Engaging with Reluctant Clients Funded by the Archstone Foundation

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Engaging withReluctant Clients

Funded by the Archstone Foundation

Biopsychosocial Assessment Trainer's Manual1Trainers Note: There is a lot of content material in this module. The experience and training level of participants will be varied, although this is designed for advanced workers. There are many tables of information included as handouts. If participants seem to know material on the slides, you may refer to the corresponding handouts and frame questions around them for discussion. Let participants know that these handouts are resource materials that they can refer to in the future.

WELCOME AND INTRODUCTIONS (PPT Slide #1)Introduce yourself. Let trainees know how excited you are to be involved in this program, and in helping them improve their skills in assessing difficult self-neglect situations. Briefly review session goals, objectives and agenda Establish norms HousekeepingBathrooms

Breaks & Lunch

Evacuation plan

Electronic devices

CEU Procedures


Professional Communication2Housekeeping: Location of the bathrooms, smoking areas, location of nearest exits and where to meet in case building is evacuated. Remind participants to sign-in, as it will be used to ensure that everyone got out of the building safely.Schedule: Give times of breaks, lunch- participants can be given the option of hr lunch, or hour lunch and get out hour early. Cell phones/pagers/blackberries-ask participants to set to silent and no texting. If participant needs to take a call that cant wait until the break, ask that s/he goes out into the hall.CEUs procedures: Remind participant to signed the CEU and to pay any fees, if needed. Introductions3



Years with the agency

One thing you hope to get out of todays trainingProfessional Communication3Participants are asked to introduce themselves to the group. Introductions should include the following information about each participant:NameWork settingLength of time with agency/ APS program

Discuss the use of the parking lot (place to keep running list of issues to be addressed at later time)What the participants hope to get out of the training, can list these items on a flip chart. Throughout the day, as these items are addressed, note that to the participants. Trainer also has the opportunity to address false expectations from the start in asking this question (may be too complicated, too agency specific, require some research, so refer back to supervisor)Evaluation Process4

Explain that participant feedback is vital for the Academy to develop appropriate trainings.Developing an ID CodeWhat are the first three letters of your mothers maiden name? Alice SmithWhat are the first three letters of your mothers First name? Alice SmithWhat are the numerals for the DAY you were born? Nov 29th

Trainee ID Code

5SMIALI29Learning Objective 1Identify the factors that contribute to a clients or family members resistance:


Why do theseclients refusemy help?Emphasize that participants already have much of the knowledge and skill sets covered in this training. The training may offer new insights and new approaches to challenging clients, and will offer opportunities to practice skills in a safe learning environment. Learning Objective 2Gain skills that would enhance the movement towards growth and change

How do I convince him to accept help?

Learning Objective 3Gain skills that would minimize the fear of change.

How do Iminimize hisfear of change?

Learning Objective 4Remember the basic tenets of self-care for helpers.

How do I manage my own frustration?

Remember the old joke: How many social workers does it take to change a light bulb?Only one, but the light bulb has to really want to change!10One of our major problems in this field of protective care has been that our goals have not been clear, nor generally acceptable; nor its extent and complexity known; nor have there been norms or standards upon which to base program objectives

Mildred Barry at the 1960 Arden House Conference on Aging as quoted by Georgia Antesberger at the International Elder Abuse conference in 2008Unique Challenges of APSNote that this comment was allegedly made in 1960.Antesberger suggests that 50 years after Mildred Barrys comments:

Challenges Continued.Vague problem definition in law and researchLack of national prevalence dataPublic skepticism about APSLack of a federally enforced model or universally applied practice standardsInadequate funding in most statesQuestionable APS effectivenessFrequent isolation of APS workersResearch is being done, which may lead to practice standards - but we still have a long way to go (National Adult Protective Services Association NAPSA, National Center on Elder Abuse NCEA, Center on Abuse and Neglect of the Elderly CANE)

13Resistance: What is it?A natural response to change

Resistance is triggered by anxiety/fear - conscious or unconscious

A vitally important communication of a part of the clients problems and often can be used as an opening into their defenses According to Milton Erickson

Resistance as natural-we seek the familiar, in order to organize our lives, give us security. Any change causes some loss of the familiar.Ask: What does this quote mean to you? Ask-How do you know someone is resisting your efforts?What does resistance look like?Resistance can include:

Overt hostility/refusal Diverting to another topic/issue Passive agreement with no action Taking action, but sabotaging the results What else have you encountered?

15The more pejorative the helper is to resistance, the more resistant the person will become.

Uncontrolled pain may contribute to resistance.

The ways resistance is shown is affected by culture

Contributing factors to resistanceUncontrolled pain-cant think beyond the discomfort. Chronic pain contributes to sleep deprivation, nutritional problems, which can impact cognitive functioning Cultural issues: In cultures in which people defer to authority, client may agree with SW, but not act the plan suggested. This is not passive aggressive, but a way of demonstrating respect and avoiding direct conflict. ACTIVITY: My most difficult clientStep 1Step 2Step 3Step 4Identify your most difficult client.

Write about the interventions you have tried. Do not write on the back.

Exchange forms with a neighbor and complete the back. Return the forms to original author. Read the back and then debrief with trainer.

Biopsychosocial Assessment Trainer's Manual16Purpose of this exercise: to demonstrate skills the participants already have (eg. ability to formulate possible strategies, evaluate the effectiveness of interventions, communication skills)Ask: What kind of clients are considered difficult? What strategies didnt work? Which ones did? 17Characteristics of a Difficult Person:Experience reality differently than you doMake untrue accusationsBlame you for things that arent your faultCriticize you all the timePut you in a no-win situationDeny the effects of their behaviors on family members

Ask what other characteristic make a person difficult18Working effectively with a difficult clientAsk yourself, What does difficult mean?

Re-examine our expectations of others

If we are defining a client as difficult we need to look at our expectations of that clients behavior.If the client was cooperative, s/he likely would not be an APS client. APS gets difficult/challenging clients that other agencies/people dont know what to do with.

The KeyTo help a difficult person accept change, we must first change ourselves

The way we see the personThe way we view our responsibilitiesThe ways we respond to the familiar provocationsThis is the good news, because we actually have control over our own behavior and responses. Ask: How many of us have heard of strength-based practice What does that mean?Do we truly believe in strength-based practice? Do we apply it to ourselves?20Trouble can lead to patiencePatience can lead to enduranceEndurance can lead to professional /personal developmentProfessional/ personal development can lead to hopeProfessionalism & ProblemsProfessional maturity is more than time in the practice. It means the capacity to continue to use what we experience to cultivate wisdom and to develop the unshakeable belief that change is possible (hope).21Anger definedAnger is an emotionEmotions are feelings so they reflect a change in both our biological and psychological stateHostile aggression refers to behavior

The outward expression of anger is generally initiated by fear-the fear of physical or emotional harm or that something will be taken away.What happens physiologically when someone experiences anger? Adrenaline starts to pump, respiration/heart rate/blood pressure go up, the body is readying to take action (fight or flight). 22Anger is functional when it is in the right proportion, expressed in a constructive way and with low arousalIntense anger may become harmfulHigh levels of chronic anger and aggressive behavior can be harmful: higher mortality and coronary heart disease

Anger can be addictive-note how the physiologic responses to anger parallel the use of uppers/meth. Chronically angry people can learn constructive ways of managing through anger management techniques.

23Disturbed vs. Adaptive AngerDisturbed anger:Adaptive anger:Purpose is to punish/intimidatePurpose is to correct/restore the situationElement of retaliation, intention to hurt the otherThere is no malice, hatred, etc.Expression is delayed or sustained long after the incidentExpression follows close to the time of the