimensional Family Therapy Solution-based Behavioral Narrative Family systems model Family disease model Cognitive-behavioral Multidimensional
  22. 22. What if The Parent is right The Procedures and or policies are incorrect The flow of information is wrong The presentation of material needs adjusting The parents get caught in an alienation coalition
  23. 23. Recovery Issues Issues Early Middle Advanced Grieving Identify ones losses Learning to grieve Grieve past and present losses Neglecting ones own needs Realization of needs Beginning to get needs met Getting needs met Being Over responsible Identifying boundaries Setting limits Responsible for self-clear boundaries Low self-esteem Identify Sharing Affirming – improved SE Control Identify Taking responsibility Responsibility& letting go All or none thinking Recognize & identify Learning there are choices Multicolored world Being Real Recognize Risking being real Being real
  24. 24. Recovery Issues Issues Early Middle Advanced Trust Trust can be helpful Selective Trusting Trusting appropriately Feeling Recognizing & Identifying Experiencing Observing & Using Hi Tolerance inappropriate beh. Questioning behaviors Learning Knowing & having safe folks Abandonment & Conflict Recognizing & Identifying Grieving & Resolving Freedom From & work thru current conflicts Giving and Receiving Love Defining: What is love Practicing Refining, loving self, higher power Dependence & Independence Identifying Learning/ Practicing Being healthy
  25. 25. Stages Of Change Precontemplation Contemplation Preparation Action Maintenance
  26. 26. In between the cravings Find the Spaces In between Omar Manejawa MD Cravings – Myopic Spaces- Change Habits -Actions
  27. 27. Motivational Interviewing  Directive client center approach  Process not Technique  Collaborative  Evocation- elicit clients internal viewpoint  Autonomy  Roll With Resistance
  28. 28. MI Spirit  Rogerian approach  Coupled with a direction  Equalitarian  Warm, Empathetic, Affirming & Respectful  Guiding & eliciting vs. instructing & persuading
  29. 29. Characteristics of MI  Counselor is active and directive  Counselor helps shape behavior  MI strategy is specific and systematic  Consistent with principles of client choice and empowerment  Consistent with cultural sensitivity in that client leads and counselors agenda is not imposed
  30. 30. Traps to Avoid  Question-Answer  Labeling Trap – dx codes  Premature Focus Trap-start with clients concern not yours  Expert  Taking sides  Blaming Others _ who is to blame is not as important as to what your concerns are
  31. 31. Principles Of MI Express Empathy Roll with Resistance Develop Discrepancy Support Self Efficacy
  32. 32. How to Express Empathy Use your Oars Open Ended Questions Affirmations Reflections Summaries
  33. 33. What Type of Communication Skills Do you Have?  Echo Key Words  Open Ended Questions  Paraphrase  Body Language  Summarize  Self -Disclose
  34. 34. How do you Listen ?
  35. 35. Listening Exercise Break up in dyads Practice Listening – 3 minutes- Listen to what is said and what is unsaid Debrief
  36. 36. Personal Roadblocks Kids are sick Had a fight with partner Phones are ringing-cannot spend a lot of time Woke up late Boss is edgy Oh no not that Family– AGAIN !
  37. 37. 12 Roadblocks to Listening  1. Ordering, directing, commanding  2. Warning or threatening  3. Giving advice, suggestions, solutions  4. Persuading with logic, arguing,  5. Moralizing, preaching  6.Disagreening, judging, criticizing , blaming
  38. 38. 12 Roadblocks to Listening  7.Agreeing, approving, praising  8. Shaming, ridiculing or labeling  9. Interpreting or analyzing  10. Reassuring, sympathizing  11. Questioning or probing  12.Withdrawing, distracting
  39. 39. Assumptions To Avoid  Person OUGHT to change  Person WANTS to change  Persons health is prime motivation factor  If she/he decides not to change consultation is a failure  Individuals are either motivated to change or they are not  Now is the right time to consider change  A tough approach is always the best approach  I am the expert and know best  A equalitarian approach is always best
  40. 40. Listen Reflectively Being quiet and actively listening Responding with a statement that accurately reflects the essence of what the client meant Listen carefully think Reflections
  41. 41. Reflections  Think in terms of forming an hypotheses or best guess at what client is saying  Take a guess –Do you mean…  You have to differentiate between a question and a statement  Voice goes down at end of statement rather then up with a question  “You're angry with your mother …  A statement does not require an answer .  Used strategically emaphsize, clients view , feelings, ambivalence, emotion change talk
  42. 42. Level of Reflection  Repeating repeat what someone has just said  Rephrase – substitute a few different words  Paraphrasing-make a fairly major restatement inferring what you think a person has said  Reflecting feeling – special kind of paraphrase where you are not necessarily relecting content rather feeling
  43. 43. Simple Reflection  Client: This parent is driving me crazy trying to make a decision Counselor; Her methods are really bothering you Client: I don’t have anything to say Counselor- You are not feeling talkative today
  44. 44. Amplified Reflections Exaggerate what client says be careful not to be sarcastic So if I hear you correctly your son/daughter needs… you to bring him xx So you are likely to keep bailing ..
  45. 45. Other strategies for Handing Resistance Clarification Shift focus away from stumbling block Emphasize Personal Choice and Control
  46. 46. Provide Summaries  Communicate what you have tracked what the client has said so that you have understanding of what is being said  Helps structure session so you do not get sidetracked  Provide opportunity to emphasize statements a client has made about change talk gives client another opportunity to hear what she has said in context provided by the counselor
  47. 47. Example  So Sally , let me know if I heard you correctly. You care about your children and you are hoping social services does not intervene. You believe you need to change your realtionships that involve using and aren’t quite sure how to do that?  Or what else would you add ?......
  48. 48. Decisional Balance Worksheet (Fill in what you are considering as change ) Good things aboutGood things about Changing behaviorChanging behavior Good things aboutGood things about changing behaviorchanging behavior Not so good things aboutNot so good things about behaviorbehavior Not so good things aboutNot so good things about changing behaviorchanging behavior
  49. 49. Exploring Ambivalence The Existence of conflicting emotions or thoughts about a person object or idea
  50. 50. DARN (Desire, Ability , Reason, Need)  What do you think you will do ?  What does this mean about your habit ?  What are your options?  What's the next step for you?  What are some good things about making a change ?  Where does this leave you?
  51. 51. 59 Scaling QuestionsScaling Questions  Motivation MIMotivation MI On a scale of 1-10, ten being most important, how important is it for you to do things differently? On a scale of 1-10, ten being most important, how important is it for you to do things differently? Confidence - SFTConfidence - SFT On a scale of 1-10, 10 being the most confident - how confident are you that you can do x, y, z? Confidence teaches you what skills you need to teach your participants. On a scale of 1-10, 10 being the most confident - how confident are you that you can do x, y, z? Confidence teaches you what skills you need to teach your participants.
  52. 52. Resistance Traditional  Client not getting it MI View  Counselor may not be getting it  Case Example –Jon
  53. 53. Signs of Resistance  Arguing Challenging Discounting Hostility  Ignoring -Inattention -Non-answer -No response -Sidetracking  Denying  Blaming  Disagreeing  Excuses  Claiming impunity  Minimizing  Pessimism  Reluctance  Unwilling to change •InterruptingInterrupting Taking OverTaking Over Cutting OffCutting Off
  54. 54. Hard Questions to Ask about Resistance
  55. 55. Ten Strategies for Evoking Change  1. Ask Evocative questions  Why would you want to make this change? (Desire)  How might you go about that ? (Ability)  What are the three best reasons for doing that ? (Reasons)  How important is it for you to make this change? (Need)  So what do you think you will do? (Commitment)
  56. 56. Ten Strategies for Evoking Change  2. Ask for Elaboration  When change talk emerges ask for more detail. In what ways?  3. Ask For Examples Ask for specific examples, when was the last time that happened ? give me an example  4. Look Back Ask about a time before current concern emerged. How were things better? different?
  57. 57. Ten Strategies for Evoking Change  5. Looking Forward- What would happen if things stay the same/ If you are 100% successful in making changes you want what would life look like ?  6. Extremes What is the worst thing that could happen? What is the best thing that could happen
  58. 58. Ten Strategies for Evoking Change 7. Use Change Rulers  On a scale of 1-------------------10 8. Explore Goals and Values  What are the persons values and goals 9. Join up –Come along side
  59. 59. Ten Strategies for Evoking Change 10. Responding to Change Talk (EARS)  EXPLORE  AFFIRM  SUMMARIZE
  60. 60. Solution-Focused Coaching 1. Not necessary to understand deeper cause or meaning 2. Goals are defined by client, focusing on the possible and changeable, honorig client choice 3. Small change is often all that is possible 68
  61. 61. Assumptions of SFT 4. When goal is defined by client, you have cooperative client 5. Counselor, interventionist, admissions, call center person adopt a posture of inquiry, of not knowing 69
  62. 62. Assumptions of SFT 4. When goal is defined by client, you have cooperative client 5. Counselor, interventionist, admissions, call center person adopt a posture of inquiry, of not knowing 70
  63. 63. Have Crucial Conversations 1. Client is always right 2. Agree with clients goal, its about choice 3. Use client’s language 4. Develop Compliments to support change 71
  64. 64. Talking With Families 4. Develop Compliments to support change 5. Provide bridging statement and rationale for suggestions 6. Assign Tasks based on relationships 7. Seek solutions 72
  65. 65. The Interview Initial Break Ending or Close 73
  66. 66. Interviewing Questions 1. Precession Change 2. Coping 3. Relationship 4. Exception 5. Miracle- In a Perfect 6. Scaling 74
  67. 67. Compliments Direct: Positive verb, attribute or reaction to client Indirect-Something that implies positive Self Compliment- “I” statement 75
  68. 68. Assignments Always based on relationship Readiness to Change Focus on Attainable goals Design ,Small steps Proceed slowly 76
  69. 69. Cases I want to know everything that is said in treatment You are not responding to my child’s needs
  70. 70. King Baby- and Father- VIP WE are VIP I only talk to Mike Neatherton or Paul Alexander If I have to I will call Greg, Elizabeth, Colin , etc though all reluctantly as I am a VIP
  71. 71. Queen Baby – Mother and Daughter The problem is you your treatment center does not understand our daughter. She is unique She requires we speak every day She requires her phone She requires ……….
  72. 72. Heroic Families Attunement Individualization Healthy Boundaries Own Recovery Talking care of ones self physically, emotionally and consistent with ones values
  73. 73. Always Have Heroic Counselors
  74. 74. Always Remember
  75. 75. 83 Recovery is Like Walking on Sunshine
  76. 76. Resources  The Daring Way-Brene Brown  Crucial Conversations-Patterson et al  The Parallel Process- Krissy Pozatek LCSW  The Journey of the Heroic Parents-Brad M. Reedy PHD  If You Meet The Buddah on The Road-Kill Them- Sheldon Kopp  Motivational Interviewing- Miller and Rollnick  Solution Focused Therapy –Insoo Young and Peter Berg
  77. 77. Resources Minuchin Family Center Therapy Dr. Louise Stanger Motivational Interviewing Institute For Solution Focused