HOW TO FACILITATE CHANGE WITH DIFFICULT CLIENTS

KIMBERLY R . BECK, M.ED. LPC, CRAADC, CCJP, CCDP-D

REGIONAL SOCIAL SERVICES DIRECTOR, MIDLAND DIVISION

YOU CAN’T HELP ME!

INTRODUCTION

Masters Degree in Counseling – Boston University

Bachelor of Science in Psychology – University of Maryland

Doctoral Candidate in Counseling –University of Missouri St. LouisEmphasis Areas

AddictionMarriage and FamilyCrisis InterventionVeteransHomelessAt- Risk YouthProfessional Development

LEARNING OBJECTIVES

ARTICULATE BEHAVIORAL PATTERNS AND CHARACTERISTICS OF PEOPLE WHO TEND TO BE RESISTANT/DIFFICULT

EXPLAIN COMMON RESPONSES TO DIFFICULT CLIENTS AND ARTICULATE MORE EFFECTIVE RESPONSES TO THAT BEHAVIOR

EVALUATE STRATEGIES COUNSELORS/CASE MANAGERS CAN USE TO EFFECTIVELY COUNTER THE DIFFICULT BEHAVIOR AND DISENGAGEMENT

PRACTICE UTILIZATION OF STRATEGIES THROUGH ROLE PLAY IN SMALL GROUPS

REALITY CHECK

Professional Development Training is often delivered via a one-time clinical workshop.

Is it realistic to believe that practitioners will actually acquire skillfulness through such training?

Study by William Miller ant Kathy Mount () suggest the following: -on paper and pencil measures participants reported large

increase in skills - observational measures reflected more modest changes in

practice -clients did not show the responses changes that were found

to be predictive of better outcomes of the skill attainment

PRE-TEST

1) Gather information about your knowledge of the topic prior to participating in the training

2) To call your attention to topic areas prior to participation in the training

3)Wake you up after lunch by scaring you half to death!

Please take a few minutes to complete this and do not share answers with your neighbors

Ice-Breaker

Your NameYour PositionYour LocationDescribe your most challenging clientTell us what you want from this training

What Makes A Case Difficult?

Diagnostic dilemmaPoor prognosisMultiple problemsLack of interagency coordinationInvoluntary participationLack of ProgressMalingering and Deception

What Makes A Case Difficult?

Imminent dangerCultural competency gapsConflicting ethical principalsEligibility limitationsLimited resourcesUnacceptable client expectations

Natural Categories of Difficult Cases

Challenges to the professional’s skillChallenges to the professional’s personalityUnmatched expectationsSystem issues such as eligibility and

coordination problemsPhysically dangerous clientsLegally dangerous clientsSocially dangerous clients

Six Categories of Intervention

A. Authoritative CategoriesA. i. Prescriptive interventionsB. ii. Informative interventionsC. Ii. Confrontational interventions

B. Facilitative categoriesi. Cathartic interventionsii. Catalytic interventionsiii. Supportive interventions

Degenerate Types of Interventions

1) Unsolicited2) Manipulative3) Compulsive4) Unskilled

Degenerate Classes of the six categories

Authoritative categories Prescriptive Degeneration

Benevolent take-over Moralistic oppression

Informative Degeneration Seductive over-teach Oppressive over-teach

Confronting Degeneration Sledgehammer Smiling demolition (the smiler)

Degenerate Classes of the six categories

FacilitativeCathartic Degeneration

Encouraging dramatisation Nut cracking (too deep too soon)

Catalytic Degeneration Implicit take-over (the compulsive search for order) Scraping the bowl

Supportive Degeneration Moral patronage (or your character is coming along nicely) Qualified Support

I JUST WANT TO HELP YOU!

Why are clients difficult and resistant when all we are trying to do is help them?

Why do some clients come in for help with the attitude or notion that “ You can’t help me!” “Resistant client behavior seems …to conform to

Newton’s third law of motion: For every force there is an equal and opposite counter force. In a mode in which overcoming resistance potentially becomes a contest, the client will often win.” Cowan and Presbury, 2000, p. 412

I JUST WANT TO HELP YOU!

“ We tell our clients things like, ‘You can’t change other people; you can only change yourself.’ Then we go into a session trying to change our clients. This is hypocritical. I teach, You can’t change your clients. You can only change how you interact with your clients and hope that change results. That’s all you get” Clifton Mtichell – Effective Techniques for Dealing

With Highly Difficult Clients

Who’s Who of Difficult Clients

Intimidating clientsCritical clientsRageful clientsThreatening clientsAutonomous clientsActing-out clients

Who’s Who of Difficult Clients

Wealthy, influential clientsAngry victim with cultural or gender

differencesUncooperative clientsPassive-Aggressive clientsMistrustful clientsUnempathic clients

Reasons Clients Are Resistant

FearFear of FailureFear of SuccessFear of taking riskFear of changeManipulationPassive-aggressive behaviorShameJealousy or desire to sabotage the

relationship

Reasons Clients Are Resistant

ExhaustionA personality styleLack of optionsCultural and value differencesOver-reactionImpaired by chemicals or catastrophic mental

illnessEmotional paralysisLimited approachesNeeds are met

Reasons Clients Are Resistant

Conflict gains attentionIgnoranceThe familiarity trap

Let’s Try A Reframe

Creating Lasting Change

People rarely change because of the logic of the situation; people change when they have an emotionally compelling reason.

Clifton Mitchell

The Therapeutic Alliance

The counselor client relationship is key to helping the client move forward. Clients are less resistant if they feel connected to the counselor. If the client will not disclose their inner wants, actions, feelings and thinking, change is very difficult.” Robert Wubbolding- Director of Training William Glasser Institute

It’s All About You!

Start with self-awarenessUnderstand the concept of changeSharpen the Saw (Practice, Practice,

Practice)

General Principles for Dealing with Resistance

Do the UnexpectedSlow the Pace, Focus on the Details, Process feelings

relative to meaningTreat Clients’ Resistance with RespectMaintain an Attitude of Naïve PuzzlementNever Label Clients with Terms that Imply

ResistanceFocus Where Clients Are StuckFrame All Desires in the PositiveIf they are not confused, Confuse themResist the Urge to confront Initially

• CLIFTON MITCHELL

11 Solutions For Counseling Difficult Clients

Eliminate the Power struggleFeed Your Clients Therapeutic Big MAC’sTeaching is CounselingStop Believing In Denial Use Strengths to Compensate for DeficitsMotivation Is the Key to ChangeGive Your Clients A Million DollarsParadoxical InterventionsBring In OthersHealthy ModelingLet the Train Wreck Happen

• RICHARD K NONFARD

FRAMES

Feedback is given to the individual about personal risk or impairment.

Responsibility for change is placed on the participant.

Advice to change is given by the provider.Menu of alternative self-help or treatment

options is offered to the participant. Empathic style is used in counseling. Self-efficacy or optimistic empowerment is

engendered in the participant.Source: Miller and Sanchez, 1993

Motivational Enhancement Techniques

Ask Open Ended QuestionsUse AffirmationsUse Reflective Listening, Reframing, Roll

With ResistanceSummarizing

Closing Thoughts

How does a therapist (case manager) position himself or herself to work with reluctant clients? How does he or she react to clients who potentially challenge his or her sense of power, confidence, and effectiveness as a therapist (case manager)? (Wessler, Hankin &Stern, 2001)

Self-awareness/reflection, education/training, practice, practice, practice, feedback/evaluation….continually

Let’s Practice

Group Work

Post -Test

Demonstrate an understanding of the material presented in the workshop

Officially document your participation in the workshop

Freak you out at the end of the workshop!

Resources

Succeeding With Difficult Clients –Applications of Cognitive Appraisal Therapy - Wessler, Hankin & Stern

A Small Study of Training in Motivational Interviewing: Does One Workshop Change Clinical and Client Behavior? Miller and Mount

Managing resistant Clients – Lynne Shallcross , Counseling Today February 2010

11 Solutions for Counseling Difficult Clients, Richard K. Nongard

Effective Techniques for Dealing With Highly Resistant Clients, Clifton Mitchell, 2006

Heron, J (2001) (5th ed) Helping the client – a creative practical guide.

Contact Information

Kimberly R. Beck314-646-3154 work314-960-2530 cellKimberly_Beck@usc.salvationarmy.org

Thank You!!!!!!!!!!!!!!!!!