Critical Reflection

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Course of Study: (MHNS6004) Physical Health Care in Mental Health

Title of work: European psychiatric/mental health nursing in the 21st Century; a person-centred evidence-based approach (2018)

Section: The withdrawn or recalcitrant client pp. 1--15

Author/editor of work: Santos, José Carlos; Cutcliffe, John R.

Author of section: R Lakeman

Name of Publisher: Springer

The withdrawn or recalcitrant client

By Richard Lakeman DNSci

This is an early draft and adaptation of Lakeman, R. (in press, 2018). The withdrawn or recalcitrant client. In Santos, J. & Cutcliffe, J.R. (Eds). European Psychiatric / Mental Health Nursing in the 21st Century. London: Springer

Reprinted for Southern Cross University with permission from the author – In this paper the term ‘health professional’ is used instead of nurse

There are few groups who raise the anxiety of health professionals more than those

who don’t improve as expected, who don’t follow recommendations or who fail to

engage with them in a respectful or cooperative way. Main (1957, p. 129) suggested

that the sufferer who frustrates a keen therapist by failing to improve is always in

danger of meeting primitive human behaviour disguised as treatment. He observed

that nurses would only give a sedative when they were unable to stand the patient’s

problems without anxiety, impatience, guilt, anger or despair; whatever their

justification for the treatment. Today the reluctant, recalcitrant or a-motivated service

user is at risk of coercion and increasingly desperate and frequently non-evidence

based treatment measures. An armoury of long acting ‘depot’ medications, other

dangerous medications and ECT may be imposed on individuals who fail to improve

at the pace expected of them, often perpetuating a cycle of further resistance and

reluctance to engage with the health care system.

Assessment and the seeds of resistance People who fail to follow health care advice, who are seen to lack motivation or who

actively resist caregivers are often labelled as resistant or reluctant. For the most

part, resistance and social withdrawal are best understood as functions of the

dynamics between people. People tend to resist what they fear, what they don’t

want, and what is imposed on them. Yalom (1992, p.220) tentatively proposes

“perhaps symptoms are messengers of meaning and will vanish only when their

message is comprehended”. Health professionals need to consider what symptoms

mean. As a first example, problems with drive and motivation may be part of

recognised disorders but this does not render those symptom meaningless; often

people diagnosed and treated for mental illness have quite understandable reasons

for resisting the well-meaning ministrations of treatment teams. It is worth

familiarising yourself with some of the disorders that are thought to impact on

motivation and drive.

Withdrawal and amotivation as symptoms Social withdrawal and amotivation have long been considered part of a range of

disorders and syndromes (see table 1). In neurology, amotivation falls on a

continuum from apathy or indifference at one end, aboulia or a lack of will or initiative

in the middle and at the extreme pole, akinetic mutism (an absence of movement

and speech). Treating the primary cause where possible, optimising the person’s

physical well-being, reducing medications that aggravate amotivational symptoms,

understanding and remediating cognitive deficits and creating an enriched positive

environment are important treatment considerations. At the extreme end of the

continuum pharmacological treatments may be introduced as part of treatment e.g.

activating antidepressants, dopamine agonists and stimulants, in addition to

specialist neuropsychological treatments (Marin and Wilkosz, 2006).

Neurological disorders

 Frontal lobe

o Frontotemporal dementia

o Anterior cerebral artery infarction

o Ruptured anterior communicating artery

o Tumour

o Hydrocephalus

o Trauma

 Right hemisphere

o Right middle cerebral artery infarction

 Cerebral white matter

o Ischemic white matter disease

o Multiple sclerosis

o Binswanger’s encephalopathy

o HIV

 Basal ganglia

o Parkinson’s disease

o Huntington’s disease

o Progressive supra-nuclear palsy

o Carbon monoxide poisoning

 Diencephalon

o Degeneration or infarction of thalamus

o Wernicke-Korsakoff disease

 Amygdala

o Klüver-Bucy syndrome

 Multifocal disease

o Alzheimer’s disease (apathy may be mediated by damage to prefrontal

cortex, parietal cortex, amygdala)

Medical disorders

 Apathetic hyperthyroidism

 Hypothyroidism

 Pseudohypoparathyroidism

 Lyme disease

 Wilson’s disease

 Chronic fatigue syndrome

 Testosterone deficiency

 Debilitating medical conditions (e.g., malignancy, renal or heart failure)

Drug-induced conditions

 Neuroleptics, especially typical neuroleptics

 Selective serotonin reuptake inhibitors

 Marijuana dependence

 Stimulant (cocaine, amphetamine) withdrawal

 Cocaine-related subcortical strokes

Socioenvironmental effects (lack of reward, loss of incentive, lack of perceived control)

 Role change

 Institutionalism

Environmental effects

 Motor vehicle accident

 Falls (particularly among elderly)

 Sports-related injury

 Combat-related injury

Table 1: Conditions associated with apathy, abulia, and akinetic mutism.

Reproduced from Marin and Wilkosz (2005, p. 382).

In psychiatry degrees of amotivation may be part of common syndromes such as

depression and psychosis, and may be exacerbated by common pharmacological

treatments (particularly the major tranquilisers). Bleuler who first coined the term

schizophrenia suggested that the most prominent symptoms could be categorised as

the “4 As” i.e. problems with Associations between thoughts, Ambivalence, Affect

and Autism. Although debates continue about what were the more important

symptoms of Bleuler’s definition and in particular the importance of dissociation and

splitting (see Moskowitz and Heim, 2011), Bleuler recognised that some people with

this complex syndrome of heterogeneous symptoms withdraw from the world and

become preoccupied with their inner experience (autism). More recently distinctions

have been made between negative symptoms (an absence or diminishment of

functioning), positive symptoms (reflecting an excess) and cognitive symptoms

(Marneros, Andreasen and Tsuang, 2012). Positive symptoms (which include

delusions and hallucinations) are generally considered more amenable to treatment,

and social withdrawal and cognitive problems are generally considered to be more

disabling and resistant to pharmacological treatments. Avolition is the term used to

describe a general decrease in the motivation to initiate and perform self-directed

purposeful activities which is sometimes observed in people who may be diagnosed

with schizophrenia.

Carpenter, Heinrichs and Alphs (1985) note the importance of distinguishing

between what they call “secondary” negative symptoms from those that appear

persistent. For example they note that some negative symptoms are associated with

dramatic exacerbations of psychosis during which time people tend to try and

dampen down external stimuli to prevent being overwhelmed. Negative symptoms

may also be secondary to the use of neuroleptic drugs (which traditionally have been

very tranquilising and induce states similar to Parkinson’s disease). Negative

symptoms may also be a response to unstimulating environments (a feature of

impoverished community settings as well as traditional total institutions). More

recently it has been noted that negative symptoms may not cluster together so neatly

and unsurprisingly are inconsistently responsive to pharmacotherapy (Erhart, Marder

and Carpenter, 2006). Regardless of cause however, apathy and amotivation appear

to be the most important predictor of poor functional outcomes in research involving

people diagnosed with schizophrenia (Fervaha et al, 2013).

What may be considered a contentious part of one syndrome may sometimes be

considered an essential feature of others. Anhedonia for example is the loss of

enjoyment in activities previously found enjoyable. This concept is central to notions

of depression, although depression too is an amorphous syndrome with multiple

possible causes. People diagnosed with schizophrenia often report anhedonia, but

they have been found to enjoy activities “in the moment” as much as people without

this diagnosis (Strauss, 2013). Where they may differ is in the anticipation of

pleasurable experiences (if people don’t anticipate that an activity is likely to be

pleasurable, their motivation to do it is reduced). There is some evidence that

negative thoughts about one’s ability to successfully perform goal-directed behaviour

can prevent behaviour initiation, engagement and anticipatory pleasure (Campellone

et al, 2016). Beck et al (1979) famously observed that depression can be

characterised as holding negative beliefs about oneself, the world and the future

(known as the cognitive triad of depression). From this model the remedy is to assist

the person to adopt more reasonable, realistic thoughts about themselves and the

world, and reduce ruminations and thinking which are predictive of bad outcomes.

Finally fatigue or tiredness, chronic pain and indeed chronic stress can sap people’s

drive and motivation and can contribute to depression and hopelessness.

Resistance Resistance connotes a more active stance on the part of people to not move forward

or do what is needed (at least as perceived by therapists). Traditionally resistance

was understood as an effort to repress anxiety-provoking insights and memories,

and later was ascribed to a reluctance to accept the interpretation of the therapist. In

other words resistance is an attempt to control anxiety and it is more or less

functional, and necessary for mental health. Resistance can be a function of people’s

stage of development. For example it is a natural part of adolescence to resist the

direction and control of adults and to identify more strongly with peer groups. This

pushing against parental or adult authority assists in the process of identity formation

and is arguably essential to enable the young person to leave the comfort of home.

Resistance however can be reflected in distorted thinking, a failure to see the best

way forwards, an unwillingness to change and sometimes in overt opposition to the

health professional or helping process. Generally speaking when engaging with a

person in a therapeutic conversation, topics that appear to engender resistance and

shifts in affect should be carefully noted and attended to. Sometimes the

communication can be quite overt – “Don’t go there”, the subtext being that this topic

is potentially too anxiety-provoking right now. The health professional may use this

moment to make an empathic comment e.g. they can see or sense that this topic

causes some discomfort and ask the person whether they would prefer to discuss it

at a later time.

The notion of resistance as a feature of the psychology of the individual (whether

unconscious or an actively chosen behaviour) can be useful. However, this view can

obscure the more commonly encountered reasons for resistance, which are more to

do with the dynamics or relationships between people. A view which considers

interpersonal dynamics invites the health professional or therapist to consider how

their own behaviour may influence the behaviour of the other/s (see for example

table 2). It can be empowering to “reframe” resistance as a health professional or

therapist issue: it is widely recognised that one cannot change clients, whereas one

can change how one interacts with them.

 Resistance occurs when the health professional fails to recognise that all

clients are ambivalent about change.

 Resistance sometimes occurs when the health professional wants more for

clients than clients want for themselves. In this sense, resistance can be a

values clash between the health professional and the clients in which the

health professional’s values are overly present.

 Resistance occurs when the health professional’s goals clash with the client’s.

 Resistance is a result of the health professional being too intent on his / her

own agenda.

 Resistance occurs when the health professional or therapist is going too fast.

 Resistance occurs when the health professional does not know what to do.

 Resistance occurs when the health professional asks the wrong question or

makes a poorly worded or unacceptable statement which to the client is

unfathomable and unrealisable.

 Resistance is anything the client does that makes the health professional

uncomfortable.

 Resistance occurs when the health professional fails to cooperate with the

client.

 Whenever you feel that your client is being resistant, you must also be

resisting your client’s position. From this perspective you are being resistant.

When considered in this context, resistance is a nursing problem.

Table 2: Resistance as a health professional problem. Adapted with permission from

Reproduced from Mitchell (2012, p. 8).

Trauma and learned helplessness Childhood abuse, neglect and trauma have been found to play causal roles in

depression, anxiety disorders, post-traumatic stress disorder, eating disorders,

substance abuse, personality disorders, dissociative disorders and psychosis (Read,

Mosher and Bentall, 2004). The greater the number of adverse childhood

experiences a person is exposed to, the more likely they are to engage in risk taking

behaviour, have poor health maintenance behaviours, become ill from a range of

often preventable diseases and die prematurely (Felitti et al, 1998). Not surprisingly

people exposed to trauma early in their lives, particularly when they do not

experience secure, warm and consistent attachment to a caregiver, subsequently

have a great deal of difficulty trusting people and sustaining relationships with others

(Pearlman and Courtois, 2005). The relationships people have with health

professionals may also be tenuous – why should people trust health professionals or

other relative strangers when the person’s experience of their primary care-givers or

others in authority has been a failure to protect, inconsistency and sometimes

abuse?

The person’s experience of health and welfare systems may also exacerbate a

sense of powerlessness and mistrust, and a feeling that relationships with helpers

are shallow, coercive and uncaring. Watkins (2001, p.133) suggests that it is not

surprising that people with “severe mental health problems” are unwilling to engage

with mental health services, given there is sometimes a “legacy of distrust” founded

on dealings with statutory agencies, traumatising experiences of past

hospitalisations, enforced treatment and experiences of discrimination and racism in

their past dealings with health professionals. The experience of having to tell a story

multiple times or having to see multiple health professionals before engaging with a

primary therapist can be psycho-noxious for someone with attachment-trauma.

Health professionals need to be alert to the impact of early attachment experiences,

trauma and people’s experience of engagement with the health care system and

anticipate that many people will not conform to a compliant or acquiescent patient

role.

Health professionals may need to earn the trust of people they work with through

demonstrating unconditional positive regard (Rogers, 1957) and engaging in a

certain kind of respectful, “containing” relationship which individuals may not expect

or have experienced before. Indeed, purposefully doing the unexpected is a tool to

deal with resistance. As Mitchell (2012, p.37) notes, “… socially typical responses

are, by and large ineffective in creating therapeutic movement. Typical responses

beget typical reactions…”. Responding to hostility, blaming, anger or expressions of

hopelessness (which might ordinarily elicit rejection or defensive behaviour) with

compassion, curiosity, empathy and hope may not only help build an alliance, they

may also be inherently therapeutic.

Early research examining what happens to both animals and humans when exposed

to repeated traumatic events over which they have little control elucidated the

concept of ‘learned helplessness’ (Mikulincer, 2013). Over time people in essence

give up trying to change their situation or resist what they perceive as being beyond

their control. They become apathetic and a-motivated. Resistance can be a highly

adaptive response to situations of abuse or injustice, yet people often don’t engage

in health affirming behaviour because they don’t perceive that it will make a

difference. This can in part explain highly institutionalised behaviour. The kind of

resistance often seen in response to coercive care might also be considered a

natural, if not healthy response.

The Coerced or Involuntary Client In many parts of Europe and the Western World a large proportion of people who

use tertiary mental health services experience coercion to receive assessment or

treatment at some point in their journey. Police (sometimes in conjunction with

mental health co-responders), ambulance, paramedics and emergency services staff

frequently compel people to be assessed by mental health professionals. All

Western countries have legislation to enable such compulsory assessment and

treatment. People who have committed crimes may also be compelled to submit to

therapy including those who have committed sexual offences or who have been

identified as having problems with illicit drugs or alcohol. Not surprisingly people tend

to resist (often quite actively through anger and sometimes violence) the deprivation

of their liberty and treatment or care imposed on them.

Regardless of their legal status people may perceive that they have little choice in

their treatment or care, or about important decisions in their lives. The perception of

coercion and perception of choice are pivotal to the dynamics that may play out

between the individual and health providers. Some people who are legally required

to engage in treatment may have no perception of coercion at all, and others may

welcome help and treatment regardless of perceived legal pressure. Others may not

be subject to any legal order but fear that if they don’t comply they will be compelled

to go to hospital, lose entitlements (e.g. housing or pensions) or lose valued support.

People’s fears and perceptions around coercion need to be explored.

People may come to accept the need for coercion, particularly when they have been

engaged in dangerous behaviour but they often assert that coercive processes could

have been undertaken in a more considerate manner (Sibitz et al, 2011). In many

instances health professionals have little choice but to work with people compelled to

be involved with their service and they may be required to enforce treatment plans in

which they have little personal investment and with which they don’t agree. This

unique dynamic has rarely been explored. A useful strategy to build relationships

and to minimise conflict around coercion is for health professionals to acknowledge

this shared position with the client, being honest about what aspects of care or

treatment are non-negotiable and being clear about what choices are available.

Honesty, transparency and maximising choice are critical ingredients of recovery

orientated practices (Lakeman, 2010) and programmes such as Safewards aimed at

reducing conflict and containment measures (Bowers et al, 2015).

Motivation and readiness for change People may appear resistant or fail to adhere to treatment plans because they are

not ready to change; or more particularly, health care providers are not in step with

their stage of readiness. Motivational interviewing (MI) encompasses a range of

theories about change; it articulates ways to identify readiness and practices to

assist in shifting people towards making positive changes in their life. It is based on

an understanding that people are often ambivalent about change and may present

with conflicting emotions and thoughts about taking a particular course of action.

Ambivalent people met with highly directive or coercive demands for change from

health professionals often ‘dig in’ and resist change even further. Consider for

example, smoking cessation – most people are aware of the potential dangers of

smoking yet rarely does a health professional telling them they ‘should’ stop lead to a

commitment to changing behaviour. Resistance always arises when there is a

mismatch between the health professional’s or therapist’s aspirations for behavioural

change (ABCs) and the person’s – most commonly when the health professional’s

ABCs are high for change in particular area and the person’s are low (e.g. the health

professional believes the person should exercise more and eat less junk food,

whereas the person does not perceive this as important). The health professional

may ineffectually attempt to manipulate, persuade or cajole the person to change.

Conversely the person may have a high ABC on one issue where the health

professional’s is low (e.g. the person believes they need a medical intervention to

reduce weight whereas the health professional believes they should make lifestyle

changes). Such a clash of agendas needs to be worked through to prevent an

unproductive struggle and emphasise the importance of negotiating mutually

agreeable goals to progress.

People vary in their desire for change, perceived ability or confidence to make

changes, specific reasons for making changes, and perceptions of need for change

(consider the acronym DARN). As illustrated in table 3, the health professional can

ask questions and listen for talk about change. Note that individuals will vary in the

intensity of their desire, their confidence, how pressing their reasons and how

compelling their perceived need for change. They may for example desire something

greatly but have a low confidence in their capability to achieve it. Their ambivalence

may be expressed in statements such as “I really want to give up smoking [desire]

but I really don’t think I can [ability]”. Additionally, expressions of commitment to

change suggest a greater likelihood of actually making change, and taking actual

steps towards change may suggest that a person is ready to make change.

Change Talk Statements about… Questions to elicit change talk

Desire Preference for change: “I want to…” “I would like to…” “I wish…”

“Why would you want / like / wish / hope.… ?” How important is this to you?

Ability Capability: “I could…” “I can…” “I might be able to…”

“How would you do it, if you decided to?” “What are you able to do?” “What could you do?

Reasons Arguments for change: “I would feel better if…” “I would have more… if…”

“What are your three best reasons for …?” “Why would you make this change?” “What would be some benefits of change?”

Need Feeling obliged to change: “I ought to…” “I have to…” “I should…”

“How important is it to you…?” “How much do you need to…?”

Commitment The likelihood of change: “I am going to…” “I will…” “I intend to…”

“What do you think you will do?” “What if anything do you intend to do?”

Taking Steps Action taken: “What have you done already?” “What would be a first step for you”

“I actually went out and…” “I cut down…”

Table 3: Assessing motivation through listening and asking about change talk.

Source: Adapted from Rollnick et al (2008).

Responding to resistance and recalcitrant behaviour Just as numerous theoretical lenses can be employed for understanding resistant or

difficult behaviour, so too many different approaches may considered in determining

how best to respond. Health professionals who work with people with complex needs

ought to develop and maintain a “tool box”/set of useful psychotherapeutic skills.

Education and supervised practice in solution focused and strengths based therapies

(See for example: Ungar, 2015), positive psychology and motivational interviewing

(See for example Rollnick et al, 2008 and DiClemente and Prochaska, 1998) will be

particularly useful. The following are a precis of some general principles to consider

when working with resistant clients.

Build an alliance

The capacity to work productively with someone using any set of skills depends a

great deal on the quality of the relationship that is formed between health

professional and person. Rogers (1957) famously observed that the necessary and

sufficient conditions for personality growth of clients in therapy were: congruence on

the part of the therapist, communication to the client of the therapist's empathic

understanding, and unconditional positive regard. As has been noted, prior adverse

experience (of the patient, the health professional or both), conflicting goals and

resistant behaviour sometimes make it difficult to establish or sustain an ideal

relationship.

Trotter (2015) suggests that when working with involuntary clients (of all kinds) what

has been emphatically demonstrated to work are role clarification, reinforcing and

modelling pro-social values, collaborative problem solving, cognitive behavioural

strategies and providing a service in an integrated way. Developing the relationship,

through appropriate use of empathy, humour, the communication of optimism,

judicious use of self-disclosure, working with family and peers, and employing

principles of case management have all been found to be somewhat helpful.

Clarifying with the person what the health professional’s role is from the outset and

revisiting that periodically is helpful in building a working alliance. This is particularly

true when the health professional may have multiple roles in relation to the person.

The health professional needs to be clear with what services or tasks they may be

mandated to provide and which are negotiable.

Modelling unconditional positive regard, and maintaining a friendly, concerned and

professional countenance may be taken as a given. As important are modelling how

to contain anxiety and strong emotions, and to deal with inevitable ruptures that may

occur in the relationship. Sometimes service users may express overt hostility or

anger towards the health professional, be unable to regulate their emotions or

arouse fear and anxiety in caregivers. The health professional needs to learn to

contain these strong emotions in a similar way to that of a good-enough parent who

calmly soothes an infant experiencing distress. This skill of emotional containment

has recently been conceptualised as pivotal in the care and treatment of people with

personality disorders (Goodwin, 2005). It is now widely recognised that interpersonal

environments characterised by high expressed emotion (i.e. over involvement,

critical comments and hostility) contribute to a worsening of problematic behaviours

in a wide range of mental health presentations (van Audenhove and Van Humbeeck,

2003). Health professionals need to learn to moderate and contain their own

responses to distress and distressing behaviour (reduce expressed emotion) and

model how to solve problems.

Be motivational

Motivational interviewing involves some core skills that might be considered

universally good practice in the helping field e.g. Resisting the righting reflex,

Understanding the person’s motivation, Listening and Empowering (Rollnick et al,

2008). MI involves reaching agreement on a focus and setting an agenda, and

emphasises the “spirit” of the approach. Conversations exploring and building

motivation to change progress through exchanging information, asking useful

questions, listening reflectively and sometimes using structured approaches (e.g.

eliciting the pros and cons about a particular behaviour). Summarising progress,

returning to agenda setting, or considering the next step are part of the iterative

process.

People rarely benefit from being told that something is wrong with them, nor do they

respond well to being told what to do. A first principle in motivational interviewing is

“Resisting the righting reflex”. That is, to avoid correcting another’s course, giving

unsolicited advice or over-using direction. People have a natural tendency to resist

persuasion (no matter how well motivated). If the health professional or others argue

for change (e.g. “You ought to do…”) then the person is likely to argue against

change. Whilst there may be an occasional need to confront, inform or announce a

different viewpoint, these strategies ought to be used the least and undertaken with

great care and often with permission.

Health professionals will be well acquainted with communicating empathically (e.g.

“You feel… [identifying the correct emotion and intensity]… when or because…

[identifying accurately the trigger]”) (Egan, 2013) or using selective reflection to

enable deeper exploration about a topic of interest. A motivational form of reflection

involves selectively reflecting the change talk (illustrated in table 3) and / or the

person’s ambivalence. The goal (and natural tendency of the person) is for them to

then argue for change or a different behaviour.

Being motivational also means understanding what motivates and drives specific

individuals; understanding their values and aspirations, and whether they are

motivated primarily by intrinsic or extrinsic rewards. Where people may appear high

on desire but low on other aspects of motivation then the health professional may

need to negotiate the provision of incentives. A longstanding and robust principle of

behavioural psychology is that behaviour that is followed by positive consequences

is likely to be repeated. Providing incentives or rewards for meeting specific

behavioural goals (e.g., verified abstinence), has a strong evidence base in drug use

(Carroll and Onken, 2005) and increasingly direct incentives are proving to be useful

to secure adherence to many health treatments of importance to public health.

However, few things motivate individuals more than the praise, attention and

approval of peers and trusted people. Therefore, praise people often and

acknowledge their struggles and achievements.

Be ecological / solution focused

A tradition and tendency of health and welfare services has been the identification of

problems. Service users frequently develop or have reinforced a perception that they

are at fault and need fixing. Often however, the person’s problematic behaviour is a

response to contexts beyond their control. As Ungar (2015, p.66) notes “Individuals

are not to blame for the strategies they use to cope in contexts that deny them

choices”. An ecological approach to problems emphasises the development and

mobilisation of skills in navigation and negotiation (see table 4) to identify and

evaluate internal and external resources available to them and help people influence

which resources they receive, by whom, how, when and where. Emphasising the

idea of resourcing the person to deal with the world rather than fixing them goes a

long way to avoiding conflict and positions the health professional as an ally in

coping. Giving people something they want or need is a shortcut to building a

relationship. Indeed, whether or not people perceive they got something of value

from their first encounter with a health professional may well influence the trajectory

of the relationship from that time forward.

Being solution focused is in part a way of being as well as encompassing a set of

techniques. An elegant and respectful way to demonstrate being solution focused is

to judiciously attempt to reframe deficit and negative talk, statements about what

people don’t want into a desire for a solution, a more positive frame or a statement

about what people want.

e.g. “I really hate that doctor… he never listens to me” [person]

“You would feel warmer towards your doctor if you had more opportunities to be

heard” [health professional]

e.g. “I find it so hard to get out of bed right now” [person]

“You would like to have more energy in the mornings” [health professional]

The classic solution focused question which can elicit aspirations for positive goal

setting is the ‘miracle question’. Have the person imagine or anticipate at some point

in time in the future (the next day when they wake up, or in a year’s time) that their

problems are resolved (and they don’t need to know how it happened). Ask them to

describe how it would be and what they would be doing. A variation of this approach

can also be used with families or others in the network (Seikulla et al, 2006) – what

they imagine things might be like and how they might help people get there.

Clarify and set Meaningful Goals

People don’t tend to resist what they really want. Often people may want something

from the relationship but not always what is being offered. Early in the relationship it

is important to negotiate meaningful goals. Goal setting will proceed from an evolving

understanding of the person, their context and the resources available to them.

Where the individual’s goals appear to be discordant with the health professional or

the health team it is necessary to find some common ground. The aforementioned

miracle question can be helpful to identify areas to aspire to. It is important to explore

the person’s motivation to attain a particular goal. Goal setting involves a

commitment of one or more people to do something. As well as being specific,

meaningful, action-orientated, realistic and with a clear time frame (“SMART”) the

health professional may need to assist the person to determine who needs to do

what, and to identify motivational rewards or contingencies if the steps are not

intrinsically motivating in themselves.

Navigation Skills:

 Make resources available – Help the person identify internal and external

resources.

 Make resources accessible – Discuss how the person can access resources.

 Explore barriers to change – Discuss the barriers to change and what

resources are most likely to address which barriers.

 Build bridges to new services and supports – Discuss supports that are

available and build bridges to make new resources available and accessible.

 Ask what is meaningful – Explore which resources are the most meaningful

given the person’s culture and context.

 Keep solutions as complex as the problems they solve – Explore solutions

that are as complex (multi-systemic) as the problems they address.

 Find allies – Explore possible allies who can help the client access resources

and put new ways of coping into practice.

 Ask whether coping strategies are adaptive or maladaptive – Explore the

solutions that the person is using to cope in challenging contexts and the

consequences of the choices the person is making.

 Explore the person’s level of motivation – Discuss with the person their level

of motivation to implement preferred solutions.

 Advocate – Advocate with, or on the behalf of, the person, or show the person

how to advocate independently to make resources more available and

accessible.

Negotiation Skills:

 Thoughts and feelings – Explore the person’s thoughts and feelings about

what brought the client into contact with the helping system.

 Context – Explore the context in which problems occur, and the conditions

that sustain them.

 Responsibility – Discuss who has responsibility to change patterns of coping

that are causing problems for the person, and/or for others in the person’s life.

 Voice – Help the person’s voice be heard when they name the people and

resources necessary to make life better.

 New names – When appropriate offer new names and descriptions for

problems and explore the new meanings for the person.

 Fit – Enable the person to choose one or more descriptions of the problem

that fit with how they see the world.

 Resources – Work together to find the internal and external resources to help

the person put new solutions into practice.

 Possibilities – Enable the person to experience possibilities for change that

are more numerous than expected.

 Performance – Identify times when the person is performing new ways of

coping and discuss who will notice the changes.

 Perception – Help the person find ways to communicate to others that they

have changed or are doing better than expected.

Table 4: 20 Skills for ecological practice. Adapted from Unger (2015)

Engage allies

An ecological approach acknowledges that people are part of a social system that is

an integral part of a person’s life and is a necessary resource for a person’s well-

being. Health professionals are part of that system and whilst a fundamental goal is

to be an ally to the person, the health professional also needs to mobilise other

social resources. The health professional ought to negotiate who needs to be

involved and what roles they need to assume. Consider for example, someone who

needs to lose weight. Some people may need information (and referral to a dietitian),

some may need a coach (a referral to an exercise physiologist) or a companion to

attend an exercise class with, whilst others might need a family intervention. All

forms of family therapy and solution focused therapy acknowledge that the solutions

to problems or the resources to solve them are largely within the social group.

A sense that a team is working together to find solutions is a powerfully and

reassuring idea. It is perhaps one of the critical ingredients of programmes such as

assertive community treatment (the most evidenced based programme for people

with complex mental health needs) and is fundamental to innovative new

programmes such as open dialogue (Lakeman, 2014). Readers will note Ungar’s

(2015) list of negotiation skills (table 4) end with having the person’s voice heard and

their improvement witnessed by others. This involvement, witnessing and

engagement with others is a powerful motivator of positive behaviour and

connectedness with others is perhaps the lynchpin of mental health. People need the

opportunity to share their successes, help others and be needed by a social group.

Engaging peer support and encouraging people to be peer supporters is a sound

motivational strategy.

Lastly, health professionals need to remain engaged with allies themselves. When

enmeshed in clinical roles it is sometimes hard to see the forest (dynamics) for the

trees (behaviours). Clinical supervision or at least open dialogue with others who are

able to identify the dynamics involved in interactions, able to model the kind of

containing presence that health professionals need to model, and enrich the health

professional’s toolbox of solution focused strategies are essential to developing

effective practice with the recalcitrant or highly resistant client.

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