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Approaches to Engage Clients and to Promote Change
Bob Carty, LCSW, CADC, CCJP October 18, 2019
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Getting Started Good morning!!! Quick polling
Years of experience Work settings Overall goal: explore various ways we can engage people to overcome their barriers to change and to enhance their motivation for ongoing recovery
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Learning Objectives Identify the F.E.A.R. acronym as barriers to change Examine key aspects of denial Describe 4 foundational principles of Motivational Interviewing List ways to promote shift from Contemplation to Preparation Apply principles of Mindful Self-Compassion
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Barriers to Change “The Unmotivated Client” Factors in Getting Stuck
Discussion Questions
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“The Unmotivated Client”
Most of us can think of client who seems to demonstrate no motivation to change…and more times than not, little change occurred throughout counseling What if… We reframed the situation as the client being stuck? We looked for different ways to engage the client?
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Factors in Getting Stuck
Shame and guilt Denial F.E.A.R. Lack of connection Caught in early stages of change Being stuck as a symptom
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Shame and Guilt Almost all clients experience shame and guilt, some are immobilized by these Difference between shame and guilt Both influence clients in ways that perpetuate their problematic thinking and behaving Low self-esteem Negative self-talk patterns Self-fulfilling prophesies
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Denial Much more than conscious lying to others and self
Psychological defense, triggering automatic response to perceived threat Progressive over time Expansive to various aspects of life (not only substance use) “Recruits” others to deny – family, friends, co-workers
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F.E.A.R. Harris (2009) identified these four barriers to change
Fusion: refers to convincing ourselves that we cannot do something Excessive goals: exceeding one’s resources Avoidance of discomfort: staying comfort zone to limit anxiety regarding new behavior Remoteness of values: may have anti-social values; may have lost sight of values; may not know how to use values
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Lack of Connection Hari (2018) cites seven types of disconnection that generate depression, anxiety, and substance use From meaningful work From other people From meaningful values From childhood trauma From status and respect From the natural world From a hopeful and secure future
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Caught in Early Stage of Change
Stages of Change theory offers a model to understand how people change, especially the importance of counselors offering stage- appropriate clinical interventions However if this is not done effectively, the client stays stuck What interventions can create movement out of Pre-Contemplation? Out of Contemplation?
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Being Stuck as a Symptom
Addiction implies repetition and reliance of negative coping styles Depression and anxiety create thinking patterns and actions that reinforce one’s pathology Past treatment episodes and/or incarcerations exacerbate a sense of hopelessness and helplessness
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Discussion Questions Which one(s) of these factors seem most prevalent in your current work? What other factors may keep a client stuck? How do you address the issue of being stuck? With the client? In supervision? In your own life?
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Developing Engagement
Foundational Principles of Motivational Interviewing Professional Caring Review of Previous Client Efforts Goal Alignment
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Foundational Principles of Motivational Interviewing
These are helpful in establishing some guidelines in the clinical relationship Resist the righting reflex Understand your client’s motivation Listen to your client Empower your client
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Professional Caring Naturally, maintaining professional boundaries is a key ethical standard; however this may be perceived by the client as a distancing mechanism How do we demonstrate caring for our clients, especially early in the treatment process?
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Review of Previous Client Efforts
Effective engagement may require a clear idea of the client’s past efforts in resolving his/her problems This includes a discussion on the following: Previous treatment episodes: what worked, what did not, what was missing? Client’s own attempts to manage disorders either prior to treatment or following treatment Leading to a focus on what can be done this time
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Goal Alignment Too often, only standard treatment goals are set by the counselor (stay drug-free, learn about recovery, etc.) If the client does not buy-in, there is no change, sometimes only compliance Need to find mutually-agreed upon goals to enhance clinical engagement
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Types of Denial (Gorski)
Second Look at Denial Education on Denial Types of Denial (Gorski) Ways to Reduce Denial
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Education on Denial Telling someone that s/he is in denial is not as helpful as explaining what that means and how to get out of denial Can be done in individual counseling, group counseling or patient education sessions Be sure to cover key aspects – subconscious defense, progressive, and expansive
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Types of Denial (Gorski)
Avoidance Absolute denial Minimizing Rationalizing Blaming Comparing Flight into health
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Ways to Reduce Denial Help client to…
Recognize his/her preferred denial type Catch oneself lying and own it Identify which fears trigger his/her denial Assess how expansive his/her denial network is Ask for and become open to feedback (Johari Window)
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Johari Window
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Discussion Questions How to you address denial with people with substance use disorders? How do you do so with people who also have depression and/or anxiety disorders? How do you do so with people who have past trauma?
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Creating a Context for Change
Twelve-Step Facilitation Multiple Pathways of Recovery Acceptance and Commitment Therapy Power of Our Stories
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Twelve-Step Facilitation
Twelve-step recovery provides a descriptive map for the change process 12 steps of personal growth, highlighting important recovery values Sponsorship and fellowship, providing connection and guidance Available meetings all over the world! What happens when a client does not relate to this model?
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Client Rejection of 12-Step Recovery
If all we can offer as a recovery model is the 12-step model, numerous things may occur… You may find yourself requiring actions in AA/NA that they do not require Power struggle could develop between you and client Reversal of the foundational principles of MI, leading to reduced clinical engagement Renewed sense of being stuck
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Multiple Pathways of Recovery
Keep in mind that there are many options SMART Recovery Refuge Recovery Women for Sobriety Secular Organizations for Sobriety Harm Reduction models Discuss the pros and cons of each with the client Point out that one path may initiate recovery while a different one may sustain it
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Acceptance and Commitment Therapy (ACT)
A clinical approach that is practical and helpful in treatment because it encourages action toward the client’s stated goals Purpose: to assist a person in creating a meaningful life based on one’s values and one’s commitment to take action toward realistic goals while accepting the pain that tends to accompany change
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ACT’s Core Therapeutic Processes
Contacting the present moment: be here now Defusion: avoid getting tangled up in thinking Acceptance: open up, making room for pain Self-as-context: pure awareness; the observing self Values: know what matters Committed action: do what it takes
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Power of Our Stories Narrative Therapy: useful in providing a content for change, helping clients see how the stories they carry about their lives are useful tools in… Understanding their problems Keeping themselves stuck Finding ways to change
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Benefits of Narrative Therapy
Allows client to personalize his/her situation Opens the door for exploration of the client’s story (beliefs, worldview, etc.) in counseling Can be used in individual and group sessions Tends to be strengths-based Generates understanding and new hope
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A Few Key Concepts Thin descriptions: most clients over-simplify their lives with problem-saturated stories, leading to repeated problems Clues: counselor helps to identify exceptions Circular questioning: expands description to how others see the client Definitional ceremony: sharing one’s story in group enhances its power and invites feedback
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Meet Lee 25-year-old, single male
Reports having problems since13; no family structure; hung out with older kids; drank and drugged; HS dropout; juvenile and adult records; recent deaths of friends; three previous treatment episodes and relapses; now incarcerated on a treatment unit What might be his own narrative? How can we help him to change it?
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Thought to Ponder “Never be a prisoner of your past. It was just a lesson, not a life sentence.” Anonymous
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Motivating for Ongoing Change
Promoting Ongoing Change Making New Connections Mindful Self-Compassion
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Promoting Ongoing Change
While we believe that substance use disorder is a chronic condition, treatment providers still tend to treat it in an acute care model Lengths of stay tend to be too short to solidify necessary changes in thinking and acting; may actually promote “treatment resistance” How can we use our clinical engagement and the client’s early progress to sustain recovery?
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Making New Connections
Disconnection and isolation from others are frequent indicators of depression, anxiety, and substance use disorders As mentioned earlier, there are numerous things from which a person may feel disconnected – some require ongoing work Reconnection to other people Reconnection to one’s values Reconnection to a meaningful life
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Reconnection to Other People
Recovery support relationships need to be central, not secondary, in one’s new lifestyle Such fellowship offers… Ongoing support and guidance Models of recovery in action Sources of feedback to lessen denial Sense of community and reversal of “terminal uniqueness”
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Another Thought to Ponder
“You have to turn now to all the other wounded people around you, and find a way to connect with them, and build a home with these people – a place where you are bonded to one another and find meaning in your lives together. We have been tribeless and disconnected for so long now. It’s time for us all to come home.” Johann Hari (2018) Lost Connections
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Reconnection to One’s Values
In early recovery, there may be confusion regarding values as former ones are in question and new ones are not yet set Values can be seen as providing direction for ongoing action; they are not goals, but serve as a compass to determine if our actions align with our goals Help clients to identify what is most important to their sense of self and how can this be used to make ongoing change
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Reconnection to a Meaningful Life
As many progress through recovery, they benefit from supportive others and a new sense of self This leads to the question, “What now?” Assist client in recognizing new options in… Career paths Volunteering Relationships Service to others
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Mindful Self-Compassion
Effective in helping people caught up in lingering shame, guilt, depression, and/or anxiety Three components Self-kindness Common humanity Mindfulness Helps in overcoming “negativity bias”
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Overcoming Negativity Bias
Many of us get caught up in anxiety -- even in good times; this is especially true for clients with SU and/or MH disorders Ways to increase joy and happiness Gratitude exercises Soaking in positive experiences Loving kindness exercises Prayer and meditation
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Brief Review We covered a buffet of approaches to engage clients and to enhance motivation for ongoing change Motivational Interviewing Stages of Change Twelve-Step Facilitation Narrative Therapy Acceptance and Commitment Therapy Mindful Self-Compassion I encourage you to study further any specific approach that appealed to you
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Recommended Readings Rick Hanson (2009). Buddha’s Brain.
Johann Hari (2018). Lost Connections. Russ Harris (2009). ACT Made Simple. William Miller and Stephen Rollnick (2002). Motivational Interviewing. Kristin Neff and Christopher Germer (2018). The Mindful Self-Compassion Workbook. Martin Payne (2006). Narrative Therapy.
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Trainer Contact Info
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Closing Comments Thanks to ICB for inviting me to present this closing workshop of the Fall 2019 Conference Thanks to all of you for attending Safe travels!!!
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