HN330 UNIT 7 DBP

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CHAPTER 12: Collaborating with People for Change Introduction We have been looking at basic communication skills that create an environment in which good rapport and meaningful change are possible. There are, however, additional skills and information that might make the process of helping another person more understandable and give us a more realistic picture of how people grow and change. These enhance what you have already learned so that you give another person more robust support for change. In this chapter we will look at some enhancements that will give you added skill in your work. In 2002, William Miller and Stephen Rollnick wrote a book that changed the way many people approached their clients. The book, Motivational Interviewing, was written primarily for therapists working with individuals in the field of addictions. Their ideas about respecting and collaborating with clients even under very trying circumstances speak to the values expressed throughout this textbook. Although their book is written for therapists there are numerous ideas and skills that case managers can find helpful. For that reason, we will discuss some of these ideas case managers can use to enhance their work with clients. What Is Change? Change has different meanings for different people. It can mean immediate changes to their painful circumstances, or it can mean long-term changes that affect the person’s future well-being and sense of competence. You may begin by looking first at the near term changes such as abstinence through admission to a rehab program, relief of severe anxiety through the use of medication, or a change in an older person’s unsafe living arrangements. But at some point you and the person will address how to prevent the same problems from occurring again and how to develop a worthwhile future. When change involves giving up a way of being, an old habit, or accepting one’s diagnosis, it can be difficult. People do not just change, as you can well imagine, even when they have suffered a setback or uncomfortable crisis, asked for help, or said they want to change. Fear, uncertainty, stubbornness, denial, lack of confidence or a lack of hope, or even the inability to envision the future can be significant obstacles to change. Change takes commitment and hard work. Your role is to support that hard work and commitment. Stages of Change Because change does not happen quickly it is better to view it as a process. In order to help us better understand how change takes place Diclemente and Valesquez (2002) looked at change as a process. Their model breaks that change process down into five stages a person might go through as he works toward changing. The model was originally developed for a program to help expectant mothers stop smoking. However, we have found that the model is useful any time a person needs to make changes that are difficult. One person may need to stop smoking; another may need to take her medication; another may have to lose weight for medical reasons; a fourth person might want to upgrade his skills and return to school; and another, in a program for parents who have physically abused their children, may want to learn better ways to parent. When you meet a person for the first time, he or she may be at any one of the different points in the change process. Knowing where the person is in the change process helps you to be more effective. Let us look at the stages. Stage One: Precontemplation People in this stage are really not thinking about change and therefore are not ready to change. They may not see a need to change, or they may have tried in the past and been unsuccessful. In this stage you might reflect back to the person the fact that she is not feeling ready to change. This might be a time to invite her to look with you at her behavior. Possibly you would use an I-message expressing your concern for how this behavior or lack of behavior adversely affects her. Invite her to give you feedback. Listen to why she is reluctant to change. Explore obstacles she sees. Be matter of fact and accepting of where the person is now without passing judgment or arguing. In addition, make it clear that whether or not the person decides to change is their decision to make. You will not pressure one way or the other. Stage Two: Contemplation In this stage a person is willing to explore but not yet willing to commit to change. What you might be hearing is ambivalence about making any changes. Ambivalence is normal when we seriously contemplate changing from something familiar to something unfamiliar. In this stage he is still not ready to change. Again, accept that he is not ready and reflect that back to him. “You aren’t really feeling good about doing this.” When people feel ambivalence there is some fear that you will pressure them or force them to make changes they are not ready to make. In this stage it is a good idea, therefore, to reassure the person that the decisions to make any changes are up to them. Talk over the problem with him. To support a person’s contemplation, talk through the risks and the benefits involved in change at this point. Ask him if he sees any good points to the way things are now and what bad points he might see about the current situation. How does he see the problem? What might be some good solutions? What does he risk if he changes, and what rewards might he reap? Collaboration is important in this stage as you give information and learn from your client. You may encounter people who will never move out of this stage or remain in this stage for a long time. How long and whether or not they change is up to them so it is unwise for you to feel responsible if a person does not move beyond the contemplation stage. Stage Three: Developing a Plan At this stage the person is ready to change but needs a plan. This is a collaborative endeavor as you seek to develop a plan with her and overcome the obstacles she may see ahead. From this collaborative effort you and she aim to find the best plan of action. She may have tried to change previously and in talking with you finds that she learned some valuable lessons from those experiences. Now is a good time to brainstorm. Without judging the ideas talk about the options she sees and ideas you have. Eventually a plan presents itself. Sometimes the initial plan is only a baby-step toward a much bigger goal. That may be what she can handle at the moment. Support her efforts. If she indicates she will try something you believe may not work, use a very tentative I-message to bring up your own concerns without discouraging her. Stage Four: Implementing the Plan In this stage people will actually change their thinking or behavior or their old habits, but think of this as practice. The new way of thinking and doing things still feels new. During this trial run at changing things, it is normal to be uncertain. Some people will miss the way things used to be. Use reflective listening, as you listen without judgment to their concerns. Sometimes a person putting a plan into action will not be entirely committed or may feel awkward and inadequate. Your encouragement and support can facilitate the work this person is doing. Stage Five: Maintaining the Changes In this final stage the person is seeking to make the changes a permanent part of her life. People take varying amounts of time to make the changes permanent, and some people never quite accomplish that. What obstacles are in the way of long-term success? Are there still things that will support the original behavior, such as triggers? Does the environment support a change? Your support in the way of follow-up and encouragement are crucial at this stage. Acknowledge the successes. Work through collaboratively new obstacles that might crop up. Things can happen in this stage that you are not expecting. • A person might test herself. Can she revert to the old ways just a little bit and still be okay? • He may have discovered that the change cost him personally. Perhaps he lost friends or he had to move. Sometimes the costs aren’t visible at first. • She begins to doubt she can do this long term or sustain the effort it takes. • He may have a sudden urge to go back to the old ways, to drink again, to throw out the medicine and go without, to return to a destructive relationship. Your support and encouragement are crucial at this point. Relapse A person may find that he cannot sustain the new behavior or way of being over a long period of time. And so he may return to his addiction, another may stop his medications, another may return to an abusive relationship, while another may resume abusing her children. These relapses usually occur gradually. There is an initial slipup, which is often followed increasingly by the old behaviors. Look at the attempts your client has made rather than focusing on the failure. Talk about how she successfully maintained the changes over a period of time. What was learned? What can be done differently next time? Talk through the relapse, using your reflective listening skills, to help the person make sense of what happened and why. In some cases people can learn how to recognize a relapse, self-managing their disorder or addictions. Education about what to do and how to prevent relapse can help. Advance directives can help if the person is likely to have a relapse in her mental disorder. An advance directive allows the client to stipulate how she wants the next relapse handled. Look together at how the relapse happened: identify what is likely to bring about a relapse, note the early signals of a relapse, prepare a prevention plan, and plan for how a relapse should be handled if it occurs again. A Case History Let us follow Claudette, whose situation illustrates the stages of change. Claudette came seeking help for a compulsion to shoplift. After numerous years in therapy and several short stints in the county jail, she still felt the urge to steal. She confided that she thought she had an “addiction” because getting things out of the store without paying for them was a challenge and there was a thrill when this was accomplished successfully. When she came to the agency, she was in danger of losing her children and felt the need to try once again to stop her negative behavior. Claudette was beyond the precontemplation stage (stage 1). She had thought about changing before she came to the agency (stage 2, Contemplation). When she came in, the case manager took the social history and the two of them talked over the problem at some length. Claudette blamed an older sister and her friends for her “bad habit,” which started when they were all teenagers. Throughout the interview the case manager assured Claudette that what was decided would be her decision. They talked a little bit about the negative consequences of Claudette’s stealing, but they also examined the thrill she said she experienced each time she stole successfully. The case manager made several suggestions with Claudette’s permission and Claudette considered them, including a 12-step program, but Claudette seemed unsure. The case manager suggested Claudette think about the suggestions and also what she thought would work well and return to talk further. Claudette made an appointment the next week. She had once again shoplifted, and she was concerned that she would, in time, get caught and lose her children because shoplifting was a violation of her parole. Claudette and the worker devised a plan together (stage 3), which included Claudette attending the 12-step program every evening for the next month and seeking a sponsor there. In addition, Claudette suggested that she would not go shopping unless someone was with her who would be distressed if the person found her shoplifting again. A likely person was her aunt, and when contacted, the aunt was willing to accompany Claudette for the next month when she went shopping (Stage 4, Implementing the plan). Claudette did really well and was into her fourth month in which she had abstained from shoplifting. (Stage 5, Maintaining the changes) She reported that she liked the people she had met at the 12-step program and liked her sponsor. In addition, she had been shopping without her aunt on several occasions without any desire to shoplift. Her case manager encouraged her pointing out the strength and determination Claudette was using to change her behavior. Just before Claudette’s time in the 12-step program was completed, however, Claudette called to say she had shoplifted on a Sunday afternoon when her aunt had been busy at church and her sponsor was out of town. Out of milk, Claudette had gone to the store, promising herself that she would only buy the milk and return home, but she had also stolen four pairs of children’s socks. Claudette had relapsed. The case manager spent time talking to Claudette about how the relapse happened, what she thought had triggered it, and what she might have done differently. With Claudette’s permission, the case manager brought together the people who were most concerned and wanted to help, Claudette’s aunt and her sponsor. The initial discussion led by the case manager centered on what could be learned from the relapse. What had Claudette learned about herself? What more needed to be addressed in planning that was missed in the original plan? The case manager focused on the success of the last few months and on Claudette’s strengths and ingenuity, which she used to refrain from shoplifting. Once again a plan was devised, and Claudette actively contributed. This time it was agreed that she would call her sponsor or her aunt if she felt a compulsion to shoplift. It was agreed that Claudette and her sponsor would look for someone from the 12-step program to act as a backup sponsor if Claudette found herself feeling a need to shoplift with no support around. She would continue in the 12-step program every weeknight for another 3 months, and she and her case manager would be in contact once a week. With the sponsor acting as a peer counselor, Claudette began to make important changes. At the end of the month she had not shoplifted, and her nights in the 12-step program were reduced to three nights a week (stage 5, Maintaining the changes). Now the case manager began to work with Claudette about her future, one Claudette saw as productive and beneficial. Together they looked at the sort of work Claudette might do, the education she would need to do that work, and the need for better parenting skills. Claudette wanted to get off welfare, and she wanted to be involved in other healthy activities that would take her away from the compulsion to shoplift. In the next few months, she started school to become a nursing assistant and was enrolled in a parenting workshop. After a year there had been no further shoplifting, and Claudette seemed to be on the road to real recovery. Her grades were good, and she confided that most of her time was spent parenting or studying. She and her peer counselor remained friends, and now Claudette was beginning to help another person with a similar problem. In this case study, the case manager used all the skills he knew would be important. He stayed where Claudette was during the process, even when she relapsed. He collaborated and at times coached her. He worked through the stages with her and accepted her ambivalence. Claudette never had to listen to scolding or denigration, and she never had to use time and energy defending herself to her case manager. Instead the focus remained on where Claudette was at the moment and where she would like to go from there. The question becomes: If change is a process and the person is working with a case manager, what role does the case manager play in supporting change for that person? Below we look at some specific ideas and skills that help you do that. Understanding Ambivalence and Resistance We help people change by accepting their ambivalence and understanding their reluctance to follow through. Accept Ambivalence We have talked about ambivalence so let us look at it more closely. It is important for your own realistic expectations and the therapeutic nature of your relationship with clients that you accept ambivalence as normal. Miller and Rollnick (2002) point out that ambivalence is a normal part of change. They write, “(people) often recognize the risks, costs, and harm involved in their behavior. Yet for a variety of reasons they are also quite attached and attracted to their addictive behavior” (p. 14). We see people whose behaviors are destructive, but they are ambivalent about changing those behaviors. Miller and Rollnick write, “Passing through ambivalence is a natural phase in the process of change” (Miller and Rollnick, 2002, p. 14). Resistance Misunderstood People often move toward their recovery or change at different rates due to their ambivalence. Most people do not readily change without experiencing some ambivalence, some conflict about it, or some degree of pessimism. These thoughts and feelings are a normal part of changing. Some people stay with their ambivalence longer than others, and some people never can move beyond it. Case managers can make two mistakes. They could mistakenly characterize this ambivalence and the behaviors ambivalence elicits as resistance. Resistance suggests oppositional behavior, people who are uncooperative and difficult. It is somehow the client’s fault that she does not follow through with our directives or even plans we worked out with them. We often see this resistance to our planning as a negative part of her problems, a behavioral problem she uses that obstructs getting better or changing her life for the better. Some of that may be true, but we need to back away from these ideas and consider other possibilities. The second mistake is thinking it is the case manager who is responsible for the client making changes. The point to remember is that it is up to the client to change. Some people change and others do not. Some people change rapidly and others take years to effect a change. The client is the one responsible for whether or not change takes place. Sometimes things move too quickly for a person. Change may be coming in unexpected and very uncomfortable ways, and the old, safer ways of being and doing are giving way to the unknown. The individual may have excuses, procrastinate, find reasons to avoid you, or just ignore plans you and she made together. It may be that the goals in the action plan you both developed looked good on paper, but now she is finding it enormously difficult to implement the plan the way you both constructed it. According to Miller and Rollnick (2002), we should see resistance as a “signal to respond differently.” (p. 40). In other words, what goals we worked out with the person or the way we are supporting the person’s path to change needs a different approach. Often untrained workers argue with the individual, pointing out the work put into the plan for change or the person’s initial participation, and why the plan is a good one. That worker is laboring under the false belief that by arguing he can make the other person see things the way he does. But that other person may have a very different perspective, and plans that seemed reasonable when the two of them sat down together in the office no longer seem reasonable when the client attempts to put the plan into practice in real life. According to Miller and Rollnick (2002), writing about the role of the worker, “One does not directly oppose resistance but rather, rolls or flows with it” (p. 40). They go on to write, “Reluctance and ambivalence are not opposed (by the worker) but are acknowledged to be natural and understandable” (p. 40). Here are some ideas you can use when the plan is not working out well or the client is having trouble following through with the plan. • Coming Alongside. Rather than arguing start where the client is. As Miller and Rollnick (2002) point out that there is always a “degree of discrepancy between status and goal” or between the way things are now and the way the client would like them to be. They write that the discrepancy exists “between what is happening at present and what one values for the future” (p. 10). Reflect back to people matter-of-factly their feelings about not following the plan, not making the change. WORKER: “So in other words your ex-husband called you and was having trouble on his job and you felt you were the best person to help him with that so you went back to him.” WORKER: “It sounds like you really felt an urge to eat those desserts because all your friends were celebrating and now you feel sort of down on yourself.” WORKER: “So there was a party for your father’s 75th birthday and you felt that one drink or even two would not mess up your sobriety.” • Discuss the Reluctance You See. Talk openly about what you perceive to be reluctance, using an I-message and making it clear that you could be wrong or have misunderstood. WORKER: “I can see this is really hard for you.” WORKER: “To me is seems like you really feel torn about this.” WORKER: “ At a party where everyone is drinking it is hard to be different.” • Allow People to Continue as Before. Do this collaboratively and respectfully. This is not a cunning technique to trick people into changing their destructive behavior. Simply reflect back to the other person what you feel he or she sees as the reasons not to change. Often this allows the other person to argue for change. WORKER: “So for right now you would like to stay with him.” WORKER: “It sounds like you are feeling that for the time being you want to eat the way you did before, at least for awhile.” • The Decision Is Theirs. Point out unequivocally that the ultimate decision for what takes place belongs to the client. Neither you nor anyone else intends to force someone to do something he or she is not ready to do or feels uncomfortable about. WORKER: “You are in charge of what you decide to do.” WORKER: “How ever you want to proceed from here is your decision.” • Ambivalence Is Normal. Acknowledge that feeling uncertain, wanting to reexamine things, stop and back up, and all the things people do when they are not sure about changing are normal. Ambivalence comes before real change. The person needs to hear that from you and know that you accept where he or she is at the moment. WORKER: “It really can be hard to make these changes. Let’s talk about how this is going and what you’re going through.” WORKER: “It really isn’t always easy to make changes like this. Maybe we can slow down and take another look at this together.” Encouragement We support people in their efforts to change and in their setbacks with the strategic use of encouragement. In the stages of change above we looked at the importance of encouragement, particularly where a person’s environment doesn’t provide supports for change. Here we look at this important skill more closely. When Clients Are Discouraged Part of the case manager’s work in the relationship is to provide encouragement to people who may feel very discouraged. Many of the people we see are discouraged as a result of their circumstances, disease, or illness, or because of what has happened to them. Here are some symptoms commonly seen in discouraged people: • The situation seems to overwhelm them. • They have low regard for their capabilities or put themselves down. • They are unwilling or unable to take responsibility. • They describe their circumstances or other people as totally domineering and overwhelming. • They have no trouble discussing their problems but are unable to focus on solutions to those problems. • Their goals seem impossible or unrealistic to them. • They set impossible standards for themselves. • They sprinkle their conversation with negative global statements such as “Everybody hates me” or “Nobody ever calls here” or “Everything is rotten” or “Bad things always happen to me.” How Case Managers Motivate and Encourage Case managers often provide the encouragement people need to reach beyond their current situations. As noted above, case managers encourage people to look for and try alternative ways of doing things, but often thinking about change is frightening to people. These are skills you would employ beginning with your first contact with the client and they are part of your strategic assessment skills. The following sections discuss these techniques. Begin Where the Client Is. The first step in encouraging others is to accept people exactly where they are in the change process. This starts with the very first contact with clients. The worker does not denigrate the person for needing help or coerce the person to be better or work harder. Arnold R. Beisser (1970) talked about Frederick Perls, the father of Gestalt therapy, and what Beisser called Perls’s “paradoxical theory of change.” Beisser defines the theory this way: “Change occurs when one becomes what he is, not when he tries to become what he is not” (p. 77). Perls believed that forcing people to be different never accomplished real or lasting change. People first have to come to terms with who and where they are at the moment and find some degree of acceptance in that. If you start immediately telling people how to do things differently, how their behavior has been the root of the problem, or how erroneous their thinking has been, they will find it important to argue and defend themselves—to explain why they have done those things or thought that way. Valuable time is wasted and rapport is lost as people move into a defensive position rather than a collaborative one with you. One case manger related that she had begun to work with a person who had battled numerous psychotic episodes. This woman had a severe mental disorder that had required emergency hospitalizations in the past, but once she was stabilized on medication and doing well, she would stop the medication and try her best to go on as if she did not have a disorder to address. This is much like the diabetic who knows he is diabetic but goes on drinking sodas or eating cookies anyway in an attempt to ignore his disease. The case manager said it was not until she and the client worked together, moving carefully through the stages of change, that the woman was able to accept the facts of her illness. She began to move beyond denial, to thinking of small steps that would help her take better care of herself, and eventually she achieved some of her long-range goals. Until the woman accepted her disorder, no change or recovery was possible. As of this writing, this woman is getting married and holds a meaningful job. As a case manager, you may be the first person to really listen to people entering the system. Use this opportunity to bring acceptance and understanding to the way things are now. Let people be exactly where they are at the moment they first see you, without remonstrance from you. In other words, convey to the person that it is perfectly all right to be where the person is now, given what has gone before. Once the person’s footing is secure he or she can see about moving to another, better spot of the person’s choosing. Beisser (1970, p. 77) wrote, “The premise is that one must stand in one place in order to have firm footing to move and that it is difficult or impossible to move without that footing.” To really provide useful assistance to people and encourage them to grow into their true potential, start exactly where they are, not where you think they should be. See the Person’s Strengths. Case managers who use encouragement as a tool see people as basically capable and wanting to take as much responsibility for their lives as possible. Our clients come with varying degrees of independence and abilities. Seeing these accurately is part of your assessment skills. Some people are independent when we meet them, some can grow into full independence, and others will always need some help. In this wide spectrum of abilities and needs, you will undoubtedly see the strengths of each individual and point those strengths out to the person. Hearing it from you is often all it takes for a person to stop and reconsider. Then together you can work to help the individuals maximize and take pride in those strengths. For example, you might say, “I think that what you told her really explained the situation and sounded like you have this well organized.” Or you might say, “I was impressed by your ability to finish the course even when you hated the instructor. That’s real perseverance.” Accurately Assess the Person’s Obstacles. Sometimes people appear overwhelmed and either unable or unwilling to take responsibility. Try to understand accurately how real these obstacles are. For example, an inability to use public transportation may be a small obstacle that is easily overcome for a depressed college graduate but a very real obstacle for an individual with moderate intellectual disabilities. A person may not follow through on projects or goals the two of you set together. The reason may have more to do with the projects than with the individual. It may be that the two of you set a goal that is too complicated for now. Perhaps the goal looked safe when the client sat with you in the office, but now it looks terrifying. Explore this with the individual. Don’t assume that people who do not follow through are being obstinate or uncooperative. Appreciate Every Effort. Suppose your client resolves to try something new, and the first efforts are not very successful. To encourage this person to try again, focus on the efforts, not on the results. The attempt to grow or to change is more important than whether or not it worked the first few times. Point out that the attempt gave valuable experience or information and that it creates a basis for improving. Paula, a case manager for people with intellectual disabilities, wanted to help Bart learn how to get to his new job. Bart had been hired to collect the market carts in the parking lot of a large supermarket and bring them into the store. The job gave Bart something useful to do each day and a small income. However, the store was nearly 6 miles from Bart’s group home. Paula initially walked Bart to the bus stop and showed him that he needed to catch the number 12 bus. Bart insisted he could do this, but he ended up on the number 2 bus several times. He was downcast when he called from the store. He had been most of the morning riding buses even taking the number 12 going the opposite direction. When Paula got to the store Bart was down on himself, calling himself “stupid” and talking of giving up the job. Paula, however, told Bart he had done a good job of striking out independently to get to work and she would help him fix the mistake. Her upbeat message was encouraging. She and Bart caught the number 12 together the next morning and Paula got off before the store so that Bart could get the rest of the way on his own. They wrote the number 12 in big letters on a paper, which Bart carried with him each morning until he got the hang of it. Bart had the idea of putting a chalk x on the sidewalk in an out-of-the-way place so he could see it and reassure himself he was at the right bus stop. From then on Bart was able to get to work independently. Paula focused on Bart’s efforts not on the mistake, which allowed him to start over and learn his bus route. Never Lose Sight of Potential. Focus on people’s potential. You know all about their deficits or weaknesses. So do they, but they have far less certainty about their potential for growth and change. Look at clients’ strengths, their past experiences, and their accomplishments, however small. Use these to guide you in planning the small steps they can take toward positive change. Figure 12.1 summarizes the differences between a human service professional who provides encouragement and one who provides discouragement. FIGURE 12.1: Encouragement vs. discouragement Recovery Tools Another way we help people change is by employing the 10 fundamental components of the Recovery Model (See Appendix A). Below is an abbreviated list of these components. The full list can be found in Appendix A. • Self-direction: Individuals take charge of how they will recover, including making significant choices and decisions. • Individualized and person centered: Consideration is given to the very unique attributes each person brings to recovery, including culture, preferences, personal experience, and a collection of strengths and needs. • Empowerment: People participate to the fullest extent possible in decisions that will affect them and are given the information they need to participate fully. They speak for themselves and control the elements in their own recovery. • Holistic: Recovery addresses a person’s whole life, looking at more than the issues that caused the person to seek help. A person’s role in the community, preference for where to live, what work to pursue, and what spiritual needs are not being met, are all considerations. • Nonlinear: Recovery does not happen in predictable steps but involves growth and occasional setbacks. • Strengths-based: Recovery is based on the strengths people bring to the process, including their interests, talents, accomplishments, coping skills, and much more. • Peer support: Mutual support and encouragement are provided by peers who share experiences and information and even advice. • Respect: People are accepted and appreciated, their rights are protected, and discrimination and stigma are eliminated wherever possible. • Responsibility: Individuals are personally responsible for their own self-care and path to recovery, relying on their own courage and energy to do so. • Hope: Recovery involves striving for a better future, and people are encouraged to envision themselves overcoming obstacles and moving forward. These components are principles we follow to support the client’s efforts. Let us examine several of these in more detail. Self-determination Self-determination means that to the extent the individual is able, he or she drives the recovery or change process. Self-determination involves the person’s right to direct his care and to determine the elements that will go into the service plan. In some locations clients are given the resources to pay for the care they deem important to their recovery. For example, Gladys thought she would recover better if she had acupuncture along with her medications and counseling. Arrangements were made to make the resources available for Gladys’s acupuncture, and Gladys attributed her seven sessions of acupuncture with augmenting and enhancing her road to recovery. Within the limits of what is reasonable and the person’s capacity for self-determination, people have the freedom to choose what is best for them and the authority to develop meaningful plans directed toward their own recovery. Their vision of recovery prevails, not the case manager’s. Peer Support Another recovery component is peer support. Some time ago, when people with problems were viewed as incompetent and hapless, asking one of these people to help another was seen as ridiculous. Today peer support has become a significant part of a person’s recovery. Peer counselors greatly diminish the feeling of being alone with one’s problems. Sometimes a person will recover if given more sustained time and support, but the case manager does not have the time to devote to this one person. Sometimes a client will benefit from the help of another who has “been there.” Peer support by others who have waged a similar struggle and recovered can have an enormous impact on recovery. One agency director offered this analogy: “A person is in a hole and can’t get out. The public walks by, but they don’t know what to do so they call the experts. The experts come and bring a ladder, but it isn’t enough. Then the peer support counselor comes along and gets in the hole too. The peer shows the person in the hole how to get out, how to use the ladder effectively because they’ve done it before themselves. That is the beauty of peer support.” Today peer counselors are viewed as having something valuable to contribute to the team, and they are used in a wide variety of settings. Communication Skills That Facilitate Change There are some communication techniques, many of which come from Motivational Interviewing. These enhance your ability to support people as they make positive changes. Here we will look at a few of these. Make It Safe to Explore Using reflective listening from the start is important in setting a climate in which exploration of the problem is safe. You might start an interview the first time you meet the client with questions that show your interest in the person’s point of view: • “Tell me a little bit about how you see this situation.” • “Tell me a little bit about what brought you in today.” • “Let’s talk about what you feel is most important here?” “Tell me what you feel we should address first?” You might continue with something like this: • “So it is really hard right now to see a way out of this?” • “So what you feel is most important is to contact your ex-wife to see what she knows about this?” These are simply considerate ways to address people in any interview, but the questions indicate that you value clients and their agenda for themselves. It respectfully allows others to set the priorities. The safety comes from your acceptance without judgment of the other person’s goals and concerns. Steer around Initial Worries Sometimes clients come in believing that we will prescribe the best course of action. Betts was sure the case manager was going to recommend a dietitian who would put her on a stringent diet. Bill came in convinced that the case manager would tell him he had to stop drinking before he could be helped. Others come in convinced that there are just too many obstacles to surmount in order to solve their problems. Perhaps they feel there isn’t enough money, too little time, too many people will be disappointed or feel betrayed, or solving the problem will entail giving up too much. A good case manager might say something like this: • “Wow, you’re really moving ahead of things. Today I just want to know how you see the problem and what you think about it.” • “You’re way ahead of me here. I just want to know what you think about your situation.” Articulate Self-determination When it comes to changing a situation or behavior, state the obvious: • “In the end, what happens here is entirely up to you.” • “You are free to choose either alternative.” • “You will be the one to decide what happens here.” For many people, this sense of personal autonomy is relieving and takes away one reason for taking an adversarial stance with the case manager. When you have one agenda for the person and he has another or when there are two alternatives and you like one and he is torn between the two you can set up tension and communication barriers. Say, for instance, that Pete wants to stop drinking and he also feels as if doing so is a lost cause because he tried it before and it didn’t work. If you are arguing for him to change and he is arguing with you about why this won’t work, it makes the relationship far less effective for Pete. You are not helping him change at this point but simply arguing for your point of view. Let Pete decide which alternative to choose and whether or not this is the time to change. Help People Talk about Change Arguing with you about why they should not change convinces people that they should not change. For example, if you tell Pete why he needs to change he is probably going to tell you why that is nearly impossible and convince himself that change is nearly impossible. The opposite is also true. When people tell you why they should change, they are very likely convincing themselves that change is possible and can be done. If Linda explains to you why staying in an abusive relationship has numerous disadvantages and dangers to herself and her children she is more likely to consider leaving seriously. If you argue with Linda telling her all the reasons she needs to leave she is very likely to explain why leaving is not possible. What you want to do, therefore, is engage people in what Miller and Rollnick (2002) refer to as “change talk.” Here you are constructing the interview so that they tell you why change would be beneficial. Using your skills, ask open questions about change. Rather than asking why a person doesn’t change, ask instead about how that person sees change occurring: • “Tell me a little bit about how you would like things to be.” • “What are some of your ideas about how you might bring this about?” • “What do you think might be a good place to start?” • “How would things be for you if you did leave.” • “Tell me something about what you have considered doing to change the situation.” • “Let’s look ahead about 3 years and tell me where would you think you would like to be?” • “Say you are coming in here about 3 years from now. Tell me a little bit about how things would be different.” When clients respond to questions like these, be sure to reflect the responses back to them. This way, clients hear the responses twice. • “So, in other words, you thought you could cut down gradually by smoking one cigarette less each day for a month?” • “What you really want is to be free of your symptoms and go back to school.” • “So staying there has some real dangers associated with it.” • “In other words, if you left you could go back to school and continue your nursing degree.” With comments like these, you place people in a position in which they are the ones arguing for and articulating change. It is the client who is describing how change would be beneficial. Discuss Discrepancies People become ambivalent because discrepancies exist between the way things are and the way they would like things to be. The more a person deals with these discrepancies, the more likely it is that the person will move toward change. The idea here is to allow the person to discuss why it would be an advantage to change. For example, Trudy did not want to take her medication because she felt it labeled her as mentally ill. On the other hand, she recognized that she not only felt better on her medication, but she was also more productive. Consequently, she went on and off her medication with predictable swings in mood. Here is what a good case manager might ask: • “Tell me a little bit about the problems in the way you are taking your medication now.” Here the case manager elicits from the client herself what might be impractical or negative about her use of her medication. This is more effective than the case manager lecturing the client about how to take her medications. A good case manager might also say: • “Tell me about how things would be if you took the medication consistently.” Again, the case manager is allowing the client to talk about the advantages, rather than listing them for her. A case manager with poor insight and skills might be tempted to ask instead: • “Well, why don’t you take the medication the way it was prescribed? It would make you feel better. It would no doubt help you go to work and get things done.” • “Do you really think this is not a problem for your health? You are staying in bed, sleeping all the time, neglecting your family and your hygiene. How do you think this isn’t a problem?” Open questions about what Trudy values or would like to see in her life 4 or 5 years from now also illustrate the difference between the way things are and the way the client would like things to be. For example: • “Let’s put aside how hard it might be to change and tell me how you would like things to be in 5 years.” • “Tell me something about the values you have that make you consider staying on the medication.” Again, reflect the responses to such questions back to the person, so they are heard twice. It may be easier for people to change when they can see a clear difference between the way things are and the way they want them to be. Ask questions that will help your clients see that discrepancy. Look for ways to allow people to discuss the disadvantages of their present situation and the advantages that could be had if things were different: • “How would things be different if you decided to do this?” • “Maybe we could look at how this change would make things better.” • “Could we look at how things might be a bit better if you do this?” In these questions, the case manager is asking the client to discuss disadvantages. The case manager might also ask: • “Tell me about the concerns you have right now if you make the change.” • “Describe some of the main reasons for not making a change like this?” • “Let’s look at not taking the medication. I’m wondering if you were to stay off the medication, how would things be then?” • “Tell me a little bit about the worries you have about your situation?” In these questions, the case manager is setting the stage for the client to recognize why it would be advantageous to make changes. It is not the case manager telling the client why changing would be a good thing. It is the client telling the case manager. In addition, it is the client who spells out what the disadvantages are in leaving things as they are. As always, reflect back what clients tell you so they hear it twice. Allow People to Express Ambivalence If people feel safe with you, they will talk more openly. For that reason, you will be more likely to hear people talk about their ambivalent feelings. This is particularly true if you use good communication techniques that value or appreciate the client. When people tell you about their ambivalence, you know you are doing something right. Focus, using reflective listening, on what the person is concerned about. For example, Jose knows he should diet, but he tells you that doing so would mean a damper on family get-togethers, denying himself the food he loves, and eating food that seems boring to him. On the other hand, he wants to live a long life, see his children grow up, and knows that his present weight has caused his diabetes and high blood pressure. Through reflective listening, the case manager accepts these concerns as making sense within the context of Jose’s life. A good case manager might say: • “So it would be hard to eat food without much taste, particularly at family gatherings where there is lots of good food.” Here the case manager accepts the client’s concerns. A poorly skilled case manager might be tempted to say: • “You don’t have too many options if you want to reduce your blood pressure.” In this response, the case manager argues for the going-on-a-diet side while the client is forced into taking the no-diet side of the discussion. Bring Out Confidence Consider a lack of confidence part of normal ambivalence. Some people will be more confident that they can pull off a change than others will be. Ask for expressions of optimism and confidence: • “Tell me about your personal strengths that will help you succeed here.” • “If you decide to change, what do you think will work for you?” • “Tell me about the confidence you have that you can do this.” These questions allow the other person to express explicitly what he or she has that will contribute to success. Generally people have made some changes or have some accomplishments in their past. Talk about that: • “You said you wanted to drop out of school, but in the end you didn’t. You graduated. Tell me how you did it.” Ask for details so that people have to talk about their successes and will hear how they overcame obstacles. Pima did not want to finish high school. She was having some trouble with English, she liked being home with her mother doing housework, and she did not have hopes of going on to college. But Pima stayed in school and graduated. The case manager explored this situation to highlight Pima’s strengths. • “Tell me about deciding to stay in school.” • “You managed to keep going? Tell me about that.” • “Tell me about some of the reasons you were so successful in completing high school?” • “Tell me a little bit about the strengths you used to see it through?” Of course, you would not ask all these questions or ask them in rapid-fire order. Everything the person says you would reflect back and explore. “So in other words you took it one day at a time but you felt like you were sort of muddling along.” These kinds of questions help people to talk in some detail about previous successes and to tell the case manager about those successes, rather than the other way around. Talking about their own success tells people why they can probably succeed in making an important change in their lives now. You might also ask people to list for you the positive strengths and characteristics they see in themselves that will help them get through a change in their lives. Again, by using reflective listening between questions, you can encourage people to tell you what strengths they have, rather than your telling them, although occasionally you may have to begin the list of strengths for the person. “Sounds like you see yourself as pretty stubborn,” might be one way to feed back what the person has told you. Facilitate Commitment Another important approach is to elicit intentions to change from the client. A case manager might ask: • “Can you describe something you would be willing to try at this point?” • “Tell me about your intentions to just get started.” Generally, at some point, people will develop a plan they believe will work for them. If you ask permission to share that plan with others, it often strengthens a person’s resolve to follow through. For example, are there family members the person wouldn’t mind inviting to hear about the decisions that have been made? Are there other workers who might be invited to hear about the change? Always ask permission to do this, make sure it is the client who does the telling, and accept any hesitance to share the plan with others. Reflect the Opposite Side Sometimes a person is reluctant to make a change. In this situation, it can be helpful if you carefully take the opposite side. That is, you reflect the reluctance back without sarcasm. This is not a cynical ploy to trick your client. The client is not an adversary but a collaborator. For example, Trudy did not want to take medication, even though she had been too depressed to work. The case manager said: • “You really feel that taking medication is a sign of weakness and will label you a ‘mental patient,’ and it seems better to you to be depressed and unable to work at this time rather than take the medicine.” It is important to hear the matter-of-fact tone the worker is using, rather than a sarcastic, facetious tone. The case manager has reflected back the reluctance and even added the other side of the situation, what it will be like without the medication. In this case, the client responded by saying: • “I suppose I should take the medication if it would really get me back to work.” Here the case manager’s empathic reflection of her client’s reluctance, along with highlighting the obvious consequences, caused the client to rethink her reluctance in a new light. Now it is the client who argues for positive change. In another example the worker said, “I can see that you find it really exciting to go to the track and make those bets. You have a lot of friends there and when you win you really feel great. It sounds like you want to continue to do that for now even though it is costing you a lot of money.” In this case the client responded with, “I don’t know. It does seem like I could find something else to do.” The client did not sound convinced but he was beginning to look at things from another perspective. The worker went on to say, “tell me a little bit about those things.” The client began to talk about his other interests. At no time did the worker resort to arguing with him about not gambling. Trapping the Client The client expresses ambivalence. She is not sure she wants to change, to stop smoking or to return to school or to take her medication. The case manager tells her why she should want to change. The client tells the case manager all the reasons why she shouldn’t want to change or why she can’t change. She talks about how it is too late to change. She admits this behavior has some negative consequences, but she focuses on all the positive rewards she gains from it. In the process, she convinces herself that she does not want to change and that she probably couldn’t if she tried. The case manager concludes the situation is hopeless. The client is resistant, in denial. The client has already made up her mind and doesn’t want to change, and so the case manager stops really trying. Another person is an alcoholic, and the case manager uses the aggressive form of confrontation with him. The case manager readily tears the person down in an effort to get him to “take a really good look” at himself. The case manager tells him he could change if he wanted to, and that the problem is he is too lazy, too self-centered, and too much of a “cry-baby.” Most of us would lose trust in a situation that produced that kind of confrontation. When the client drifts away, the case manager decides that the client is unmotivated and hopeless and labels the client “resistant.” The problem in the two scenarios just described is that arguing with people about changing and confronting clients with what bad people they are generally won’t help them make constructive changes. People stay and work on their situations and problems more often when they feel the environment is safe, they are in control of their own situation, and someone will listen to their vacillation on the way to changing (Miller and Rollnick, 2002). In the two instances described earlier, well-intentioned case managers used techniques of dubious value and unwittingly further trapped the individuals in their negative situations. People change when case managers use the attitudes and skills you learned in the previous chapters and practice the techniques noted above. Therefore, we will look next at how to enhance these skills and use them strategically. From Adversarial to Collaborative Brainstorming Spend some time with the person who is having trouble considering how to bring about desired changes. Ask the person to list as many ideas as she can think of for making the changes. You add some ideas too. As the ideas are proposed, list them without judgment. Jenny and her case manager were brainstorming about what to do about Jenny’s abusive marital situation. In the course of this brainstorming, Jenny offered several ideas that her case manager felt were impractical and even dangerous. For instance, Jenny suggested that she and her husband continue to live together and seek counseling. The case manager knew from experience that in most such cases, the mere mention of abuse before a counselor, provided the abuser went for counseling, could result in more abuse after the counseling session was over. Nevertheless, the case manager said nothing until all the options were on the list and no one could think of any other. Then, while going over the various options, the case manager asked permission to share her experiences with this particular course of action and Jenny agreed. As a result of the discussion, Jenny decided to go to counseling for herself and ask her husband to join a group for abusive men. She wasn’t sure her husband would go to such a group, but she felt this was the best way to start. In brainstorming, if all the options are laid out, usually a solution appears. Sometimes several solutions appear, or a good one is developed by combining elements of several different ideas. Offering Information and Advice In one case management unit, the clients were told what they needed to do. Phillip resented being told by his case manager that he needed to go to the welfare office; he had hoped that a change in his medication might mean he could get a job. While he felt he might need welfare at the moment until he “got on his feet,” he resented never being able to talk about what he hoped would come next. As a case manager, you should offer your own ideas only: 1. After you have fully listened to and explored those of the client 2. After first asking for permission to do so 3. When you believe it can help the person or you need to warn the person about a threat to his or her safety 4. After making it clear it is up the person whether or not he uses the advice or not It is arrogant to approach people as if we have all the answers for their lives. It is respectful and collaborative to offer ideas after we have heard theirs. Our purpose is to have people work together with us, not be put off by us. Summarizing Miller and Rollnick (2002), in their book Motivational Interviewing, discuss the importance of a good summary. If you are skilled at reflective listening, you can do summarizing well. Miller and Rollnick suggest three types of summaries that reflect back to people important points that they need to hear again. If your summary hits most of the important points, clients will move again to discussions of how the changes can take place. Collecting Summaries. In collecting summaries, you simply pull together the important points you have heard thus far. These should be short so they do not interfere with the person’s train of thought. You can end these with the question “What else?” to keep the person going on the same topic. Here is an example by a case manager: • “Let me just go over what you have said so far. You are interested in quitting drugs, particularly marijuana, and you think if you stay away from school you would be less likely to have access to it. You feel pretty sure your friends won’t understand and may even make fun of you if you tell them that you want to quit. What else?” Linking Summaries. In a linking summary, you bring together and link important points, some of which were made earlier in the discussion. These summaries are often used to clarify where the person is feeling ambivalent. The case manager gives both sides expressed so far and allows the client to explore them at the same time. • “Let’s see. You have decided that you want to stay away from school to avoid your friends and access to drugs. You feel this will help you to stop using drugs. On the other hand, you also think it would be a good idea to get your high school diploma, and you are hoping to use it to go to the community college for a degree in math.” • “So you want to stay away from school in order to avoid your friends who sell drugs and you want to get your high school diploma.” • “It seems like a good idea for you to stay away from school to avoid your friends who are selling and using drugs. At the same time you feel you need to get your high school diploma.” Notice that the case manager is using reflective listening and is matter-of-factly acknowledging the fact that there is ambivalence about what to do in this situation. In other words, the client sees the situation in two different ways and the case manager is simply reflecting those two views. The case manager in the previous examples uses the words “on the other hand” or “and” rather than “but,” and there is a reason for this. When you use the word but, you tend to negate all that was said before it. You want to acknowledge both sides of the situation as equally important. Transition Summaries. In transition summaries, you are preparing the client to move forward, whether toward another interview with you or one with the provider where the client will be referred. Your transition summary might go something like this: • “Let me see if I can summarize where we are before we stop today. You are thinking about dropping out of school in order to avoid drugs and the friends you have who push them. You feel that these friends would not understand your plan to stop using drugs and would not support your plans to stay in school and attend the community college. You feel you should get your high school diploma, and you are willing to explore how to do that with the counselor you will be seeing next week.” Summaries help people clarify, organize, and start again. These summaries are one of the ways the case manager shows acceptance and prepares the way to move forward. Always use a transition summary at the end of your time with a person so that you and the client can move toward the next contact you have together. Steering around Obstacles Just because people argue against change does not mean they are dead set against it. Some case managers are tempted to give up at this point. They hear the person giving reasons the change can’t happen or won’t work, and they decide the person is right. Maybe the client is right, but before you jump to that conclusion, it is important to shift the discussion to a point where the client can talk about what change would be like, how it might happen, and what things would be like if there were no obstacles and the client got there finally. People often come to us with no hope and little vision. They have lost faith in themselves and lost their hope for the future. The transfusion, if there is to be one, comes from the case manager who uses reflective listening and asks the right questions to help people begin to envision change. This is another way of steering around obstacles. Here is an example of how such an exchange might sound: CLIENT: I can’t see any way out of this mess. WORKER: Right now it looks pretty hopeless to you. CLIENT: Well, yes. WORKER: Tell me a little bit about what brought you here. CLIENT: My wife left, I don’t know where she is, and I feel like I’ll never get my marriage back together again. WORKER: You’d like to get your marriage on track again? CLIENT: Yeah, but I’m pretty sure she won’t go for that. She was pretty mad when she left. Said she was through and I haven’t heard from her since then. I tried to talk to her once but she changed her phone number. WORKER: Tell me about your marriage. CLIENT: (talks about a troubled relationship and his wife’s complaints that he is rarely home and is not interested in the children). WORKER: When you talk about getting the marriage back on track, what would your marriage look like then? CLIENT: (describes a better relationship, including his being more attentive). WORKER: I know things look bleak now, but let’s take a minute and try to think of all the ways you might be able to bring this about. What ideas do you have for starters? Some case managers might listen during an exchange like this—using good reflective listening and even asking good open questions—and conclude that the client is right and the marriage situation is hopeless. In this example, however, the case manager goes directly to the better vision. (You’d like to get your marriage on track again.) Later she asks for information about what his on-track marriage might look like. This brings the client to a point where he can begin to envision change. Finally, the case manager suggests they look at options for change anyway. These are just a few of the ways case managers begin to gently steer clients toward a positive vision of the future. When the case manager remains hopeful and encouraging, the client receives a transfusion of these positive attitudes from the case manager and begins to look in a new direction. When the case manager assumes that all is hopeless because that is what the client says, it is the case manager who has taken the transfusion, and it is not a very constructive or helpful transfer. Nor is it the reason the client sought the case manager’s help—so that they could both feel equally bad about change. Case managers are responsible for maintaining a positive, but realistic, attitude and helping clients explore solutions to their situations in a hopeful way. Summary Nearly every person who comes to us for help is looking for something better, some sort of improvement. The request for help, however uncertain the person might be, indicates some sense that things could possibly be healthier or more appropriate, more useful or more comfortable. Change and recovery are difficult processes and proceed at different rates for different people. Many people look at their mental or emotional illness, their addiction, their current marital situation, their criminal history, or their self-destructive behaviors and choices and decide to change. Some of them do make changes in the direction of a more stable, healthy life on their own. Some do not. When people reach out for help, it is often case managers who facilitate the move toward the change they are contemplating. Just because people reach out for our help, however, does not mean that they are entirely prepared to change their situation or their behavior. People come to us who are thinking about possibly changing or who are mandated to come by their employer or the courts. People come to us because they know they should change but really like things the way they are. They are, in a word, ambivalent. There is a conflict for them between what is presently knowable and what they think they should be doing or even what they want to do, if they thought they could. Some people have lived so long with their illness, situation, or addiction that they feel hopeless. Others just want a little coaching to get on another track in life. Still others come to us for help again and again but never make the change. Coaching, collaborating, and planning are ongoing processes as people grow and see themselves as doing more, accomplishing more. In the work you do with people, the first plan may open up to a second more independent plan that paves the way to an even more accomplished third plan. Some plans move quickly. Other times clients may become stuck and things move slowly or erratically. Expect that clients will move at the different rates and some may never completely resolve their problems. Seeing people as ultimately responsible for the direction their lives take and viewing ourselves as a resource, a coach, an encourager, and a source of support for change makes our work more effective and gives people more opportunity to recover successfully.

CHAPTER 12:

Collaborating with People for Change Introduction We have been looking at basic

communication skills that create an environment in which good rapport and meaningful change are

possible. There

are, however, additional skills and information that might make the process of

helping another person more understandable and give us a more realistic picture of how people

grow and change. These enhance what you have already learned so that you give anot

her person

more robust support for change. In this chapter we will look at some enhancements that will give you

added skill in your work. In 2002, William Miller and Stephen Rollnick wrote a book that changed the

way many people approached their clients. T

he book, Motivational Interviewing, was written primarily

for therapists working with individuals in the field of addictions. Their ideas about respecting and

collaborating with clients even under very trying circumstances speak to the values expressed

thr

oughout this textbook. Although their book is written for therapists there are numerous ideas and

skills that case managers can find helpful. For that reason, we will discuss some of these ideas case

managers can use to enhance their work with clients. Wha

t Is Change? Change has different

meanings for different people. It can mean immediate changes to their painful circumstances, or it

can mean long

-

term changes that affect the person’s future well

-

being and sense of competence.

You may begin by looking fir

st at the near term changes such as abstinence through admission to a

rehab program, relief of severe anxiety through the use of medication, or a change in an older

person’s unsafe living arrangements. But at some point you and the person will address how

to

prevent the same problems from occurring again and how to develop a worthwhile future. When

change involves giving up a way of being, an old habit, or accepting one’s diagnosis, it can be

difficult. People do not just change, as you can well imagine, ev

en when they have suffered a

setback or uncomfortable crisis, asked for help, or said they want to change. Fear, uncertainty,

stubbornness, denial, lack of confidence or a lack of hope, or even the inability to envision the future

can be significant obstac

les to change. Change takes commitment and hard work. Your role is to

support that hard work and commitment. Stages of Change Because change does not happen

quickly it is better to view it as a process. In order to help us better understand how change take

s

place Diclemente and Valesquez (2002) looked at change as a process. Their model breaks that

change process down into five stages a person might go through as he works toward changing. The

model was originally developed for a program to help expectant mo

thers stop smoking. However, we

have found that the model is useful any time a person needs to make changes that are difficult. One

person may need to stop smoking; another may need to take her medication; another may have to

lose weight for medical reason

s; a fourth person might want to upgrade his skills and return to

school; and another, in a program for parents who have physically abused their children, may want

to learn better ways to parent. When you meet a person for the first time, he or she may be

at any

one of the different points in the change process. Knowing where the person is in the change

process helps you to be more effective. Let us look at the stages. Stage One: Precontemplation

People in this stage are really not thinking about change and

therefore are not ready to change.

They may not see a need to change, or they may have tried in the past and been unsuccessful. In

this stage you might reflect back to the person the fact that she is not feeling ready to change. This

might be a time to in

vite her to look with you at her behavior. Possibly you would use an I

-

message

expressing your concern for how this behavior or lack of behavior adversely affects her. Invite her to

give you feedback. Listen to why she is reluctant to change. Explore obsta

cles she sees. Be matter

of fact and accepting of where the person is now without passing judgment or arguing. In addition,

make it clear that whether or not the person decides to change is their decision to make. You will not

pressure one way or the other

. Stage Two: Contemplation In this stage a person is willing to explore

but not yet willing to commit to change. What you might be hearing is ambivalence about making any

changes. Ambivalence is normal when we seriously contemplate changing from something

familiar

to something unfamiliar. In this stage he is still not ready to change. Again, accept that he is not

ready and reflect that back to him. “You aren’t really feeling good about doing this.” When people

CHAPTER 12: Collaborating with People for Change Introduction We have been looking at basic

communication skills that create an environment in which good rapport and meaningful change are

possible. There are, however, additional skills and information that might make the process of

helping another person more understandable and give us a more realistic picture of how people

grow and change. These enhance what you have already learned so that you give another person

more robust support for change. In this chapter we will look at some enhancements that will give you

added skill in your work. In 2002, William Miller and Stephen Rollnick wrote a book that changed the

way many people approached their clients. The book, Motivational Interviewing, was written primarily

for therapists working with individuals in the field of addictions. Their ideas about respecting and

collaborating with clients even under very trying circumstances speak to the values expressed

throughout this textbook. Although their book is written for therapists there are numerous ideas and

skills that case managers can find helpful. For that reason, we will discuss some of these ideas case

managers can use to enhance their work with clients. What Is Change? Change has different

meanings for different people. It can mean immediate changes to their painful circumstances, or it

can mean long-term changes that affect the person’s future well-being and sense of competence.

You may begin by looking first at the near term changes such as abstinence through admission to a

rehab program, relief of severe anxiety through the use of medication, or a change in an older

person’s unsafe living arrangements. But at some point you and the person will address how to

prevent the same problems from occurring again and how to develop a worthwhile future. When

change involves giving up a way of being, an old habit, or accepting one’s diagnosis, it can be

difficult. People do not just change, as you can well imagine, even when they have suffered a

setback or uncomfortable crisis, asked for help, or said they want to change. Fear, uncertainty,

stubbornness, denial, lack of confidence or a lack of hope, or even the inability to envision the future

can be significant obstacles to change. Change takes commitment and hard work. Your role is to

support that hard work and commitment. Stages of Change Because change does not happen

quickly it is better to view it as a process. In order to help us better understand how change takes

place Diclemente and Valesquez (2002) looked at change as a process. Their model breaks that

change process down into five stages a person might go through as he works toward changing. The

model was originally developed for a program to help expectant mothers stop smoking. However, we

have found that the model is useful any time a person needs to make changes that are difficult. One

person may need to stop smoking; another may need to take her medication; another may have to

lose weight for medical reasons; a fourth person might want to upgrade his skills and return to

school; and another, in a program for parents who have physically abused their children, may want

to learn better ways to parent. When you meet a person for the first time, he or she may be at any

one of the different points in the change process. Knowing where the person is in the change

process helps you to be more effective. Let us look at the stages. Stage One: Precontemplation

People in this stage are really not thinking about change and therefore are not ready to change.

They may not see a need to change, or they may have tried in the past and been unsuccessful. In

this stage you might reflect back to the person the fact that she is not feeling ready to change. This

might be a time to invite her to look with you at her behavior. Possibly you would use an I-message

expressing your concern for how this behavior or lack of behavior adversely affects her. Invite her to

give you feedback. Listen to why she is reluctant to change. Explore obstacles she sees. Be matter

of fact and accepting of where the person is now without passing judgment or arguing. In addition,

make it clear that whether or not the person decides to change is their decision to make. You will not

pressure one way or the other. Stage Two: Contemplation In this stage a person is willing to explore

but not yet willing to commit to change. What you might be hearing is ambivalence about making any

changes. Ambivalence is normal when we seriously contemplate changing from something familiar

to something unfamiliar. In this stage he is still not ready to change. Again, accept that he is not

ready and reflect that back to him. “You aren’t really feeling good about doing this.” When people