6 Elements that enabled change A person who was interested in himA vision that the future could be differentA belief that he could make a choiceA belief that he could learn to do something he valued.
7 What makes therapy successful? Meta Analyses of Research on Family SupportTHERAPY NEUTRAL e.g. psychodynamic bed-wettingCLIENT HOPEFULNESS - statements about the futureCLIENT CHARACTERISTICS - GIVENSOCIAL SUPPORT – FGCs, harnessing strengths, SEE PLAN = family doing the work!RELATIONSHIPS - positive work / questionnaires (200) / professional clear boundaries / …The model works with a range of therapeutic techniques – I also manage a Voluntary Sector Family Centre, which has a long-standing commitment to psychodynamic social work. The model still works for them – if the family centre things that e.g. Johnny’s bed-wetting is down to his childhood sexual abuse and a therapeutic treatment will help him recover – then a reduction in his bed-wetting may provide evidence of the treatment’s effectiveness.Client Hopefulness – our outcomes are statements about the future and we use scaling (as I will come on to) to measure progress – gaining hope with intractable problems is a frequent report coming back from families that I have been doing research with.Client Characteristics and Social Support – We can’t do much about client characteristics, but we can mobilise family support, and our services are premised on doing this. As I said, we use family group and community conferencing to support people with change.Relationship – The key question here is how working towards outcomes effects the relationship between staff and service users. The evidence (of around two hundred questionnaires we’ve had back on this subject) demonstrates that the model helps staff and families to be clear about their roles and to be clear about how they can work together to produce change. Whether they like each other or not is irrelevant – it’s a professional – change-making relationship.Kieran McKeowan A guide to what works in family support services for vulnerable families (Dublin, 2000)
8 Seven steps to determination I accept there is a problemI have some responsibility for the problemI have some discomfort about the problem and my part in itI believe that things must changeI can make a choiceI can see that I can be part of the solutionI can see the first steps towards the change
19 How might resistance show itself? By only being prepared to consider 'safe' or low priority areas for discussion.By not turning up for appointmentsBy being overly co-operative with professionals.By being verbally/and or physically aggressive.By minimising the issues.(Egan, 1994)
20 What might we be doing to make it worse? Becoming impatient and hostileDoing nothing, hoping the resistance will go awayLowering expectationsBlaming the family memberAbsorbing the family member's angerAllowing the family member to control the assessment inappropriately
21 What might we be doing to make it worse? Becoming unrealisticBelieving that family members must like and trust us before assessment can proceed.Ignoring the enforcing role of some aspects of child protection work and hence refusing to place any demands on family members.(Egan, 1994)
22 What It Is Not Skills training Confrontive denial breaker Simply sitting there listening and reflectingThe solution to all client issues and clinician headaches
23 The Problem With Them Is…. They don’t see (insight, denial)They don’t knowThey don’t know howThey don’t care
24 So The Answer is…..Give them Insight……if they just see they will change.Give them Knowledge….. if they just know they will change.Give them Skills….. if you can just teach them how to change, then they will change.Give them Hell….. if you can make them feel bad or afraid enough they will change.
25 And Yet….. Sometimes Insight, Knowledge, Skills, And Feeling Bad Or Fearful Is Still Not Enough
26 What Is Happening? Issues of…… Ambivalence Motivation Readiness Confidence
27 Key Assumptions Motivation is interpersonal Resistance is interpersonalClinician approach and behaviors matterPersuasion is usually not an effective method to increase motivation and change
28 MI: How it WorksClinician manages important in-session behaviors of client using MI spirit, principles and skillsInteraction ofclinician and clientIncrease Change talkandDecrease ResistanceLeads to
31 Basic MI Principles D = Develop Discrepancy R = Roll with Resistance E = Express EmpathyS = Support Self-efficacy
32 Develop DiscrepancyChange is motivated by a perceived discrepancy between present behavior and important personal goals or valuesThe person rather than the counselor should present the arguments for change
33 Roll with Resistance Avoid arguing for change Resistance is not directly opposedResistance is a signal to respond differentlyThe person is a primary resource in finding answers and solutions
34 Express Empathy Acceptance facilitates change Skillful reflective listening is fundamentalAmbivalence is normal
35 Support Self-Efficacy A person’s belief in the possibility of change is an important motivatorThe person, not the counselor, is responsible for choosing and carrying out changeThe counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy (HARP)
36 Strategies OARS Open Questions Affirming Listen Reflectively SummarizingDunn/MINT
37 Original idea from Bem’s theory Change TalkOriginal idea from Bem’s theory“I learn what I believe from what I hear myself say.”
38 Eliciting Change Talk: A Technique For The Road
39 Assessing Importance How important on a scale of 1-10? 1---x yWhy X and not 1?What would have to happen for you to go from X to Y?
41 ConfrontationIn child welfare services, the Children’s Service Worker must be a skilled confronter. Confrontation is, basically, facing the client with the facts in the situation and with the probable consequences of behaviours(Texas Department of Human Resources)
42 ConfrontationClient: The doctor is telling lies about me. I didn't hurt Angie, she fell downstairs. She is always having accidents.Worker: I understand that children have accidents. Angie's injuries could not have been the result of a fall down stairs. There are two partially healed fractures in addition to the new head injury. Angie's buttocks and back are marked with bruises in the shape of a hand.(Texas Department of Human Resources)
43 ConfrontationClient: I know we haven't been to counselling in three weeks. Get off my back! My husband and I have other things to do.Worker: Going to counselling regularly is a part of your agreement with us to regain custody of your children. If the agreement is not followed, we can't recommend that the children come home.(Texas Department of Human Resources)
44 Effective work involves Logical discussionFocusingPrioritisingSummarisingSetting realistic limits
45 Effective work involves UniversalisingConfrontingEducatingModelling behaviour
46 Effective work involves Recognising differenceAcceptingAllowing ventilationRelating to feelingsDirect intervention in the environment
47 A scale for assessing motivation Shows concern and has realistic confidence.Shows concern, but lacks confidence.Seems concerned, but impulsive or carelessIndifferent or apathetic about problemsRejection of parental role.
48 Shows concern and has realistic confidence. Parent is concerned about children’s welfare; wants to meet their physical, social, and emotional needs to the extent he/she understands them.Parent is determined to act in best interests of childrenHas realistic confidence that he/she can overcome problems and is willing to ask for help when neededIs prepared to make sacrifices for children.
49 Shows concern, but lacks confidence Parent is concerned about children’s welfare and wants to meet their needs, but lacks confidence that problems can be overcomeMay be unwilling for some reason to ask for help when needed. Feels unsure of own abilities or is embarrassedBut uses good judgement whenever he/she takes some action to solve problems.
50 Seems concerned, but impulsive or careless Parent seems concerned about children’s welfare and claims he/she wants to meet their needs, but has problems with carelessness, mistakes and accidents. Professed concern is often not translated into effective action.May be disorganised, not take enough time, or pays insufficient attention; may misread ‘signals’ from children; may exercise poor judgement.Does not seem to intentionally violate proper parental role; shows remorse.
51 Indifferent or apathetic about problems Parent is not concerned enough about children’s needs to resist ‘temptations’, eg competing demands on time and money. This leads to one or more of the children’s needs not being met.Parent does not have the right ‘priorities’ when it comes to child care; may take a ‘cavalier’ or indifferent attitude. There may be a lack of interest in the children and in their welfare and development.Parent does not actively reject the parental role.
52 Rejection of parental role Parent actively rejects parental role, taking a hostile attitude toward child care responsibilities.Believes that child care is an ‘imposition’, and may ask to be relieved of that responsibility. May take the attitude that it isn’t his or her ‘job’.May seek to give up the responsibility for children(Magura et al,1987)