Dr. Louise Stanger of All About Interventions describes SFT, motivational interviewing and parallel processes to help addiction professionals integrate these transformational processes into practice.
Working with the resistant client and their family
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
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
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
13. Family Fusion & Lack of Boundaries
Lack of personal space
Taking over-controlling
Blurred lines
Blaming
Power
Denying
Rescuing faulty reasoning
Lack of boundaries
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
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?
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
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
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 !
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
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.
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
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 ……….
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
Editor's Notes
I don’t know whty everybody is maing such a big deal over my drinking. I don’t drink that much