HOW DO WE ENGAGE FAMILIES AND YOUTH: A Critical Component of Treatment Success

Transcription

1 HOW DO WE ENGAGE FAMILIES AND YOUTH: A Critical Component of Treatment Success Phillippe B. Cunningham Family Services Research Center Department of Psychiatry and Behavioral Sciences Medical University of South Carolina

2 GOALS 1. Review the importance of family engagement in Mental Health and Social Services. 2. Describe factors that contribute to family engagement. 3. Provide practical strategies and suggestions for Social Workers to enhance family engagement.

3 Martin Luther King, Jr. once said: Every man must decide whether he will walk in the light of creative altruism or the darkness of selfishness. This is the judgement. Life s most persistent and urgent question is, what are you doing for others?

4 Randomized Trial with Substance Abusing/Dependent Offenders (N=118): MST vs. Community Treatment (Henggeler et al., 1999, NIDA) Engagement and Retention in Treatment 98% (57 of 58 MST families) treatment completion (4 months)

5 Always seek good advice...

6 The situation confusing.

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8 We don t know one millionth of one percent about anything Thomas Edison

9 ENGAGEMENT: THE START OF SOMETHING GOOD

10 ENGAGEMENT DEFINED Broadly: An active process whereby the professional and an individual make a commitment to work together to accomplish mutually agreed upon goals.

11 Engaging Families in Treatment/Services I. Signs of Engagement 1. Attendance 2. Decreased Negativity 3. Trust 4. Agreement on Goals 5. Active/Emotional Involvement 6. Follow Through II. Signs of Disengagement 1. Missed Appointments 2. Expressed Blame and Negative Affect 3. Distrust 4. Lack of Agreement 5. Avoidance

12 Multiple Levels of Engagement Recruitment Initial attendance Retention Therapy Process Treatment acceptability Therapeutic relationship Group process (Lau, Ho, Webster-Stratton, & Reid, 2010) Parent participation

13 Problems Associated with Poor Engagement Child Welfare Only 10-22% of mothers involved in child welfare with substance abuse problems complete mandated treatment. Mental Health and Substance abuse Treatment Inpatient/outpatient SA drop out rates range from 17-74% Anywhere from 30-75% of referred children either fail to initiate treatment or drop out. One factor that accounts for the largest variance in treatment dropout is problems with the therapeutic relationship Health Adherence to treatment recommendations in pediatric asthma in one study was only 58%. Non-compliance rates across acute and chronic pediatric medical conditions is around 50%. Non-Adherence to ART has been estimated between 40-85% Attrition rates high as 45% have been reported in family-based weight loss interventions for minority adolescents Costs of medical non-adherence has been estimated to be $100 billion a year Criminal Justice Approximately 50 to 70 percent of probationers and parolees fail to comply with their release conditions (e.g., drug testing, attendance at drug treatment, avoidance of criminal activity)

14 WHY IS FAMILY ENGAGEMENT SO IMPORTANT TO YOUR WORK? Wastes time, effort, and money No shows decrease cost-effectiveness as missed appointments decrease your productivity Cause an increase in unit costs of services Failure to adhere perpetuates problems Predictive of worse outcomes Results in problems getting worse Victim Blaming It steals your Joy!!! IF YOU ENJOY WHAT YOU DO YOU WON T WORK A DAY IN YOUR LIFE

15 Poor Engagement is Not Just a Mental Health Problem HOW MANY OF YOU RIGHT NOW ARE NOT FOLLOWING YOUR DOCTOR S RECOMMENDATIONS?

16 Poor Family Engagement is a Problem at Multiple Levels Poor Engagement Parent Factors Professional/ Clinician Factors P x T Interactions

17 Factors that Contribute to Poor Engagement

18 PARENT FACTORS Practical/Concrete Challenges Low Social Support Parenting Skills Commitment to Parenting Poor Bond/Attachment Parent Engagement Parenting Knowledge/Beliefs Substance Use Psychiatric Problems Marital Difficulties

19 Does This Look Familiar?

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21 PARENT FACTORS continued Negative Emotion History of 10,000 defeats Parent s Story About the History I Won t Parental Resistance (Avoidance) Homework Parent Pathology I Can t Social Disadvantage Depressive Antisocial Stress Education (Patterson & Chamberlain, 1992) Occupation

22 CLINICIAN FACTORS Relationship Factors Warmth Genuineness Honesty Humor Self-confidence Empathy Provides Hope Understanding Skill Factors Collaboration Elicit Concerns Perspective Taking e.g. regarding barriers, potential barriers Word Choice Praise Use of existing Strength Flexibility Attendance to caregiver reaction Directive Solution-focused Structured Modeling

23 CLINICIAN FACTORS continued Amount and Type of Supervision Number of Hours Direct Observation Old African Adage: Until Lions have their own historians tales of hunting will always glorify the hunter.

24 Parent x Clinician Interactions When their stuff meets your stuff!!!

25 STRATEGIES TO ENHANCE FAMILY ENGAGEMENT

26 EMPIRICALLY SUPPORTED FAMILY ENGAGEMENT STRATEGIES McKay et al. (2004) 1. Clarification of roles 2. Setting the foundation for collaborative working relationship 3. Identification of concrete, practical issues that can be immediately addressed 4. Development of a plan to overcome barriers to ongoing involvement with the agency

27 EMPIRICALLY SUPPORTED FAMILY ENGAGEMENT STRATEGIES continued Strategic Structural Systems Engagement (Szapocznik & Kurtines, 1989) 1. Use structural and strategic family therapy principals to understand and address engagement 2. Joining and restructuring techniques a. Thoroughly joining b. Establishing alliances c. Advising the caller about negotiating and reframing strategies d. Joining family members other than the caller e. Conducting out-of-office visits to family members or SO who are critical to Tx process

28 PRACTICAL STRATEGIES TO ENHANCE FAMILY ENGAGEMENT

29 GENERAL GUIDELINES FOR ENGAGEMENT AND PERSUASION OF CAREGIVERS (MST) 1. Invite caregiver(s) to collaborate with you to discuss goals and suggestions for interventions instead of presenting yourself as the expert. Ask them for their suggestions. 2. Let the caregiver(s) know that you would like them to discuss their concerns with you about a suggestion that you have made as soon as they realize that they have concerns. 3. Make sure that you fully understand the caregiver(s) perspective on childrearing, before you provide suggestions. 4. When you talk with caregiver(s) about parenting strategies and you provide them with suggestions, chose your words very carefully and consider the impact of your words ahead of time. 5. Ensure that you project ongoing warmth and positive affect during all interactions with the caregiver(s)

30 GENERAL GUIDELINES FOR ENGAGEMENT AND PERSUASION OF CAREGIVERS continued 6. Develop interventions for the caregiver(s) based on their strengths. 7. Before you meet with the caregiver(s), think specifically about what you are going to say to them. 8. Be ready to be flexible with your suggestions, so that you can tailor your suggestions to the needs of the caregiver(s). 9. Be an astute observer of the caregiver(s) reactions to you while you are talking with them, so that you can mentally hypothesize about their unspoken feelings. 10. Develop interventions that are based on the factors that have contributed to the problem behaviors that you ve observed. 11. For caregiver(s) who seem reluctant to try your suggestions no matter how you have presented these to them, do not keep giving them the same suggestions over and over. 12. Be sure to follow-up after you have made suggestions to discuss what happened with the caregiver(s) when they tried your suggestion

31 Core Interpersonal Skills That Can Facilitate Engagement 1. Strength-Focused 2. Reflective Listening 3. EMPATHY* 4. Hope and reinforcement 5. Reframing 6. Authenticity, Warmth, and Flexibility 7. Preparing Families for Disengagement 8. Maintain a Family Focus 9. Value the Family s Culture 10. Maintain Productive Communication 11. Scientifically minded

32 Ways to increase engagement Give Good Initial Rationale (Ask-Tell-Ask) Collaborative language in developing the intervention (emphasizing you statements) Provide rationale First sentence of rationale (vague versus specific; tied to caregiver s goals; language consistent with caregiver s expectancies) Listening/looking for ambivalence and inquiring (I think you may have reservations) Clarification of parent s point of view OARS, rolling with resistance, eliciting and reinforcing change talk (MI)

33 OARS (Borrowing from MI) Open-questions (elicit exploration of topics)- AVOID ASKING QUESTIONS LIKE A PROSECUTOR Affirmations/Appreciations (focusing on client strengths, efforts, patience, etc.) Reflections of client point of view (nondirective, then directive) Summarize (capture essence, link topics, transition conversation)

34 Reflective Listening: Borrowing MI Repeating simply repeating an element of what the client has said Rephrasing substitutes synonyms or slight rephrases, while keeping the same message Paraphrasing clinician infers meaning and adds to/extends what has already been said Reflection of feeling emphasizes the emotional dimension through feeling statements, metaphor, etc.

35 Complex Reflections You re tired of people telling you what to do. [Client s true meaning] On the one hand, you really want your son s behavior under control, and on the other hand, it s a big pain to keep track of so many things. [double-sided] You re disappointed when you miss out on things like spending time with your friends. [client feeling] You really want to make this change so that your son will do better. [importance] You can t imagine ever being able to make these changes. [amplified] Taking your medication is like forcing yourself to eat brussel sprouts [metaphor/simile] You ve only had a few really minor difficulties as a result of your drinking. [minimizing]

36 PEOPLE DON T CARE WHAT YOU KNOW UNTIL THEY KNOW THAT YOU CARE

37 Roadblocks to Active Listening What NOT to do! Do not persuade, give advice, command, warn, preach, label, analyze, reassure, or agree Do not raise your voice at the end, turning a reflection into a question Do not use a judgmental, accusatory, sarcastic, OR eager tone of voice Do not overuse the same stem (e.g., It sounds like ) Do not change the subject Do not worry about making too many reflective statements it s impossible!

38 Affirmations Providing reinforcement for clients positive ideas, expressing appreciation for their efforts, and supporting their self-efficacy help to increase their confidence in their ability to make a change Role Play Counselor finds specific statements or behaviors to reinforce

39 Examples of Analogies/Metaphor A mother is a vise that keeps a family together A dad is like a machete who clears a way of life for his children through the jungle of the city." Parenting teens is like an extreme sport... A new sport for the Olympics: Extreme Parenting Children are like diamonds-parents need to chip away carefully at the hard edges of the diamonds to see their beauty. Of course, hard diamonds are very valuable. Teaching children is like flossing your teeth: You have to keep doing it over and over to get long-term results.

40 Using Analogies/Metaphors Think of praising and playing with children as building up your bank account. You have to keep putting something in all the time-only then will you have something to draw on when you need it. Grounding and other forms of discipline will not work unless there is a bank account of positive resources to draw from. In fact, sending a kid to their room from an aversive relationship may actually be reinforcing.

41 Even More Examples of Analogies/Metaphor Arguing and reasoning with a child when he is noncompliant and angry is like throwing gas on the flame. Monitoring kids means keeping your radar antennae up at all times, so that you know where your child is and what he or she is doing. That way, you can spot potential problems before they develop. Antennae are important not only so that you can assure yourself that your child is not in trouble, but also so that you can spot positive behaviors that need to be reinforced. Our work is about helping you develop new tools. Tools are something you use for specific purposes. When you have a new purpose, you reach for a new tool. If a better tool comes along, you drop the old one and use the new one.

42 Summaries It is important to pause and summarize what the client has been saying to reinforce positive points and make sure that you aren t missing anything Counselor Summarize what the speaker said regarding his/her desire, ability, reasons and importance of making the change. Then ask, So what do you think you ll do (and listen with interest!)

43 Borrowing from MI Part II: Change Talk is an Important Factor in Change Client Centered: OARS Directive: Change Talk

44 Categories of Change Talk Change talk is the most important component **The goal of MI is to elicit & reinforce change talk. Desire to change I really want to do a better job I wish I could do it, but I don t know how Ability to change I think I could do it if I tried That sounds like something I could do Reasons for change I m sick of losing my job It scares me when I feel out of control

45 Categories of Change Talk (cont.) Need to change If I don t make a change, I guess I could die I have to stop missing so much school/work Commitment to change I ve decided that I ll try it I m going to start taking my medication regularly Taking steps I ll ask my wife to come to counseling with me I m going to ask my doctor about the nicotine patch

46 Eliciting Change Talk Exploring current situation, client s point of view Looking backward Considering importance of situation, dilemma Exploring values and value-behavior congruence Looking forward - hopes, dreams Considering pros and cons of change (decisional balance) Considering importance of change (ruler) Considering confidence past successes, strengths, supports Planning and committing to specific change attempt

47 The Staging Ruler On a scale of 1 10, how important is making this change to you? Why did you choose 5, and not 2? What would it take to move you from 5 to 7? On a scale of 1 10, how confident are you that you could make this change if you decided that you wanted to?

48 The Decisional Balance What are the good things about the status quo (e.g., drinking, eating junk food, not taking meds, etc.) What are the not-sogood things about the way things are now? Always ask about the reasons not to change FIRST!

49 Rolling With Resistance Resistance arises from the interpersonal interaction between therapist and client, not some personality flaw of the client!!! Therapy should be a dance, not a wrestling match Ways to handle resistance effectively include: Simple reflection, amplified reflection, doublesided reflection, shifting focus, reframing, emphasizing personal control, and siding with the negative

50 Offering Advice Ask Permission If you re interested, I have an idea for you to consider. Would you like to hear it? If you d like, I can tell you about some things that other people have tried successfully. Would that be okay? Offer Advice Based on my experience, I would encourage you to consider. Given what you ve told me so far, I think you might have some success if you tried.

51 Offering Advice (cont.) Emphasize Choice And I recognize that it s your choice to do so. Of course you know best what will work for you. Voice Confidence I m very confident that if there comes a time when you make a firm decision and commitment to, that you llfind a way to do it. I strongly believe that you could accomplish if you put your mind to it. Elicit Response What do you think about that idea? I m interested in hearing your thoughts about this idea.

52 In simplest form, the implicit theory of MI posits: MI will increase client change talk MI will diminish client resistance The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change The extent to which clients verbally argue for change (change talk) will be directly related to behavior change **

53 Summary: MI Principles Express Empathy!!! a la Carl Rogers Avoid Argumentation Client should never be in the position of arguing for the status quo Roll with Resistance Underscored by psychological reactance Develop Discrepancy Dissonance person becomes motivated to reduce discrepancy Support Self-Efficacy Builds on expectancy theory increasing confidence increases intent to behave

54 Interpersonal Strategies Comment on process: I m aware of myself starting to get locked into trying to persuade you of something, but I have a feeling that I m not going to be able to. It seems to me like you re feeling kind of skeptical. Is that true? I d like to spend a little bit of time trying to understand what s going on between us right now. Somehow I imagine that nothing I might say will seem meaningful to you. I feel like it would be easy for me to say something that would offend you. I have an imagine of the two of us fencing. I m aware of feeling cautious in what I say to you, as if I could easily say or do the wrong thing. Does that feedback make any sense to you? What is it that you see me doing that gives you that impression. I have an image of you weighing what you tell me. It sounds to me like you re feeling kind of cynical and not to hopeful about

55 Putting it All Together MI Assessment sandwich concept: MI strategies during opening 20 minutes Agency intake assessment MI strategies during closing 20 minutes

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57 St. Ignatius of Loyola once prayed: Teach us to be generous, good Lord; Teach us to serve you as you deserve; To give and not to count the cost, to fight and not heed the wounds, to toil and not seek to rest, to labor and not ask for any reward save that of knowing we do your will.