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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How do our Families Arrive ?

Substance Abuse

Mental Health

Other –Legal, Physical, Family History

Family History

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

Family Strengths( Lamm, 2009)

Communication

Caring

Health

Commitment

Resilience

Spirituality

Family Systems Minuchin

Parent

SiblingCouple

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

Good - Not So Good

Portlandia

Family Fusion & Lack of Boundaries

Lack of personal space

Taking over-controlling

Blurred lines

Blaming

Power

Denying

Rescuing faulty reasoning

Lack of boundaries

Before Treatment Families Confused

Bewildered

Attached to The Problem

Deny

Minimize

Feelings Families HaveConfusion

Anger

Sadness

Love

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

What’s your Attitude ?

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

Stages Of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

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

Principles Of MIExpress Empathy

Roll with Resistance

Develop Discrepancy

Support Self Efficacy

How to Express Empathy Use your Oars Open Ended

Questions

Affirmations

Reflections

Summaries

What Type of Communication Skills Do you Have?

Echo Key Words

Open Ended Questions

Paraphrase

Body Language

Summarize

Self -Disclose

How do you Listen ?

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

Hard Questions to Ask about Resistance

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

Ten Strategies for Evoking Change10. Responding to

Change Talk (EARS)

EXPLORE

AFFIRM

SUMMARIZE

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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The Interview Initial

Break

Ending or Close

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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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CasesI want to know

everything that is said in treatment

You are not responding to my child’s needs

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

Always Have Heroic Counselors

Always Remember

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Recovery is Like Walking on Sunshine

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

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