The document discusses approaches for working with resistant clients and their families in the context of substance abuse and mental health treatment. It focuses on identifying resistant clients, introducing solution-focused therapy (SFT) and motivational interviewing (MI), as well as the importance of family involvement and communication. Key concepts include understanding family dynamics, incorporating change processes, and utilizing specific techniques for effective engagement and support during treatment.

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. 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. How do our Families Arrive ?
Substance Abuse
Mental Health
Other –Legal, Physical,
Family History

4. Family History

6. 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

7. Family Strengths
( Lamm, 2009)
Communication
Caring
Health
Commitment
Resilience
Spirituality

8. Family Systems Minuchin
Parent
SiblingCouple

9. 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

10. Good - Not So Good

11. Portlandia

13. Family Fusion & Lack of Boundaries
Lack of personal space
Taking over-controlling
Blurred lines
Blaming
Power
Denying
Rescuing faulty reasoning
Lack of boundaries

14. Before Treatment Families
Confused
Bewildered
Attached to The Problem
Deny
Minimize

15. Feelings Families Have
Confusion
Anger
Sadness
Love

16. 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

17. What’s your Attitude ?

19. 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

20. 21
Families/Clients are experts
3. Counselor expertise is
called along the way.
4. Remember this is not
about you
5. Avoid one upmanship

21. Assumption is they are motivated
 Probability of behavior change
or movement toward or against
goal
 Extrinsic…….
 Intrinsic ……
 What are they motivated to do?

22. Parallel Processes
Families must have
opportunities to grow
alongside their loved one
that is in treatment.
Krissy Pozatek, LICSW

23. Parallel Processes
Letting go of Reins
Emotional Attunement
Listening Reflectively
Shifting Responsibility

24. Multidimensional Family Therapy
Solution-based
Behavioral
Narrative
Family systems model
Family disease model
Cognitive-behavioral
Multidimensional

25. 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

26. 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

27. 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

28. Stages Of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance

29. In between the cravings
Find the Spaces In between
Omar Manejawa MD
Cravings – Myopic
Spaces- Change
Habits -Actions

30. Motivational Interviewing
 Directive client center approach
 Process not Technique
 Collaborative
 Evocation- elicit clients internal
viewpoint
 Autonomy
 Roll With Resistance

31. MI Spirit
 Rogerian approach
 Coupled with a direction
 Equalitarian
 Warm, Empathetic, Affirming & Respectful
 Guiding & eliciting vs. instructing & persuading

32. 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

33. 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

34. Principles Of MI
Express Empathy
Roll with Resistance
Develop Discrepancy
Support Self Efficacy

35. How to Express Empathy
Use your Oars
Open Ended Questions
Affirmations
Reflections
Summaries

36. What Type of Communication Skills
Do you Have?
 Echo Key Words
 Open Ended
Questions
 Paraphrase
 Body Language
 Summarize
 Self -Disclose

37. How do you Listen ?

38. Listening Exercise
Break up in dyads
Practice Listening – 3
minutes- Listen to
what is said and what
is unsaid
Debrief

39. 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 !

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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 ..

48. Other strategies for Handing
Resistance
Clarification
Shift focus away from
stumbling block
Emphasize Personal
Choice and Control

49. 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

50. 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 ?......

51. 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

52. Exploring Ambivalence
The Existence of
conflicting emotions
or thoughts about a
person object or idea

53. 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?

54. 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.

55. Resistance
Traditional
 Client not getting it
MI View
 Counselor may not be
getting it
 Case Example –Jon

56. 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

57. Hard Questions to Ask about Resistance

58. 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)

59. 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?

60. 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

61. 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

62. Ten Strategies for Evoking Change
10. Responding to
Change Talk (EARS)
 EXPLORE
 AFFIRM
 SUMMARIZE

63. 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

64. 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

65. 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

66. 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

67. 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

68. The Interview
Initial
Break
Ending or Close
73

69. Interviewing Questions
1. Precession Change
2. Coping
3. Relationship
4. Exception
5. Miracle- In a Perfect
6. Scaling
74

70. Compliments
Direct: Positive verb,
attribute or reaction to
client
Indirect-Something that
implies positive
Self Compliment- “I”
statement
75

71. Assignments
Always based on
relationship
Readiness to Change
Focus on Attainable
goals
Design ,Small steps
Proceed slowly
76

72. Cases
I want to know
everything that is said
in treatment
You are not
responding to my
child’s needs

73. 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

74. 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 ……….

75. Heroic Families
Attunement
Individualization
Healthy Boundaries
Own Recovery
Talking care of ones self
physically, emotionally and
consistent with ones values

76. Always Have Heroic Counselors

77. Always Remember

78. 83
Recovery is Like Walking on Sunshine

79. 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

80. Resources
http://www.minuchincenter.org
Minuchin Family Center Therapy
http://www.Allaboutinterventions.com
Dr. Louise Stanger
http://www.motivationalinterviewing.org
Motivational Interviewing
http://www.solutionfocused.net
Institute For Solution Focused