1. Helping in the Most Helpful Ways: Decreasing resistance in the intervention process Christine Hallman, M.S.W., M.Ed. Child & Family Connection 312 Waller Mill Road Williamsburg, VA 23185 757 229-7940 challman@kidsandfamilies.com

2. Focus of Early Intervention Increasing children’s participation in family and community activities identified by the family AND Supporting the family in identifying learning opportunities and enhancing their child’s development “Parents teach their children every day- they are the ones who make the most difference in their child’s development. In order for early intervention supports and services to work best, there needs to be an active partnership between the parents and the services providers. This partnership includes the family and other caregivers being involved in each early intervention session.” Early intervention supports and services in the Infant & Toddler Connection of Virginia: Family information

3. Key EI Terms/ Concepts Active partnership between family and EI staff- –Active- 1. acting; working 2. causing motion or change 3. lively; agile –Partner- 1. one who joins in an activity with another or others 2. a player on the same team

4. EI staff to serve as coach/ consultant to family –Coach- an instructor or trainer –Consultant- 1. a person who consults another 2. an expert who gives professional or technical advice Consult- 1. to talk things over; confer 2. to seek advice or information from 3. to consider

5. The Helping Dilemma We want to help families, but why then do some families not go along with our help? –Chose the goals but don’t seem to work on them? –Asked for help, but not doing all that is recommended to do? –Declining our services, either through direct communication or unspoken behavior?

6. Things to Consider Instead of thinking why some families become resistant, why DO some families change? Helping professionals want to believe it is the service they provide that causes the change, but for EI to work the best it is the family that has to facilitate or make the changes.

7. The Nature of Change Change is natural Change can occur quickly Change is dependent on the person’s faith in the possibility of change Change is also dependent on the person’s desire to make change

8. Ambivalence Ambivalence is a necessary and normal component of the process of change The person has conflicting desires- –to change AND not to change

9. Reactance If a person feels a personal freedom is being challenged or infringed upon, including the right to decide on a course of action, the person will defend the alternate option. The behavior that is defended will then appear more desirable and will be maintained or increased. Even offering multiple options won’t work because of the very nature of ambivalence (“Yes, but…)

10. Major Point!!! Resistance is in the Relationship Reactance/ Resistance is a relational issue How you behave influences how the other person behaves –Have to be aware of this and mindful of how one behaves so that well-intended “helping” behaviors don’t have the opposite effect.

11. To Minimize Resistance Instead of thinking why isn’t a family motivated, we need to think for what is the family motivated? Specifically what are they ready, willing, and able to do now? What do they require to feel ready, willing, or able to make other changes eventually?

12. Necessary Conditions for Change READY, WILLING, AND ABLE WILLING- Seeing the importance of a particular change ABLE- Feeling confident a particular change is possible and the individual can cause it READY- Prepared to make the particular change a priority

13. Suggestions for EI Practice Establish and maintain a collaborative relationship –From the very start explain the EI model- family as expert of child with other experts of child development who serve as coaches and consultants Try to get at the family’s understanding of the situation –Especially what it is that they want Don’t jump too quickly at giving advice or deciding the plan for the family –Ideally we want the family to be voicing the reasons for change and they ways to change –Ask the family for permission before giving advice and try to give multiple options Continually emphasize respect for the family, and the personal choice and autonomy of the family members –Point out/ highlight the choices the family makes along the way

14. What to do if Family Starts Getting Defensive/ Resistant Don’t get defensive if a family resists change, resistance is normal –Acknowledge that you see that the family is still deciding what they want to do. Offer the family time to think it through and re- emphasize their right to decide. –Breathe- remember you are the professional. Your job is to help the family and the child by suggesting options to the family. Try to behave in a way that promotes that mission.

15. Whatever you do- Try to Minimize Resistance Remember if we keep suggesting one thing while the family is in the process of deciding, the family might come to convince themselves of the opposite.

16. When Both You (and Family) are Calm Try to determine what the issue is? Is the family ready, willing, and able to make the change? Are you focusing on something the family is not motivated to change? –If so, what are they willing to change?

17. Helpful Questions To Determine Motivation Willing –What are you most concerned about? –What is your number one concern or priority? –Do you understand why the team suggested this goal? Do you also see it as important to address? –Please rank the possible goals/ areas to address.

18. More Helpful Questions Able –Do you believe a change is actually possible? –How likely do you think a change is? Do you think it will be hard to change? –Do you feel like you know enough to make the change? –What do you need to feel comfortable with working toward the change? –What supports/ strengths do you have that will help with the change?

19. More Helpful Questions Ready –I can tell you are a busy family. We try to help you figure out strategies that you are able to use during your family’s normal routines. It will require some time and energy, especially at the outset, for you to figure out and learn the ways that will encourage your child’s development. With all that is going on in your family, do you feel ready for services to start? –If not, when do you think you might be ready? –What do you think you might be able to start doing now? How might you like us to be of help?

20. Considerations Throughout the EI Process Remember it is an ACTIVE PARTNERSHIP!!

21. Initial referral/ phone contact Why did they choose to make the phone call to EI? Did someone else suggest they make the call? Do they agree with this person’s concerns? Describe EI process while emphasizing it is based on family’s unique priorities, resources, and concerns. State the belief that family are the experts of the child. The early intervention process is combining the family’s expertise of the child with the other professionals’ expertise of child development. Emphasize that family always has a right to stop the process and therefore chooses anything that is done regarding their child. Emphasize confidentiality. If notice apprehension, remind family that after screening/ initial meeting they can choose whether to proceed to the next step.

22. Initial meeting/ screening Before starting the screening, explain what it is and why it is done. Tell them that after it is done you will share the results and that they will chose what they would like to happen next. Tell family that you want them to feel comfortable throughout the process. Do they have any concerns they would like to share with you or any questions?

23. Assessment Emphasize that the family’s opinions and perceptions of the child are a part of the assessment process. Another component is the behaviors observed during the assessment process. Explain that a full developmental assessment is required as part of the EI process. Explain that a report must be prepared in which the assessment team documents what they observed.

24. Eligibility Determination State that child is eligible for Part C services and the reasons why. Explain that family can decide if an IFSP meeting is held during which the team, including the family, develop goals for the child/family and figure out how and who will do what. If family is hesitant, emphasize that the plan is strongly based on family’s input, and that after the plan is developed, the family will have to sign before any services/ supports are started. Additionally family can decline all or parts of the plan at any time.

25. IFSP development Not only must we determine what the family wants, but why and how the family wants it to be addressed –Family must see short-term objectives as consistent with long-term goal Also must determine family’s level of readiness and perceived ability to work on the goals –Related supports to help –More frequent or intense services to support If family is still resistant, suggest that plan be written to end after a short trial period or schedule an IFSP review within a short period.

26. Service Delivery Want ongoing partnership with family –Don’t tell them what to do, instead offer, or better yet, help them figure out what they could do and encourage family to decide what to do. –Before offering suggestions, etc., ask permission to share. Try to offer multiple options. –Continually assess perceived levels of willingness, readiness, and ability when you suggest an additional strategy. –Encourage family to be honest with you. If they don’t like something you say or suggest, tell them that’s okay. You want to help them figure out what will work for them. –If you sense growing resistance, voice your concern and try to figure out what is going on.

27. IFSP Review If family isn’t working on a goal or states concerns about an IFSP goal, objective, or services/ supports, suggest that a review be done. Praise family for the changes they have made and the skills they have learned. Suggest that the plan is to be individualized for the family and flexible to their unique needs and wants. Encourage family to share any changes they might feel they need or want regarding anything in the plan. EI staff should clearly and succinctly state any concerns or desired changes.

28. Ethical Concerns Early intervention professionals have a legitimate ethical obligation to share concerns regarding the child or family to the family and/or other necessary individuals/ agencies (pediatrician, CPS) When sharing a concern emphasize to family that they are in control of what they’ll do in response. –State it as clearly and succinctly as possible. –Ask family if they understand and if they would like additional information or have any questions. –Ask them what, if anything, they think they might be willing to do based on what you have shared. –If they are getting defensive, offer to talk to them later about it or restate your desire to help them in the ways they see fit.

29. Parallel Consideration with Children Want to acknowledge a child’s emotion and not attempt to minimize it –Stress Theory- It is not the stressor, but the child’s appraisal of the stressor to which we must respond. Even if we objectively know that the child’s fear is disproportionate

30. Regulation Emotional Co-regulation- Children need to learn to realize and deal with their feelings. They do this when we help them calm by remaining calm and naming their feelings –instead of trying to act like everything is fine when it isn’t or expressing displeasure/ annoyance to the child

31. Why it Matters Impossible to learn when one is overly stressed Also EI staff is modeling to family how to help their child. EI staff are viewed as the experts.

32. Recommended Practice It is therefore recommended that practitioners base their intervention on child’s interests and follow the child’s lead. Intersperse acquisition tasks (being learned) with maintenance (already learned) tasks If you sense child is getting stressed, ease back and allow child to calm

33. Final Point We cannot control what children or families will do. –Don’t set yourself up for continual frustration! –Do your best and know in your heart that you have done the best you can at encouraging the family’s or child’s participation Primary Source Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford.