trust & engagement with challenging clients john decostanza, msw staff therapist community...

Trust & Engagement with

Challenging Clients

Trust & Engagement with

Challenging Clients

John DeCostanza, MSWStaff Therapist

Community Counseling Centers of Chicago (C4)

John DeCostanza, MSWStaff Therapist

Community Counseling Centers of Chicago (C4)

Why Engagement?Why Engagement?

• Objective Focused– Obtaining Facts

• Thorough history • Presenting Problem• Risk and Resilience Factors

• Establishing Relationship– Trust

• Antecedent for rest of your work

• Objective Focused– Obtaining Facts

• Thorough history • Presenting Problem• Risk and Resilience Factors

• Establishing Relationship– Trust

• Antecedent for rest of your work

What is Engagement?What is Engagement?

• Interactional, interpersonal process that begins at time of first contact with an agreement to work together (Compton & Galway, 1994)

• Clinical outcome in the literature (Litell, Alexander, & Reynolds, 2001)

• “dynamic, complex, multilevel phenomenon” or “positive involvement in the helping process” (Yatchmenoff, 2005)

• Interactional, interpersonal process that begins at time of first contact with an agreement to work together (Compton & Galway, 1994)

• Clinical outcome in the literature (Litell, Alexander, & Reynolds, 2001)

• “dynamic, complex, multilevel phenomenon” or “positive involvement in the helping process” (Yatchmenoff, 2005)

What is Engagement?SEVEN THEMESWhat is Engagement?SEVEN THEMES

1. Common & clear goals together2. Sense of hopefulness3. Awareness, acknowledgement, and

understanding of situations accurately (by all parties)

4. Consistent motivation5. Need for workers (attorneys) to identify,

understand, and respect cultural differences6. Truth, honesty, and respect7. Persistence, diligence, and timely work done

by all(Cooper Altman, 2008)

1. Common & clear goals together2. Sense of hopefulness3. Awareness, acknowledgement, and

understanding of situations accurately (by all parties)

4. Consistent motivation5. Need for workers (attorneys) to identify,

understand, and respect cultural differences6. Truth, honesty, and respect7. Persistence, diligence, and timely work done

by all(Cooper Altman, 2008)

Who?Who?

Your Ct Population

Your Ct Population

Barriers to EngagementBarriers to EngagementMany families come…because a crisis has forced the issue,

or an agency or court has mandated it. Motivation is uneven… They show up irregularly, mostly when new crises erupt. In sessions, they have trouble presenting their stories coherently. They seem in disarray as they talk over one another or talk hardly at all. Some have described these families as disorganized; I prefer the term underorganized.

Underorganization suggests not so much an improper or randomly chaotic organization as a lack of organization, a structure that has not fully developed. These structures have not achieved the constancy, differentiations, and flexibility they need to meet the demands of life.

Harry Aponte, Bread and Spirit: Therapy with the New Poor: Diversity of Race,Culture, & Values, 1994 p. 17

Many families come…because a crisis has forced the issue, or an agency or court has mandated it. Motivation is uneven… They show up irregularly, mostly when new crises erupt. In sessions, they have trouble presenting their stories coherently. They seem in disarray as they talk over one another or talk hardly at all. Some have described these families as disorganized; I prefer the term underorganized.

Underorganization suggests not so much an improper or randomly chaotic organization as a lack of organization, a structure that has not fully developed. These structures have not achieved the constancy, differentiations, and flexibility they need to meet the demands of life.

Harry Aponte, Bread and Spirit: Therapy with the New Poor: Diversity of Race,Culture, & Values, 1994 p. 17

Barriers to EngagementBarriers to Engagement• Multiple needs

– Trauma hx, violence– Other legal involvement, family hx

• Limited effective coping skills• Maladaptive patterns• Internalizing Disorders

– Low motivation, poor self-narrative, high levels of relational conflict, fear, anxiety, sadness, hopelessness

• Externalizing Disorders– All of the above PLUS impulsivity, outwardly

directed anger (aggression), running, etc.

• CULTURE, CULTURE, CULTURE

• Multiple needs– Trauma hx, violence– Other legal involvement, family hx

• Limited effective coping skills• Maladaptive patterns• Internalizing Disorders

– Low motivation, poor self-narrative, high levels of relational conflict, fear, anxiety, sadness, hopelessness

• Externalizing Disorders– All of the above PLUS impulsivity, outwardly

directed anger (aggression), running, etc.

• CULTURE, CULTURE, CULTURE

First ContactFirst Contact• The Antecedents

– Office set-up; Behavior in the waiting room; Snacks or candy; Documents at the ready; YOU, YOU, & YOU

• The Tool(s)– GAL Cases Background Info Form– Confidentiality (e.g. - Adolescents)

• The Interview– Narrative is a portrait of cognitive process,

mental state, and risk factors.

• The Skills– Necessary to integrate each of the above and

utilize ct’s language to clearly echo back the problem.

• The Antecedents– Office set-up; Behavior in the waiting room;

Snacks or candy; Documents at the ready; YOU, YOU, & YOU

• The Tool(s)– GAL Cases Background Info Form– Confidentiality (e.g. - Adolescents)

• The Interview– Narrative is a portrait of cognitive process,

mental state, and risk factors.

• The Skills– Necessary to integrate each of the above and

utilize ct’s language to clearly echo back the problem.

Challenging Clients & Motivational InterviewingChallenging Clients & Motivational Interviewing

Motivational InterviewingDefinition: A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

Highlights: interpersonal; client is the locus of change & motivation; purpose is CHANGE

Motivational InterviewingDefinition: A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

Highlights: interpersonal; client is the locus of change & motivation; purpose is CHANGE


• Guiding Skills - OARS– Open-ended questions– Affirmations – Reflections

• Double-sided reflections with adolescents– Highlight ambiguity: “On the one hand… on the other”

• Intensity - reflecting emotions requires precision “a little sad” vs. “totally depressed”

• Metaphors & Similies - always best if they come from the client, but occasionally you’ll be able to paint the picture.

• Drop the stem - particularly avoid naming feelings “It seems like what you are feeling is…”

– Summaries

• Guiding Skills - OARS– Open-ended questions– Affirmations – Reflections

• Double-sided reflections with adolescents– Highlight ambiguity: “On the one hand… on the other”

• Intensity - reflecting emotions requires precision “a little sad” vs. “totally depressed”

• Metaphors & Similies - always best if they come from the client, but occasionally you’ll be able to paint the picture.

• Drop the stem - particularly avoid naming feelings “It seems like what you are feeling is…”

– Summaries


RESISTANCE: A battle of counter-intuition

STOP: Don’t push back or move further

DROP (back…tone it down): Monitor your own behavior (this is about you not the client).

ROLL: Come alongside the client

RESISTANCE: A battle of counter-intuition

STOP: Don’t push back or move further

DROP (back…tone it down): Monitor your own behavior (this is about you not the client).

ROLL: Come alongside the client


Responding to RESISTANCE:

STOPTeen: “Why aren’t you letting me go home with Diamond?”

DROP & ROLL

GAL: “I’m not. This is a result of your decision to live with her in the first place.” Emphasizes personal control.

GAL: “Well, what makes you think that I don’t want you to go home with Diamond?” Redoubling

GAL: “You want me to place with you with Diamond.” Reflection

Responding to RESISTANCE:

STOPTeen: “Why aren’t you letting me go home with Diamond?”

DROP & ROLL

GAL: “I’m not. This is a result of your decision to live with her in the first place.” Emphasizes personal control.

GAL: “Well, what makes you think that I don’t want you to go home with Diamond?” Redoubling

GAL: “You want me to place with you with Diamond.” Reflection


• Strategic responses – Emphasize personal choice and control (ALWAYS)– Pros and Cons (simple lists are powerful tools)– Agreement with a Twist (“I wonder”)

Teen: Everything about school is boring. I don’t learn anything, and I don’t know why I go.

Me: It sounds like you get bored in school every day. I wonder if there’s some way that we can make classes more interesting for you.

• Strategic responses – Emphasize personal choice and control (ALWAYS)– Pros and Cons (simple lists are powerful tools)– Agreement with a Twist (“I wonder”)

Teen: Everything about school is boring. I don’t learn anything, and I don’t know why I go.

Me: It sounds like you get bored in school every day. I wonder if there’s some way that we can make classes more interesting for you.


• Strategic responses continued– Shifting Focus

• Teen: I don’t want to live with Maritza, and I know that’s what you are going to tell the judge.

• GAL: Hold on a minute. I don’t even know the whole story and I especially don’t know all of what you’re going to say. Why don’t you tell me more about your living situation right now?

• Strategic responses continued– Shifting Focus

• Teen: I don’t want to live with Maritza, and I know that’s what you are going to tell the judge.

• GAL: Hold on a minute. I don’t even know the whole story and I especially don’t know all of what you’re going to say. Why don’t you tell me more about your living situation right now?

RecommendationsRecommendations1. Time is what you have and it’s always

well spent on children. (Process)2. Take your shoes off because the

ground that you stand on is often sacred. (Culture)

3. Motivation + Engagement = CHANGE4. When in doubt, go slow, and reflect.5. Utilize consultation - talk to your CVLS

staff attorneys; consult with other professionals who have been working with your clients longer than you.

1. Time is what you have and it’s always well spent on children. (Process)

2. Take your shoes off because the ground that you stand on is often sacred. (Culture)

3. Motivation + Engagement = CHANGE4. When in doubt, go slow, and reflect.5. Utilize consultation - talk to your CVLS

staff attorneys; consult with other professionals who have been working with your clients longer than you.

Service Flow for ADHDService Flow for ADHD

• Manifestation of 1st Symptoms– Age 3; Not really diagnosable until 5-7 years

• ID– Parent– Teacher– Administrative Apparatus (rarely SSW

or Special Ed Services)

• Manifestation of 1st Symptoms– Age 3; Not really diagnosable until 5-7 years

• ID– Parent– Teacher– Administrative Apparatus (rarely SSW

or Special Ed Services)

Service Flow for ADHDService Flow for ADHD

• CPS Levels of Care– Tier I - Universal Supports

• Little $, Support• Reinforces Natural Supports• Eg. Prevention Programs

– Tier II - Targeted Support• Children with specific needs who can be pulled

out and offered services to reinforce coping skills• Eg. NRI Anger-Coping & CBITS

– Tier III - Individual Intervention• Referral to External Agencies for Dx, Psychiatric

services, and continued support• Outpatient Tx

• CPS Levels of Care– Tier I - Universal Supports

• Little $, Support• Reinforces Natural Supports• Eg. Prevention Programs

– Tier II - Targeted Support• Children with specific needs who can be pulled

out and offered services to reinforce coping skills• Eg. NRI Anger-Coping & CBITS

– Tier III - Individual Intervention• Referral to External Agencies for Dx, Psychiatric

services, and continued support• Outpatient Tx

Service Flow for ADHDService Flow for ADHD• Outpatient Tx

– Medical Dx– Individual, Family, & Group Modalities– Psychiatric Services

• Psych Eval followed by Medication Mgmt• Psych Testing (Psychologist)

– Purpose: REDUCTION of symptoms

• Intensive Outpatient (IOP) (PSR “Psychosocial Rehab” for adults)– Regular attendance (multiple sessions weekly)

– Separate Screening Process– Well Regimented Schedule

• Outpatient Tx– Medical Dx– Individual, Family, & Group Modalities– Psychiatric Services

• Psych Eval followed by Medication Mgmt• Psych Testing (Psychologist)

– Purpose: REDUCTION of symptoms

• Intensive Outpatient (IOP) (PSR “Psychosocial Rehab” for adults)– Regular attendance (multiple sessions weekly)

– Separate Screening Process– Well Regimented Schedule

Service Flow Cont.Service Flow Cont.

• Psychiatric Hospitalization– Screening Provided by SASS– Crisis Intervention – Criteria

• Injury or Risk to Self or Others• Inability to Safety Plan• Sxs seem not to respond to current level of care

– 90 Day Brief-Intervention then linkage– Hospitalization: Acute Care (stabilize child

and return family to lower level of fx)

• Psychiatric Hospitalization– Screening Provided by SASS– Crisis Intervention – Criteria

• Injury or Risk to Self or Others• Inability to Safety Plan• Sxs seem not to respond to current level of care

– 90 Day Brief-Intervention then linkage– Hospitalization: Acute Care (stabilize child

and return family to lower level of fx)

Contact InformationContact Information

John DeCostanza, MDiv MSWCommunity Counseling Centers of Chicago (C4)

2542 W. North Ave.Chicago, IL 60647

Phone: 773.365.3003Email: [email protected]

John DeCostanza, MDiv MSWCommunity Counseling Centers of Chicago (C4)

2542 W. North Ave.Chicago, IL 60647

Phone: 773.365.3003Email: [email protected]