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
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.
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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
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
Family Fusion & Lack of Boundaries
Lack of personal space
Taking over-controlling
Blurred lines
Blaming
Power
Denying
Rescuing faulty reasoning
Lack of boundaries
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
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)!
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Families/Clients are experts
3. Counselor expertise is called along the way.
4. Remember this is not about you
5. Avoid one upmanship
Assumption is they are motivated
Probability of behavior change or movement toward or against goal
Extrinsic…….
Intrinsic ……
What are they motivated to do?
Parallel ProcessesFamilies must have
opportunities to grow alongside their loved one that is in treatment.
Krissy Pozatek, LICSW
Parallel Processes Letting go of Reins
Emotional Attunement
Listening Reflectively
Shifting Responsibility
Multidimensional Family Therapy Solution-based
Behavioral
Narrative
Family systems model
Family disease model
Cognitive-behavioral
Multidimensional
What ifThe 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
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
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
In between the cravings
Find the Spaces In between
Omar Manejawa MD
Cravings – Myopic
Spaces- Change
Habits -Actions
Motivational Interviewing
Directive client center approach
Process not Technique
Collaborative
Evocation- elicit clients internal viewpoint
Autonomy
Roll With Resistance
MI Spirit
Rogerian approach
Coupled with a direction
Equalitarian
Warm, Empathetic, Affirming & Respectful
Guiding & eliciting vs. instructing & persuading
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
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
What Type of Communication Skills Do you Have?
Echo Key Words
Open Ended Questions
Paraphrase
Body Language
Summarize
Self -Disclose
Listening Exercise Break up in dyads
Practice Listening – 3 minutes- Listen to what is said and what is unsaid
Debrief
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 !
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
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
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
Listen ReflectivelyBeing quiet and
actively listening
Responding with a statement that accurately reflects the essence of what the client meant
Listen carefully think Reflections
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
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
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
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 ..
Other strategies for Handing Resistance
Clarification
Shift focus away from stumbling block
Emphasize Personal Choice and Control
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
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 ?......
Decisional Balance Worksheet(Fill in what you are considering as change )
Good things about Good things about Changing behaviorChanging behavior
Good things about Good things about changing behaviorchanging behavior
Not so good things Not so good things about behavior about behavior
Not so good things Not so good things about changing about changing behaviorbehavior
Exploring Ambivalence
The Existence of conflicting emotions or thoughts about a person object or idea
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?
59Scaling Scaling Questions 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 - SFT Confidence - 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.
Resistance
Traditional Client not getting it
MI View Counselor may not
be getting it
Case Example –Jon
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
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)
Ten Strategies for Evoking Change
2. Ask for Elaboration When change talk emerges ask for more detail. In
what ways?
3. Ask For ExamplesAsk for specific examples, when was the last time that
happened ? give me an example
4. Look BackAsk about a time before current concern emerged. How
were things better? different?
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
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
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
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Assumptions of SFT4. 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
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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
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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
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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
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Interviewing Questions1. Precession Change
2. Coping
3. Relationship
4. Exception
5. Miracle- In a Perfect
6. Scaling
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Compliments Direct: Positive verb,
attribute or reaction to client
Indirect-Something that implies positive
Self Compliment- “I”
statement
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Assignments Always based on
relationship
Readiness to Change
Focus on Attainable goals
Design ,Small steps Proceed slowly
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King Baby- and Father- VIPWE 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
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 ……….
Heroic Families Attunement
Individualization
Healthy Boundaries
Own Recovery
Talking care of ones self physically, emotionally and consistent with ones values
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