Strengths-Based EngagementA Comprehensive Approach to Working

with Adolescents and Families

Bob Bertolino, Ph.D.Assistant Professor, School of Health Professions

Maryville University – St. Louis, MissouriSr. Clinical Advisor, Youth In Need, Inc. – St. Charles, Missouri

Becoming

Strengths-

Based

Personal Philosophy & Worldview

PRACTICES“What we do”

↑THEORY/MODELS“How we think”

↑PERSONAL PHILOSOPHIES

“How we are”

There is More to See

“You must be the change you wish to see in the world”

– Mahatma Gandhi

Expanding Our Worldviews

Expanding Worldviews1. What are the core beliefs you have about the

adolescents and families with whom you work?2. How have you come to believe what you believe and

know what you know? What have been the most significant influences on your beliefs?

3. How have your beliefs and assumptions affected your work with adolescents and families? With colleagues? With the community?

4. Do you believe that change is possible even with the most “difficult” and “challenging” adolescents and families?

5. How do you believe that change occurs? What does change involve? What do you do to promote change?

6. Would you be in this field if you didn’t believe that the adolescents and families with whom you work could change?

H. O. P. E.

HHumanism

OOptimism

PPossibilities

EExpectancy

“Optimism is the faith that leads to achievement.Nothing can be done without hope or confidence.”

- Helen Keller

What is Strengths-Based?A strengths-based perspective is not a theory but an

overarching philosophical point of view. It is one in which people are seen as having capabilities and resources within themselves and their social systems. When cultivated, activated, and integrated with new experiences, understandings, ideas, and skills, people’s strengths offer pathways to reduce pain and suffering, resolve concerns and conflicts, and cope more effectively with life stressors. The outcome is an improved sense of well-being and quality of life as well as higher levels of relational and social functioning. Strengths-based practitioners promote change through respectful educational, therapeutic, and operational processes that encourage and empower others.

Traditional and Strengths-Based Philosophies

Traditional View• Search for impairments/deficits• Focus is on discovering pathology• Belief is people are bad, have hidden

agendas, and are resistant• Focus is on the practitioner finding and

administering cures• The practitioner is the “expert”• Focus is on the past/past events• Practitioners emphasize expression of

emotion as necessary for change• Practitioners diagnose stuckness• Emphasis is on finding identity and

personality problems

Strengths-Based• Identify competencies/abilities• Focus is on promoting health/well-being• Belief is people have good intentions,

are cooperative• Focus is on creating small changes that

lead to bigger ones• Services are collaborative—both the

practitioner and client(s) have expertise• Focus is on the present and future• Practitioners validate felt experience• Practitioners are change-oriented• Emphasis is on action and process

descriptions

How We Think:Primary Research Agendas/

Theories and Models

Primary Agendas in Researchand Practice

1. Empirically-Supported Treatments (ESTs); Evidence-Based Practices (EBPs)

2. Empirically-Supported Relationships (ESRs)

3. Common Factors (Meta-analysis)

4. Outcome Management

EBP/EST• Division 12 of APA – Committee on Science and

Practice (formerly TFPP)• Viewing models, methods, and techniques as the

primary causal agents of change (as proven though RCTs)

• Increased relevance and dissemination to the professions and public

• Developing a single list of Empirically Supported Treatments (EST)

• Comparative Analyses• Allegiance effects• Efficacy vs. effectiveness settings

Empirically-Supported Relationships (ESR)

• APA – Division 29 Task Force • Formed to identify elements of effective therapy

relationships that affect treatment outcomes and determine efficacious methods of customizing therapy to individuals on the basis of their characteristics

• Includes client and therapist factors and variables that Includes client and therapist factors and variables that influence relationships and affect changeinfluence relationships and affect change

• ““Efforts to promulgate practice guidelines or evidence-Efforts to promulgate practice guidelines or evidence-based lists of effective psychotherapy without including the based lists of effective psychotherapy without including the therapy relationship are seriously incomplete and therapy relationship are seriously incomplete and potentially misleading on both clinical and empirical potentially misleading on both clinical and empirical grounds.” (Div. 29 TF)grounds.” (Div. 29 TF)

Meta-Analysis

Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.) (1999). The heart and soul of change: What works in therapy. Washington, D.C.: American Psychological Association.Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books.

Effects on Outcomes

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. New Jersey: Lawrence Erlbaum.

Outcomes Management• Dose-Response Effect• All major meta-analytic studies indicate the most

significant portion of change occurs earlier in treatment (within the first 5 sessions)

• The average length of time that clients attend therapy is 6-10 sessions (regardless of the model)

• Real-Time Feedback Mechanisms• Alliance (WAI, HAq-II, SRS, etc.): client ratings of relationship• Outcomes (OQ Family, ORS, etc.): individual (well-being),

interpersonal, and social role functioning• Real-time (outcomes and alliance) feedback can

improve outcome between 40-65% • “Factor of Fit” and “Practice-Based Evidence”

APA on EBP

“The integration of the best available research with clinical expertise in the

context of patient characteristics, culture, and preferences.”

APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273

Points of ChangeIntersection and Convergence

Empirically-Supported

Relationships(ESR)

Evidence-Based

Practices(EBP/EST)

Common Factors

(CF)

OutcomesManagement

(OM)

Principles of Change(POC)

Convergence?

• Interpretations of data are most frequently are drawn from the same studies and the same body of research (Beutler & Castonguay, 2006).

• Castonguay and Beutler (2006), “We think that psychotherapy research has produced enough knowledge to begin to define the basic principles that govern therapeutic change in a way that is not tied to any specific theory, treatment model, or narrowly defined set of concepts” (p. 5).

Beutler, L. E., & Castonguay, L. G. (2006). The task force on empirically based principles of therapeutic change. In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 3–10). New York: Oxford University Press.

Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change: What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 353–369). New York: Oxford University Press.

Strengths-Based Principles

Client Contributions

The Relationship and Alliance

Cultural Competence

Focus on Change

Expectancy and Hope

Factor of Fit

Martin Seligman

“What we have learned is that pathologizing does not move us closer to the prevention of serious disorders. The major strides in prevention have largely come from building a science focused on systematically promoting the competence of individuals…. Fifty years of working in a medical model on personal weakness and the damaged brain has left mental health professionals ill-equipped to do effective prevention. We need massive research on human strength and virtue. We need practitioners to recognize that much of the best work they do is amplifying the strengths rather than repairing their patient’s weakness.”

Convergence and Change• View the client(s) as a primary factor in change

(i.e., identify and build on internal strengths and social support systems)

• Consider that the strength of the therapeutic relationship and alliance from the client’s perspective is most important

• Convey empathy• Convey positive regard• Be congruent and genuine• Consider the client-practitioner match

Convergence and Change (cont.)

• Be sensitive and respectful to the unique cultural and contextual characteristics of each client

• Create a respectful therapeutic climate in which clients are able to explore and express their personal stories or narratives and associated emotions

• Include clients in processes (i.e., preferences, service planning, goal setting, tasks, etc.)

• Select and match methods with clients according to factors such as preferences, level of need, state of readiness, level of distress/impairment, and coping style

Convergence and Change (cont.)

• Use educational and developmental processes that increase social skills, coping skills, and self-regulation

• Incorporate client-practitioner feedback loops (i.e., monitor the strength of the alliance and outcome/the subjective impact of therapy)

• Attend to alliance ruptures• Pay attention to practitioner contributions to change (e.g.,

expectations, preferences, level of personal awareness, patience, etc.)

• Employ structure/focus in sessions/meetings/interactions• Explore client expectations• Create or rehabilitate hope and a future focus• Use self-disclosure

Active Client Engagement5-Point Process

Create a Context of Collaboration

Point

• Start services by offering options that are respectful of clients and their cultures and incorporate their preferences and perceptions

How

• Keys to Collaboration

Strengthen Through Presence

Point• Listen and Attend to Clients’

Stories and Strengths

How• Acknowledge and validate• Separate experience from action• Summarize, validate, and soften• Avoid platitudes or trying make

things more “positive”• Be aware of stories of

impossibility• Consider the influence of words• Use possibility-laced language• Be a “life witness”

The Therapeutic Relationship in Context…

Even for those who are convinced that the therapeutic relationship is healing by and of itself, there are strategies that can foster its impact. In other words, since not all kinds of relationships are likely to bring about change, one needs to be aware of interventions (including modes of relating) that should be encouraged or avoided for the relationship to become a corrective experience. (Castonguay & Beutler, 2006, p. 353)

Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change: What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 353-369). New York: Oxford University Press.

Strengthen Through Presence

Point• Listen and Attend to Clients’

Stories and Strengths

How• Acknowledge and validate• Separate experience from action• Summarize, validate, and soften• Avoid platitudes or trying make

things more “positive”• Be aware of stories of

impossibility• Consider the influence of words• Use possibility-laced language• Be a “life witness”

The Influence of Words

The Influence of Words

Sad. Helpless. Inconvenience. Defeat. Tired. Oppressed. Doubtful. Uninterested.

Life is so hard. Nothing seems to go my way. There is no one to turn to. It feels like I’ve been forgotten. Times are hard. Nothing seems to

help. Things will not get better. In fact, they will probably get worse. There is no hope.

The Influence of Words

Exciting. Fun. Laughter. Joy. Anticipation. Possibility. Aliveness. Love. Peace.

When I think about the future I become energized. There is so much I can

accomplish. Life is wonderful. There are so many possibilities in the world.

Possibility-Laced Language1. Reflect client statements in the past tense.

► From: “It’s always that way.”► To: “It’s been that way.”

2. Move from global (“everybody,” nobody,” “always,” “never”) to partial (“recently,” “somewhat more,” “a lot”).

► From: “He’s always in trouble.”► To: “He gets in trouble a lot.”

3. Move from truth/reality to perception (“It seems to you,” “You’ve gotten the idea”).

► From: “Things will never get better.”► To: “From where your standing it really seems that it will

never get better.”

Possibility-Laced Language

1. Assume the possibility of future change and/or solutions by using words such as “yet” and “so far.”

► From: “It’s always going to be this way.”► To: “So far you haven’t found any evidence that things will be different

than the way they are now.”

2. Recast the problem statement into a statement about a preferred future or goal.

► From: “I’ll never be able to have the life I really want.”► To: “So you’d like to be able to move toward the life you really want.”

3. Presuppose that changes and progress toward goals will occur by using words such as “when” and “will.”

► From: “I just want my kids back home.”► To: “So when you when you are in a place where we agree that it is safe

for your kids to be back home with you what will be different?”

Possibility-Laced Language Include any parts, objections, feelings, aspects

of self, or clients’ concerns that might have been left out or seen as barriers to change/goals.

From: “Nothing will change until people get off my case.”

To: “Things can change while people are continuing to work with you.”

From: “I can’t focus on anything when these kids are screaming!”

To: “You can find a way to focus even during times when your kids are being loud.”

Service PlanningPoint

• Information-gathering• Learning clients’ perceptions

and perspectives• Understanding problem-

severity• Gaining Focus

How• Formal IG: Assessment• Informal IG: Establishing

directions and goals• Primary Matching: Assess

clients’ readiness for change• Real-time feedback

mechanisms (Outcome and Alliance)

Formal-Information Gathering: Establishing Directions and Goals1. Problem Description: What needs to

change?• Action-talk (all 3 points)• Scaling questions (with all 3 points)

2. Vision of the Future: How will we know that change has been achieved?

• Miracle question, crystal ball, time machine, etc.• General future-oriented questions

3. Movement: How will we know that progress is being made?

Informal Information-Gathering: Assessment

• Pre-session/Pre-meeting change

• Primary Areas (Spokes of Life)

• Exceptions• Scaling Questions

• Rate Intensity and variations

• Effects of Problem of Person

• Effects of Person over Problem

8Other

7Work/

Employ-ment

6School/

Education

5Outside Helpers

4Commun

-ity

3Friends/Social

Relation-ships

2Family

1Client

Primary Matching: Exploring Client Readiness for Change

• Stage of Change• Motivational Interviewing• Clients’ relationships with concerns and

problems• Be culturally-sensitive

Real-Time Feedback Alliance

The client’s rating of the alliance HAq-II; WAI; SRS (every session) In Initial Sessions and Interactions; “Checking In” –As

Sessions and Interactions Progress; At the End of Sessions and Interactions

Outcome The client’s rating of the subject impact of services on

majors areas of life (functioning) OQ-45 /LSQ; OQ/Y-OQ 30.2; ORS (session 1-3 then

minimally every third subsequent session) Measures: paper or electronic; data

management

Focus on Change

Points• Consider strategies that offer

the best possible “fit” and are sensitive of clients’ cultures, beliefs

• Focus on processes that enhance change

How• Secondary Matching• Collaborate on tasks/way to

achieve goals and improve outcomes

• Focus on processes that enhance change

Secondary Matching Culture (including disabilities, development) Listen for client expressions of change

experiences and expectations (i.e., experiential, cognitive, behavioral, interactional, etc.)

Explore clients’ coping styles (internal or external)

Match methods with clients’ ideas, expectations, and previous change processes

Reassess Client Readiness

Evaluate and Monitor Progress, and Respond

Points• Evaluate progress• Explore benefits and highlight

gains• Create a responsive climate

How• Identify and amplify change• Address alliance ruptures• Address lack of progress,

deterioration• Change approach methods• Transitions• Pathways of Impossibility

Responding to Alliance Ruptures

• Discuss the here-and-now relationship with the client.• Ask for feedback about the therapeutic relationship.• Create space and allow the client to assert any negative feelings

about the therapeutic relationship.• Engage in conversations about the client’s expectations and

preferences.• Discuss the match between the therapist’s style and client’s

preferred ways to relate.• Spend more time learning about the client’s experience in therapy.• Readdress the agreement established about goals and tasks to

accomplish those goals.• Accept responsibility for his or her part in alliance ruptures.• Normalize the client’s responses by letting him or her know that

talking about concerns, facing challenges, taking action, and/or therapy in general can be difficult.

Responding to Alliance Ruptures (cont.)

• Provide rationale for techniques and methods.• Attend closely to subtle clues (e.g., nonverbal behaviors, patterns

such as one-word answers) that may indicate a problem with the alliance.

• Offer more positive feedback and encouragement (except when the client communicates either verbally or nonverbally that this is not a good match).

• Engage in further supervision and/or training

Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 235–254). New York: Oxford University Press.

Lack of Progress/Deterioration

• Revisit the current stage of the client’s change. (Ask: What is the client’s state of readiness for change?)

• Focus more on the client’s view of the problem or situation—this will not require action.

• Ask open-ended questions that will allow the client to notice one or more aspects that have been downplayed or have gone unnoticed about the situation (take care not to imply that the client’s perspective is “wrong”; try only to introduce other ways of viewing that may offer new possibilities or will encourage the client to talk about the problem or situation differently).

• Help the client to weigh the possible positive and negative effects of his or her behavior.

• Help the client to weigh the possible benefits and drawbacks of change.

• Demonstrate genuine confidence that the client has the strength to face his or her challenges.

• Reorient to the client’s concerns to ensure that you and the client are focusing on the same issue.

Lack of Progress Deterioration (cont.)

• Offer straightforward feedback without imposing it (for example, “From where I am standing, I’m concerned about what might happen if this continues. Of course, that is for you to decide, but I believe it’s my responsibility to speak about it.”) (Note: Always provide more directive feedback and make necessary safeguards if there is risk of harm to self or other.)

• Avoid a “solution-forced” situation when the client’s conversational preference is to talk more about problems and his or her ambivalence.

• Acknowledge further—ensure that the client feels heard and understood and verifies this either verbally or nonverbally (ask questions or use an alliance measure as needed).

• Discuss with the client whether the level of services is a good fit and/or whether he or she is ready to be in therapy.

Bertolino, B. (2010). Strengths-based engagement and practice: Creating effective helping relationships. Boston: Allyn & Bacon.

Now What?

What Do the Most Effective Therapists Do?

• Maintain a posture of awareness, being alert, observant, and attentive in each encounter

• Compare new information and what is learned with what is already known

• Remain acutely attuned to the vicissitudes of client engagement—actively employ processes of gaining and incorporating ongoing formal feedback

• Consistently achieve lower scores on standardized alliance measures at the outset of services because they are more persistent and perhaps, more believable, when assuring clients that they seek honest feedback, enabling them to address potential problems in the alliance (workers with lower rates of success, by contrast, tend to receive negative feedback later in services, at which point clients have already disengaged)

What Do the Most Effective Therapists Do? (cont.)

• Spend more time on strategies that might be more effective and improve outcomes as opposed to hypothesizing about failed strategies and why methods did not work

• Expand awareness when events are stressful and remaining open to options

• Evaluate and refine strategies and seek outside consultation, supervision, coaching, and training specific to particular skill sets

“It’s not enough to be compassionate. You must act.”

– Tenzin Gyatso14th Dalai Lama, 1992

“Never doubt that a small group of thoughtful committed citizens can change the world; indeed it’s the

only thing that ever does.”– Margaret Mead

ThankYou

Bob Bertolino, Ph.D.TCCT, LLC – P.O. Box 1175 – St. Charles, Missouri 63302

+01.314.852.7274 – bertolinob@cs.com – www.bobbertolino.com

Maryville University650 Maryville University

DriveSaint Louis, Missouri

63141 USA+01.314.529.9659 (Phone)

+01.314.529.9139rbertolino@maryville.edu

www.maryville.edu

Youth In Need, Inc.516 Jefferson

Saint Charles, Missouri 63301 USA

+01.636.946.0101 (Phone)+01.636.925.0125 (Fax)

rbertolino@youthinneed.org

www.youthinneed.org