Effective Services for Adolescents

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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

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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

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Identity Development Where Do You Stand?
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Role of Resistance in Adolescence

• Adolescents main role is identity formation
  (Erickson, 1968).
• This involves trying on identities and resisting
  those that dont fit (Luyckx, Goossens, Soenens,
  Beyers, Vansteenkiste, 2005)

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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

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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!

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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.

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Physical Considerations

• Adolescent Brain Research (White, 2003)
• Myelin sheath development lags behind in critical
  structures.

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Physical Considerations
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Physical Considerations

• Homeostatic neuro-efficiency Feeding what
  works, starving what doesnt.

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Why DO People Change?

• Natural Change- It is now widely accepted that
  most people change over time without professional
  assistanceThe question isHow 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.

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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).

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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.

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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?

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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).

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Establishing a Working Alliance

• Anything that is their idea is a better
  ideaThis is as it should be!
• The best time to teach an adolescent something is
  when he or she isnt looking!
• Modeling works!

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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).

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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 adolescents
  valuesnot yours!
• Successful counselors do not take the role of
  expert, rather one of a co-explorer or
  facilitator (Biever McKenzie, 1995).

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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!

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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 dont see very often.
  Believe this Theyre watching!

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Effective Techniques

• OK, we have a decent relationship. Now what?
  Its time to work on your skills.
• Learn the difference between encouragement and
  praise.
• Examples

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Effective Techniques

• The importance of a strength-based perspective.
• Modeling
• Skill Building
• Increased buy in

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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

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Effective Techniques

• The use of humor
• Ability to laugh at oneself (Hanna Hunt, 1999).
• Use of humor in session (Adler, 1959).
• Therapeutic wonderment
• Humor as indirect communicationThis is a two way
  street!

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Effective Techniques

• Whoever made you gave you two ears and only one
  mouth, which is a gentle hintlisten more and
  talk less!
• Keep it brief.
• Ask the kid to do the advocating for change.

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Effective Techniques

• Use of story and metaphor planting the seeds.
• Dont 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).

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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

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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.

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Wrapping Up

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

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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

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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)

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Right Vs. Not So Right

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

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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 dont you want to change?
• How can you tell me you dont have a problem?
• What makes you think you are not at risk?

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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 Im trying! If my probation
  officer would just get off my back, I could focus
  on getting my life in order!
• Response Youre working hard on the changes
  you need to make.

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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.

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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 dont
  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!

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Rolling With Resistance

• Double Sided Reflection- This approach captures
  both sides of ambivalence and can be particularly
  effective.
• For example I dont smoke any more than my
  friends. Whats wrong with a joint now and
  then?
• Response I can see how this is confusing for
  you. Youve told me how youre 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!

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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.

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Other Responses to Resistance

• Reframing- Here we are taking the clients
  thought and putting a new spin on it for him/her.
  
• For example Ive tried to change so many times
  and failed
• Response Youre very persistent, even in the
  face of discouragement. This change must be
  really important to you.

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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 clients ability to change. You are building
  their confidence to pursue change.

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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!

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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?

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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?

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Putting it All Together

• Four Basic Steps or Principles of MI
• Express Empathy
• Develop Discrepancy
• Roll with Resistance/Dance with Discord
• Support Self-Efficacy

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Putting it All Together

• People Change When They Are
• Ready
• Willing
• Able

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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

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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

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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

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References

• REFERENCES
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