Elements that enabled change A person who was interested in him A vision that the future could be different A belief that he could make a choice A belief that he could learn to do something he valued.
What makes therapy successful? Kieran McKeowan A guide to what works in family support services for vulnerable families (Dublin, 2000) 7
Seven steps to determination 1.I accept there is a problem 2.I have some responsibility for the problem 3.I have some discomfort about the problem and my part in it 4.I believe that things must change 5.I can make a choice 6.I can see that I can be part of the solution 7.I can see the first steps towards the change
How might resistance show itself? By only being prepared to consider 'safe' or low priority areas for discussion. By not turning up for appointments By being overly co-operative with professionals. By being verbally/and or physically aggressive. By minimising the issues. (Egan, 1994)
What might we be doing to make it worse? Becoming impatient and hostile Doing nothing, hoping the resistance will go away Lowering expectations Blaming the family member Absorbing the family member's anger Allowing the family member to control the assessment inappropriately
What might we be doing to make it worse? Becoming unrealistic Believing 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 reflecting The solution to all client issues and clinician headaches
23 The Problem With Them Is…. They don’t see (insight, denial) They don’t know They don’t know how They 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? Ambivalence Motivation Readiness Confidence Issues of……
27 Key Assumptions Motivation is interpersonal Resistance is interpersonal Clinician approach and behaviors matter Persuasion is usually not an effective method to increase motivation and change
28 MI: How it Works Clinician manages important in-session behaviors of client using MI spirit, principles and skills Interaction of clinician and client Leads to Increase Change talk and Decrease Resistance
31 Basic MI Principles D = Develop Discrepancy R = Roll with Resistance E = Express Empathy S = Support Self-efficacy
32 Develop Discrepancy Change is motivated by a perceived discrepancy between present behavior and important personal goals or values The person rather than the counselor should present the arguments for change
33 Roll with Resistance Avoid arguing for change Resistance is not directly opposed Resistance is a signal to respond differently The person is a primary resource in finding answers and solutions
34 Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal
35 Support Self-Efficacy A person’s belief in the possibility of change is an important motivator The person, not the counselor, is responsible for choosing and carrying out change The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy (HARP)
Confrontation In 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)
Confrontation Client: 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)
Confrontation Client: 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)
Effective work involves Universalising Confronting Educating Modelling behaviour
Effective work involves Recognising difference Accepting Allowing ventilation Relating to feelings Direct intervention in the environment
A scale for assessing motivation 1.Shows concern and has realistic confidence. 2.Shows concern, but lacks confidence. 3.Seems concerned, but impulsive or careless 4.Indifferent or apathetic about problems 5.Rejection of parental role.
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 children Has realistic confidence that he/she can overcome problems and is willing to ask for help when needed Is prepared to make sacrifices for children.
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 overcome May be unwilling for some reason to ask for help when needed. Feels unsure of own abilities or is embarrassed But uses good judgement whenever he/she takes some action to solve problems.
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.
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.
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)