Engagement

February 10, 2017

AgendaSession I:

• Open discussion: documentation

• What is engagement?– Connection between

documentation and engagement

• Engagement strategies– Understanding

Behavior– Motivational

Interviewing• Exploring

ambivalence

Session II:

• Engagement strategies– Motivational

Interviewing• Exploring

ambivalence• Rolling with

Resistance• Troubleshooting

Activity

• Now that you have been implementing changes in your documentation, what challenges have you experienced?

• How have these changes impacted:– Your relationships with family members?– Your workflow?– Your outcomes?

Checking In: Documentation

What is Engagement?

• Engage – to occupy, attract, or involve someone's interest or attention

• Beyond mere compliance, engagement creates investment in services

• Engaged family members actively participate in and shape the process

What is Engagement?

• Both a process and an outcome • Requires the effective and balanced use of

helping skills and protective authority• Produces an ongoing worker/client

relationship that results in the pursuit and accomplishment of agreed upon goals

Finding the Right Balance

Neglect: Let participant

do what he/she wants

Control: Get participant to

do what I think is needed

Documentation and Engagement: A Balance

• Some recovery trainings focus on philosophy to the exclusion of all else, i.e., they neglect the business necessities and pressures of service documentation.

• Some planning trainings focus on documentation compliance to the exclusion of all else, i.e., they neglect the recovery-based foundation that is necessary for true QUALITY.

Documentation and Engagement: A Balance

RegulationsRequired Paperwork

Medical NecessityCompliance

CollaborativePerson-CenteredStrengths-Based

Transparent

Doesn’t documentation get in the way of engagement?

• If we let the need to document drive our interactions, we will fail to connect on a human level; but, if we remain person-centered, we will naturally gain the information that we need to document effectively.

• In other words, strong documentation is a natural consequence of strong engagement.

Documentation and Engagement

• Engagement involves:– Connecting around goals, hopes, and dreams– Understanding values– Learning about needs and preferences– Understanding the factors that promote and hinder

progress– Celebrating victories and finding solutions to ongoing

issues• These are the same exact skills needed for

strong documentation!

Documentation and Engagement

• Documentation provides a clear record of the issues that matter most to family members.

• Documentation supports you in keeping track of important details and in monitoring progress.

• Documentation keeps us accountable and ensures that we get results for our families!

Without Documentation…

• We have no way to keep track of important details

• We may confuse family members on our caseload

• We have no way to tell if progress is being made

• We have no way to justify the continued medical necessity of services

• Services are less effective!

What Engagement Looks Like

• How can you tell that a family member is engaged?

Tools for Creating and Maintaining Engagement

• Understanding behavior

• Motivational interviewing skills– Exploring ambivalence– Rolling with resistance

Understanding Behavior

The Purpose of Behavior

• Behavior serves a purpose• Seek to understand not only what a

person is doing, but also why they are doing it

• Troubleshoot issues by asking yourself:

What do they gain from this behavior?

The Purpose of Behavior• Acknowledging that behavior serves a

purpose:– Removes blame– Demonstrates understanding of the family

member’s perspective– Equips us to find meaningful alternatives

What’s the Purpose?

*Solutions and interventions will depend on the answer!

• Example: Missing appointments– Saves time – constantly busy either working or caring

for kids– Feels exposed and embarrassed sharing personal

information with advocate– Fears advocate won’t actually be able to help – why

get my hopes up?– Loses track of date/time

What’s the Purpose?

*Solutions and interventions will depend on the answer!

• Example: Cutting school– Avoid bullies– Avoid feeling stupid in class– Want to hang out with friends who aren’t at

school– Feel too depressed to go

Understanding Your Reaction

• As we seek to understand our families, we must also understand how we react and respond to them.

• When family members react emotionally to us, we react emotionally to them!

• Our reactions impact how we will further engage with the individual, which in turn will impact:– Relationship development– Outcomes!

Understanding Your Reaction

• How do you feel when you sense that a family member is disengaged?

• How do your feelings impact your approach?

Understanding Your Reaction

• Self-awareness allows us to acknowledge and validate our own needs first. This frees us up to be more present to our families.

• In other words, being aware of our own reactions allows us to respond more effectively.

• How might this change your approach to engaging with youth and families?

Motivational Interviewing

Motivational InterviewingW.R. Miller and S. Rollnick, 2009

• Motivation: the reason(s) one has for acting or behaving in a particular way; the general desire or willingness of someone to do something

• A collaborative, person-centered form of guiding to bring out or strengthen motivation for change

• Involves exploring and resolving ambivalence

• Not just a series of techniques but a way of being with people that improves with considerable practice over time

Common Misconceptions• This person OUGHT to (or should WANT to)

change.• Families/Youth are either motivated or not. If not,

there’s nothing we can do for them.• Now is the right (only?) time for change.• A tough approach is always best.• I’m the expert, so he/she should follow my advice.• If the family/youth decides not to change, my work

has failed.

Exploring Ambivalence

Motivational Interviewing Skill

Ambivalence

Ambivalence is “being stuck” because a person is holding a balanced view of the

positive and negative feelings about change (achieving a goal).

Ambivalence is Tricky

• AKA lack of motivation

• If you argue for one side, an ambivalent person is likely to defend the other

• As a person defends the status quo, the likelihood of change decreases

• Resist the “righting reflex”

The Righting Reflex• What is it?

– The natural inclination we have to make it better for another person

• What’s the danger?– We tell the other person what to do, how to do it, and why they

should do it without talking to them and learning what they think– It creates resistance in that we move away from the partnering

stance of MI and into the expert, top-down role• What to do when you find yourself doing this?

– Stop and Reset– “Mrs. Smith, I realize I have been just lecturing you on how you

can deal with your daughter without learning what you are thinking. Let me back up and hear from you, wherever you would like to start.”

“Righting”Reflex

Ambivalence

Ambivalence: An Example

Methods to Address Ambivalence

• Open-ended Questions

• Affirmations

• Reflective Listening

• Summaries

Open Ended Questions

Open ended questions let the family/youth tell their story.

•Closed ended questions are used to get a specific, one-worded answer: name, yes/no, zip code, etc.•Open ended questions require the person to give information/explanation.

When to Use Open Ended Questions

• You are doing too much of the talking

• You are seeking a richer, deeper

conversation• You want to have the family member

argue for change

Open Ended Questions Examples

• What brought you here today?• How were you able to (action step) to work

towards (goal)?• What would you be willing to do or to try to

do?• What worries you about your current

situation?• What encourages you to believe that you can

change if you want to?

AffirmationsStatements we make to recognize strengths,

successes, and efforts to change

•Verify and acknowledge family/youth’s behavior changes, accomplishment of action steps, and attempts to change•Avoid statements that sound overly praising and therefore insincere•Affirmations are recognitions of real effort and accomplishments

Affirmation Examples

• “Your commitment really shows by (what the family/youth is doing).”

• “With all the obstacles you have right now, it’s (impressive, amazing, etc.) that you’ve been able to (action taken by family/youth to achieve goal).”

• “In spite of what happened last week, your coming back today reflects that you’re concerned about (family/youth’s goal).”

Reflective Listening

The primary way of responding to family/youth and of building empathy.

•Listening and then making a reasonable guess about what they are saying.•Summarize (focus on) family/youth arguments for change.•Validates what family/youth is feeling and doing.

Reflective Listening Examples (Generic)

• What I hear you say…• So on the one hand it sounds like… And,

yet on the other hand…

• I get the sense that…

• It seems as if…

• It feels as though…

Reflective Listening Examples (Specific)

Parent: “I know we made all these goals about getting more resources for my child, but I’m just not comfortable asking for help.”Advocate: “Getting the help you need hasn’t been easy.”

Youth: “I just don’t like the way my family talks to me about smoking pot. They always give me a hard time but I’m not smoking as much as I used to.”Advocate: “It sounds like you are working hard to cut down smoking but your family is not giving you recognition for this.”

How might you reflect this statement?

“I’m just not sure what to do about my brother. He makes fun of me in front of my kids. My kids think it’s okay to talk back to me and repeat the things they hear from

their uncle. I love my brother and he really helps with taking care of the kids. But he’s

creating all kinds of problems for me with my kids!”

How might you reflect this statement?

“My shifts change all of the time so it’s hard for me to make it to all of the classes and be on time. I don’t know when I’m going to have

to work.”

Summaries

• Special Form of Reflective Listening• Structure:

– Indicate you are about to summarize– Be selective and concise– Note ambivalence and attend to change

statements– End with invitation

• Use to change directions or ask a key question

Summaries are Best to Use When…

• Family/youth is talkative and you need to switch topics

• It’s time to end a meeting

• It’s difficult to get more information from the family/youth

Summary Example 1

“It sounds like you are concerned about your arguments (angry reactions to) with your daughter because it is creating a lot of hostility in your family and there is a chance that she may run away again. You also said that fighting with her is the only way you seem to be able to ‘get to her’. That doesn’t sound like an easy situation.”

Summary Example 2

“Over the past three months you have talked about going to the social security office to get on SSDI, and it seems that you have more recently started to recognize that avoiding being labeled as disabled is getting in the way of the receiving financial support that would be helpful for your family. That, coupled with not having enough food to send your son to school with lunch, makes it easy to understand why you are not committed to going to the social security office.”

Rolling with Resistance

Motivational Interviewing Skill

Resistance

• Resistance is what happens when we expect or push for change when the family/youth is not ready for that change.

• Conscious or unconscious defenses against change.

• Family/youth who exhibit resistance are less likely to change.

Signs of Resistance

• The family/youth may interrupt you• The family/youth seems distracted (looking

at watch, phone, around the room, etc.)• The family/youth gets defensive• Not coming to appointments/consistently

arriving late

“There is no way to make people like change. You can only make them feel less threatened by it.” –Frederick Hayes

Why Does Resistance Occur?

• It arises as a normal, expected product of interaction.

• When resistance emerges, there are good reasons the family/youth is not ready to change the way we are asking.– The reasons may not be clear to us or to the

family/youth, but they exist.– Ignoring them gets us nowhere.

Types of Resistance• Relational Resistance

– Has to do with the relationships between you and the family/youth

– There is discord in the interactions– You can tell this by comments made:

• “You don’t understand.”• “You can’t help me.”

• Issue Resistance– Related to any goal families/youth set with you

Strategies to Use with Relational Resistance

• Respect the resistance and roll with it.• Sometimes may have to apologize or shift

the conversation.

• Always express empathy.

• Avoid arguing!

• Let go of “expert mode”.

Strategies to Use withIssue Resistance

• Express Empathy

• Develop Discrepancy

• Support Self-Efficacy

• Use Change Talk

Express Empathy

• Empathize with concern and explore

• Non-judgmental

• Assure family/youth that they are being heard and understood (reflective listening)

• Show you recognize the barriers that the family/youth is facing

Develop Discrepancy• Develop discrepancy between family/youth’s

goals/values and their current behavior.

• Focus their attention on how current behavior differs from ideal or desired behavior.

• Ask what is good/positive about a particular behavior and what is bad/not so good about it.

• The Columbo Approach

The Columbo Approach• Express curiosity• Seek clarification of the

problem• Appear unable to

understand any solution

• Your uncertainty or confusion can motivate the family/youth to offer you the solution

The Columbo Approach: Examples

• “Hmm. Help me figure this out. You’ve told me that keeping custody of your daughter and being a good parent are the most important things to you now. How does refusing to try learning new parenting styles fit in with that?”

• “So, when you drink with your friends during the week you can’t get out of bed to get to school. Last month, you missed 5 days. But you enjoy your classes, and doing well at school is very important to you.”

Support Self-Efficacy

Many families/youth have little self-confidence in their ability to achieve goals. We can help

them to increase their confidence.

•Promote belief in their ability to gain the skills needed.•Focus on part successes, skills, and strengths the family/youth has or can easily learn.•Promote self-esteem and build positive self-image.

Support Self-Efficacy: Examples• “Last week you weren’t sure that you would be able to

complete your reflection log. How were you able to complete it every day last week?”

• “So even though you had one class that you did not turn in homework, how were you able to complete most of your work?”

• “Based on your logs, you have not had any major fights with your son. How were you able to do that?”Follow up with “How do you feel about that change?”

Support Self-Efficacy:Questions to Elicit Strengths

• How have you managed to overcome/survive the challenges that you have faced? What have you learned about yourself during those times?

• Name a time things went well. How did you accomplish this? What helped?

• What positive things do other people say about you?• What are your ideas about your current situation?• What do you think is necessary for things to change?

What could you do to make that happen?• What do you do to take care of yourself?• What gives you strength in difficult times?

6 Types of Change Talk1. Desire: Statements about preference for change.2. Ability: Statements about capability.3. Reasons: Specific arguments for change.4. Need: Statements about feeling obliged to

change.5. Commitment: Statements about the likelihood of

change. The verb is will.6. Taking Steps: Statements about an action

taken.

Use Change Talk• “What would you like to see different about your

current situation?”• “What makes you think you need to change?”• What will be different if you complete your referral to

our services?”• “How can I help you get past some of the difficulties

you are experiencing?”• “Suppose you don’t change, what is the WORST

thing that might happen?”• “How would you like this to turn out for you in 2

years?”

Roll with the Resistance• Stems from fear• Use when defensive• Don’t confront• Reframe and reflect • Avoid arguing for change• Explore (+) and (-) consequences

of changing and not changing• Focus on problem, NOT

family/youth• Resistance = shift your approach

What to Say When We Hear Resistance

• Reflect the resistant statement– “You don’t like this idea.”

• Reflect the tone of what you are hearing– “You seem to feel hopeless.”– “You’re not happy about…”

• Reflect ambivalence– “On the one hand you want… and on the

other you don’t think you can…”

What to Say When We Hear Resistance

• Acknowledge the resistance process– “We seem to be arguing.”– “I’ve gotten us off track here.”

• Support choice/control– “It’s up to you.”– “You’re the one in charge here.”

• You can do several of these in the same conversation!

Group Activity:Troubleshooting

Engagement Issues