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Effective Services for Adolescents

A Collaborative Approach

Presented by: Michael Walsh, Ph.D, LPC, CRC, CPRP Assistant Professor

University of South Carolina School of Medicine

Effective Adolescent Services

Objectives

Conceptualize Adolescent “Resistance”

Understand the Factors Leading to Behavioral Change

Identify Key Factors in Building a Working Alliance

Identify Effective Interventions for Use with Troubled Adolescents

Identity Development: Where Do You Stand?

Role of Resistance in Adolescence

Adolescent’s main role is identity formation (Erickson, 1968).

This involves trying on identities and resisting those that don’t fit (Luyckx, Goossens, Soenens, Beyers, & Vansteenkiste, 2005)

Role of Resistance in Adolescence

The critical first step in identity development is often casting aside established familial and social roles in search of new ones (Cramer, 2001).

Example: TK in Atlanta, BM in Beaufort

Role of Resistance in Adolescence

Resistance is a very natural part of the change process (Prochaska, DiClemente & Norcross, 1992) .

Resistance is actually a great sign that an adolescent has skills that he/she can use!

In a very real sense, resistance is their job!

Physical Considerations

Adolescent Brain Research (White, 2003)

Frontal lobe and other critical structures lag behind in development and efficiency.

Impacted skills are impulse control, emotional decision making, social cue interpretation and planning, among others.

Physical Considerations

Adolescent Brain Research (White, 2003)

Myelin sheath development lags behind in critical structures.

Physical Considerations

Physical Considerations

Homeostatic neuro-efficiency: Feeding what works, starving what doesn’t.

Why DO People Change?

Natural Change- It is now widely accepted that most people change over time without professional assistance—The question is…How long will that take? We can use techniques to speed the process.

Brief Intervention Effects- The research clearly shows us that a little counseling can go a long way.

Why DO People Change?

Faith and Hope Effects- Ask a person how likely it is that they will make a change and the answer is a reasonably good predictor of the likelihood that change will occur.

Counselor Effects- Ask a counselor (or probation officer) how likely is that a client will change and that answer is also a reasonably good predictor (Miller & Rollnick, 2010).

Why DO People Change?

Waiting List Effects- People put on “waiting lists” tend not to improve because there is no expectation of them to do so. On the other hand, those on “waiting lists” that were given self-help materials and encouraged, tended to improve. It all has to do with positive expectations on the part of the professional and the client.

Why DO People Change?

Change Talk Effects- What people say to you about the possibility of change during your appointments is related to whether it will actually occur.

The Question is…What Can We Do to Help That

Happen?

Establishing a Working Alliance

Adolescents as bankers-they can spot phony emotional currency!

They will spot condescension even quicker!

Adolescents consistently report a desire to be treated as an equal in the counseling process (Martin, Romas, Medford, Leffert, & Hatcher, 2006).

Establishing a Working Alliance

Anything that is “their idea” is a better idea—This is as it should be!

The best time to teach an adolescent something is when he or she isn’t looking!

Modeling works!

Establishing a Working Alliance

Research indicates that adolescents report the critical areas of the working alliance are trust, listening and being helpful (Martin et al., 2006, Diamond, 1999).

Autonomy in decision making is critical to the process (DiGuiseppe, 1996).

The most successful clinicians are able to relate to their clients (Spencer, 2006).

Establishing a Working Alliance

In short, it comes down to a question of “buy in” on the part of the adolescent.

This process must be based on the adolescent’s values…not yours!

Successful counselors do not take the role of “expert”, rather one of a co-explorer or facilitator (Biever & McKenzie, 1995).

Establishing a Working Alliance

In allowing a kid to be his or her own best expert, you not only grant the respect that the kid yearns for, but you also send the message: “You can think through this for yourself”. This is at the heart of encouragement and skill building!

Putting it All Together

In sending a message of encouragement and also modeling a belief in the decision-making power of another person, you model an approach to problem solving that many kids don’t see very often. Believe this: They’re watching!

Effective Techniques

OK, we have a decent relationship. Now what? It’s time to work on your skills.

Learn the difference between encouragement and praise.

Examples

Effective Techniques

The importance of a strength-based perspective.ModelingSkill Building Increased “buy in”

Effective Techniques

The power of expectation. Expectations of success tend to lead to success (Robitschek & Hershberger, 2005).

The power of appropriate challenge.Challenges to adolescent freedom

Example-JS

Effective Techniques

The use of humorAbility to laugh at oneself (Hanna & Hunt,

1999).Use of humor in session (Adler, 1959).Therapeutic “wonderment”Humor as indirect communication—This is a

two way street!

Effective Techniques

Whoever made you gave you two ears and only one mouth, which is a gentle hint…listen more and talk less!

Keep it brief. Ask the kid to do the advocating for

change.

Effective Techniques

Use of story and metaphor: planting the seeds. Don’t be afraid to plant a seed and walk away.

Let the adolescent germinate and nurture the idea until it blooms as his or her own.

Story and metaphor can be less threatening ways to approach sensitive issues (Tomkins, Sullivan, & Lawley, 2005).

Effective Techniques

Story and Metaphor (Continued) Reach out for stories and metaphors

meaningful to the folks with whom you are working. In this way, we keep the message culturally relevant.Example: JT and the NBA

Effective Techniques

Acknowledge an effective manipulation. If a client evokes feelings in you, acknowledge them and commend the adolescent on his/her at evoking that emotion in you (Hanna & Hunt, 1999).

Intimidation as a skill.

Wrapping Up

Roll with resistance Focus on strengths Model good problem solving Keep it real Acknowledge apathy

Externalization techniques

The Power of Positive Expectations

If you treat an individual as he is, he will stay as he is, but if you treat him

as if he were what he ought to be and could be, he will become what

he ought to be and could be.

-Johann Wolfgang Von Goethe

Right Vs. Not so Right

What Not To Do…

The Righting Reflex- We all have a tendency to want to fix something that is broken. Consider what happens when someone who is “on the fence” about something (Person A) meets someone determined to set things right (Person B)…

Right Vs. Not So Right

Person B talks about what is right and Person A defends the status quo…

Right Vs. Not So Right

The research is really clear: The more a person argues on behalf of one position, the more he or she becomes committed to that position.

Avoid Questions Like: Why don’t you want to change?How can you tell me you don’t have a

problem?What makes you think you are not at risk?

Rolling With Resistance

How Do We Do That?

Simple Reflection- Sometimes the response is to simply reflect the thought back to the client.

For example: “I’m trying! If my probation officer would just get off my back, I could focus on getting my life in order!”

Response: “You’re working hard on the changes you need to make.”

Rolling With Resistance

Why Does it Work?

This de-escalates the situation. It also shows that you are actively listening to the client and builds trust.

Rolling With Resistance

Amplified Reflection- Sometimes it helps to reflect back what the person has said in an exaggerated form.

For Example: “I can take care of myself, I don’t need my parents checking up on me”

Response: “So you might be better off without parents”.

Important: In order for this to work, it is important that these reflections be done in a supportive, straight-forward, matter of fact, non-sarcastic manner!

Rolling With Resistance

Double Sided Reflection- This approach captures both sides of ambivalence and can be particularly effective.

For example: “I don’t smoke any more than my friends. What’s wrong with a joint now and then?”

Response: “I can see how this is confusing for you. You’ve told me how you’re concerned about your smoking and how it affects you and also it seems like you are not using any more than your friends do. Hard to sort it all out!”

Rolling With Resistance

Why Does it Work?

You are demonstrating you understand that change is a tough decision while communicating your support for the effort. This helps clients to focus on making changes as opposed to defending past choices of behavior.

Other Responses to Resistance

Reframing- Here we are taking the client’s thought and putting a new spin on it for him/her.

For example “I’ve tried to change so many times and failed”

Response “You’re very persistent, even in the face of discouragement. This change must be really important to you.”

Other Responses to Resistance

Why Does it Work?

You are essentially teaching the client how to think in a way that fosters positive change. You are also communicating a positive message about the client’s ability to change. You are building their confidence to pursue change.

Enhancing Confidence

Step Four

Support Self-Efficacy- This is a fancy way of saying “enhancing confidence”. If a person believes he/she can change, he/she is much more likely to change. Supporting this idea is a good thing!

Enhancing Confidence

Asking the Right Questions- Sometimes a well phrased question can help inspire confidence. Open Questions are usually best.

Examples: “How might you go about making this change”?

“What would be a good first step”?

“What gives you some confidence that can do this”?

Enhancing Confidence

Exploring Hypothetical Change- Sometimes if a client is struggling with practical ways to make change, it helps to explore it hypothetically.

Example: Suppose you did succeed and are

looking back on it now: What most likely is it that worked? How did it happen?

Putting it All Together

Four Basic Steps or Principles of MI:

1. Express Empathy

2. Develop Discrepancy

3. Roll with Resistance/Dance with Discord

4. Support Self-Efficacy

Putting it All Together

People Change When They Are

Ready

Willing

Able

Where Can I Learn More?

Why Do They Act That Way?: A Survival Guide to the Adolescent Brain and Your Teen

David Walsh

2005 Atria Books

ISBN # 978-0743260770

Where Can I Learn More?

Motivational Interviewing-3rd Edition

William Miller and Stephen Rollnick

2013 Guilford Press

ISBN # 1-57230-563-0

Motivational Interviewing with Adolescents and Young Adults

2010 Guilford Press

ISBN # 978-1-60918-062-1

Last Thoughts

Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness, concerning all acts of initiative and creation. There is one elementary truth, the ignorance of which kills countless ideas and splendid plans: That the moment one definitely commits oneself, then Providence moves too. All sorts of things occur to help one that would never have otherwise occurred. A whole stream of events issues from the decision.

-Johann Wolfgang Von Goethe

References REFERENCES

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