Trust & Engagement
with
Challenging Clients
John DeCostanza, MSW
Staff Therapist
Community Counseling Centers of Chicago (C4)
Why Engagement?
• Objective Focused
– Obtaining Facts
• Thorough history
• Presenting Problem
• Risk and Resilience Factors
• Establishing Relationship
– Trust
• Antecedent for rest of your work
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)
What is Engagement?
SEVEN THEMES
1.
2.
3.
4.
5.
6.
7.
Common & clear goals together
Sense of hopefulness
Awareness, acknowledgement, and
understanding of situations accurately (by all
parties)
Consistent motivation
Need for workers (attorneys) to identify,
understand, and respect cultural differences
Truth, honesty, and respect
Persistence, diligence, and timely work done
by all
(Cooper Altman, 2008)
Who?
Your
Ct Population
Barriers to Engagement
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 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
First 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.
Challenging Clients &
Motivational Interviewing
Motivational Interviewing
Definition: A collaborative, personcentered form of guiding to elicit and
strengthen motivation for change.
Highlights: interpersonal; client is the
locus of change & motivation; purpose
is CHANGE
Challenging Clients &
Motivational Interviewing
• 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
Challenging Clients &
Motivational Interviewing
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
Challenging Clients &
Motivational Interviewing
Responding to RESISTANCE:
STOP
Teen: “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
Challenging Clients &
Motivational Interviewing
• 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.
Challenging Clients &
Motivational Interviewing
• 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?
Recommendations
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 = CHANGE
4. 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 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)
Service 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
Service 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
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)
Contact Information
John DeCostanza, MDiv MSW
Community Counseling Centers of Chicago (C4)
2542 W. North Ave.
Chicago, IL 60647
Phone: 773.365.3003
Email: john.decostanza@c4chicago.org