Building the Therapeutic Building the Therapeutic Relationship with Relationship with

AdolescentsAdolescents

Center for Youth, Family, and Center for Youth, Family, and

Community PartnershipsCommunity Partnerships

Presentation developed by Presentation developed by

Christopher Townsend MA, LPC, LCAS, CCS, NCCChristopher Townsend MA, LPC, LCAS, CCS, NCC

AdolescentsAdolescents

Keys to working with YouthKeys to working with Youth

• Know thy selfKnow thy self• Personal VisionPersonal Vision• PassionPassion• Insight and courage Insight and courage • Think beyond the boxThink beyond the box• Establish StructureEstablish Structure• Ask for help. Ask for help.

Outreach!!!Outreach!!!• Identify and praise Identify and praise

strengthsstrengths

• Never quitNever quit• Creativity is a mustCreativity is a must• Become aware and Become aware and

conscious of the cultureconscious of the culture• Stay vigilantStay vigilant• Learn motivating drivesLearn motivating drives• Incorporate motivating Incorporate motivating

factors into your workfactors into your work• Know when you are “IN Know when you are “IN

TO DEEP.” –supervisionTO DEEP.” –supervision

Positive OutcomesPositive Outcomes

• 40% cultivating strengths, supports and 40% cultivating strengths, supports and successfully coping with life events-what the successfully coping with life events-what the family brings to treatment.family brings to treatment.

• 30% the forming and maintaining of a positive 30% the forming and maintaining of a positive therapeutic relationship-youth are engaged therapeutic relationship-youth are engaged and connected to provider.and connected to provider.

• 15%-cultivating a spirit of hope and positive 15%-cultivating a spirit of hope and positive expectations-present and future focus creates expectations-present and future focus creates a sense of empowerment and possibility.a sense of empowerment and possibility.

• 15%-the specific treatment model, techniques 15%-the specific treatment model, techniques or procedures.or procedures.

Laursen, 2003Laursen, 2003

Perception is RealityPerception is Reality

• Client expectation is an indicator of Client expectation is an indicator of treatment outcome and client treatment outcome and client satisfactionsatisfaction

• Must convey to client that there is Must convey to client that there is “something in this for you.”“something in this for you.”

• Adolescent development is a key Adolescent development is a key component in engaging them into component in engaging them into therapy therapy

Emerging Themes in Adolescent Emerging Themes in Adolescent AllianceAlliance

• Therapeutic environmentTherapeutic environment

• Uniqueness of therapeutic Uniqueness of therapeutic relationshiprelationship

• Therapist characteristicsTherapist characteristics

Elements of Building a Therapeutic Elements of Building a Therapeutic Alliance: Role CharacteristicsAlliance: Role Characteristics

• TrustTrust

• Being HelpfulBeing Helpful

• Offering support, not Offering support, not advice in honoring the advice in honoring the young person’s young person’s movement towards movement towards autonomyautonomy

• HonestyHonesty

• DirectnessDirectness

• Providing EmpathyProviding Empathy

• GenuinenessGenuineness

• Nonjudgmental stanceNonjudgmental stance

• Respect adolescents Respect adolescents perspectivesperspectives

• Giving choice in Giving choice in decision makingdecision making

• Helping young person Helping young person understand the value understand the value of therapy to their of therapy to their emotional and emotional and interpersonal needsinterpersonal needs

Study: Adult Helping Qualities Study: Adult Helping Qualities Preferred by adolescentsPreferred by adolescents

• RespectRespect

• Time SharedTime Shared

• Openness Openness

• Role characteristicsRole characteristics

• RecognitionRecognition

• GuidanceGuidance

• IdentificationIdentification

• Trust Trust

• FreedomFreedom

• Like/DislikeLike/Dislike

• ResponsibilityResponsibility

• FamiliarityFamiliarity

Take Home messageTake Home message

• Be careful about preconceived Be careful about preconceived notions about what the adolescent notions about what the adolescent wants.wants.

• Give adolescent voice in the Give adolescent voice in the development of interventionsdevelopment of interventions

““When People Matter When People Matter More Than Systems” More Than Systems”

• The person centered work begins within each The person centered work begins within each and every one of us and radiates out toward and every one of us and radiates out toward others.others.

• The planning process we engage in with people The planning process we engage in with people are a mirror image of what we believe about a are a mirror image of what we believe about a person or about a group of people.person or about a group of people.

• Thinking we are person centered does not make Thinking we are person centered does not make us person centered; it is what we actually do us person centered; it is what we actually do that ultimately reveals our true priorities.that ultimately reveals our true priorities.

Michael KendrickMichael Kendrick

The ExperienceThe Experience

It is beliefs forming thoughts It is beliefs forming thoughts giving rise to words leading to giving rise to words leading to action that, in turn, create action that, in turn, create experiences.experiences.

Person-centeredness is about Person-centeredness is about intentionally being with people.intentionally being with people.

Michael KendrickMichael Kendrick

Case StudiesCase Studies

Hear and Feel What I Can’t Hear and Feel What I Can’t SaySay

TouchstonesTouchstones

• In considering our thoughts about people with In considering our thoughts about people with whom we are planning, it’s helpful to reflect upon whom we are planning, it’s helpful to reflect upon our actions against the following touchstones:our actions against the following touchstones:

– A commitment to know and seek to understand.A commitment to know and seek to understand.– A conscious resolve to be of genuine service.A conscious resolve to be of genuine service.– An openness to being guided by the person.An openness to being guided by the person.– A willingness to struggle for difficult goals.A willingness to struggle for difficult goals.– Flexibility, creativity, and openness to trying what might Flexibility, creativity, and openness to trying what might

be possible.be possible.– A willingness to enhance the humanity and dignity of A willingness to enhance the humanity and dignity of

the person.the person.– To look for the good in people and help bring it outTo look for the good in people and help bring it out

Michael KendrickMichael Kendrick

““Within each person lies a bone deep longing for Within each person lies a bone deep longing for freedom, self-respect, hope, and the chance to freedom, self-respect, hope, and the chance to make an important contribution to one’s family, make an important contribution to one’s family, community, and the world. Without healthy community, and the world. Without healthy outlets for this powerful, natural longing, the outlets for this powerful, natural longing, the desire for freedom turns into lawlessness, and the desire for freedom turns into lawlessness, and the need for self-respect is expressed in aggression need for self-respect is expressed in aggression and violence.and violence.

Without avenues to make important contributions to Without avenues to make important contributions to family, community, and the world, hopelessness family, community, and the world, hopelessness translates into dependence, depression, violence, translates into dependence, depression, violence, substance abuse and other forms of self-abuse.substance abuse and other forms of self-abuse.

No government program can help families become No government program can help families become self-reliant, contributing members of their self-reliant, contributing members of their communities unless it is built on a recognition of communities unless it is built on a recognition of the power of this bone-deep longing for freedom, the power of this bone-deep longing for freedom, self-respect, hope, and the chance to make an self-respect, hope, and the chance to make an important contribution.”important contribution.”

Major Components of Major Components of EmpowermentEmpowerment

Beliefs and AttitudesBeliefs and Attitudes

• Foundation of the model is the adoption of Foundation of the model is the adoption of beliefs and attitudes contributing to beliefs and attitudes contributing to positive attributes about people’s positive attributes about people’s capabilities and the meaningful capabilities and the meaningful participation of people in decisions participation of people in decisions affecting their welfareaffecting their welfare

• An empowerment ideology includes the An empowerment ideology includes the belief that all people have existing belief that all people have existing strengths and capabilities as well as the strengths and capabilities as well as the capacity to become more competentcapacity to become more competent

Participatory ExperiencesParticipatory Experiences

• Opportunities that strengthen existing Opportunities that strengthen existing capabilities and promote acquistion of new capabilities and promote acquistion of new compentenciescompentencies

• Participatory experiences includes Participatory experiences includes “collective action,” collaborative “collective action,” collaborative transactions, common interest and concerns transactions, common interest and concerns to bear on solutions to problems and to bear on solutions to problems and attainment of desired goals and outcomes.attainment of desired goals and outcomes.

Empowerment OutcomesEmpowerment Outcomes

• Includes behaviors that are strengthen or Includes behaviors that are strengthen or learned as a result of participatory learned as a result of participatory experiences, and the control appraisals experiences, and the control appraisals people make about their own capabilities and people make about their own capabilities and those pertaining to control over important life those pertaining to control over important life events and situation events and situation

• Control appraisals refer to cognitive attributes Control appraisals refer to cognitive attributes that people make about their past successes that people make about their past successes and beliefs in their capabilities to produce and beliefs in their capabilities to produce desired effects: intrinsic motivation, efficacy desired effects: intrinsic motivation, efficacy appraisal, locus of control, self-conceptappraisal, locus of control, self-concept

EmpowermentIdeological

Beliefs/Values

Participatory Experiences

Empowering Outcomes

A model for depicting the relationship between three major components and dimensions of the empowerment construct

Effecitve Helpgiving

Tech

nica

l Qua

lity

Helpgiver Traits/A

ttributes

Participatory Involvement

Engaging Adolescents:Engaging Adolescents:

In the Context of the FamilyIn the Context of the Family

Multidimensional Family Therapy For Adolescent Cannabis Users Multidimensional Family Therapy For Adolescent Cannabis Users (Volume 5)(Volume 5)

Learning FocusLearning Focus

• Learn more about feelings and thinking Learn more about feelings and thinking patternspatterns

• Improve communicationImprove communication• Improve problem solving skillsImprove problem solving skills• Control anger and impulsesControl anger and impulses• Gain social competenceGain social competence

This work prepares parents and adolescents in This work prepares parents and adolescents in individual sessions to come together in joint individual sessions to come together in joint sessions.sessions.

Parenting Relationship Parenting Relationship Interventions (PRI)Interventions (PRI)

• Enhancing feelings of love and commitmentEnhancing feelings of love and commitment• Validating parent’s past effortsValidating parent’s past efforts• Acknowledging difficult past and present Acknowledging difficult past and present

circumstancescircumstances• Generating hope by presenting self as an allyGenerating hope by presenting self as an ally

The objective of these interventions are to increase The objective of these interventions are to increase parent’s commitment/involvement with their parent’s commitment/involvement with their adolescent who may be seriously involved in illicit adolescent who may be seriously involved in illicit substance use and the criminal justice systemsubstance use and the criminal justice system

Motivational InterviewingMotivational Interviewing

• Engages the person in a constructive Engages the person in a constructive discussion of the impact that discussion of the impact that inappropriate/unhealthy behavior is having inappropriate/unhealthy behavior is having on their life. on their life.

• Used as a pre-treatment engagement Used as a pre-treatment engagement strategystrategy

• MI/MET rolls with the resistance of coerced MI/MET rolls with the resistance of coerced persons to help them find areas in life persons to help them find areas in life functioning that are discrepant with their functioning that are discrepant with their goals. goals.

• Not a confrontational approach.Not a confrontational approach.

Assumptions about Assumptions about MotivationMotivation

• Key to changeKey to change

• MultidimensionalMultidimensional

• Dynamic and fluctuatingDynamic and fluctuating

• Influenced by social interactionsInfluenced by social interactions

• Can be modifiedCan be modified

• Influenced by clinician styleInfluenced by clinician style

• Clinician’s task to illicit and enhance Clinician’s task to illicit and enhance motivationmotivation

Five Principles of MIFive Principles of MI

Strategies for working through resistance Strategies for working through resistance and arguments with children/adolescentsand arguments with children/adolescents

• Express EmpathyExpress Empathy• Develop DiscrepancyDevelop Discrepancy• Avoiding ArgumentsAvoiding Arguments• Roll with ResistanceRoll with Resistance• Support self-efficacySupport self-efficacy

Increasing Motivation for Increasing Motivation for ChangeChange

• Focusing on client strengthsFocusing on client strengths

• Using empathy more than authorityUsing empathy more than authority

• Recognizing co-occurring disordersRecognizing co-occurring disorders

• Centering services on the individualCentering services on the individual

• Respecting the client’s autonomyRespecting the client’s autonomy

Elements of Motivational Elements of Motivational ApproachesApproaches

• The FRAMES approachThe FRAMES approach

• Decisional balance exercisesDecisional balance exercises

• Discrepancies between personal Discrepancies between personal goals and current behaviorgoals and current behavior

• Flexible pacingFlexible pacing

• Personal contact with clients not in Personal contact with clients not in treatmenttreatment

FramesFrames• Feedback about personal risk/impairment, following Feedback about personal risk/impairment, following

assessmentassessment

• Responsibility for change placed on client, respecting their Responsibility for change placed on client, respecting their right to make choicesright to make choices

• Advice about stopping/reducing use is given to client in a Advice about stopping/reducing use is given to client in a nonjudgmental mannernonjudgmental manner

• Menus of self-directed change options and tx alternatives Menus of self-directed change options and tx alternatives are offeredare offered

• Empathic counseling-showing warmth, respect and Empathic counseling-showing warmth, respect and understandingunderstanding

• Self-efficacy or optimistic empowerment is engendered in Self-efficacy or optimistic empowerment is engendered in the clientthe client

Decisional BalancingDecisional Balancing

• Creating a list of pros and cons of Creating a list of pros and cons of changing versus not changing changing versus not changing substance abuse behaviorsubstance abuse behavior

Discrepancies Between Goals Discrepancies Between Goals and Current Behaviorand Current Behavior

• Help clients recognize a discrepancy Help clients recognize a discrepancy or gap between their future goals or gap between their future goals and their current behaviorand their current behavior

• Question: How does your being Question: How does your being oppositional to your curfew help you oppositional to your curfew help you to gain your parents trust?to gain your parents trust?

Flexible PacingFlexible Pacing

• Meet clients at their level and use as Meet clients at their level and use as much or as little time with the much or as little time with the essential task of each stage of essential task of each stage of change.change.

• Therapeutic alliance may break Therapeutic alliance may break down if clinician push pace to down if clinician push pace to quickly.quickly.

Personal ContactPersonal Contact

• Handwritten LettersHandwritten Letters

• Telephone callsTelephone calls

• School VisitsSchool Visits

• Home VisitsHome Visits

Helps to increase commitment or Helps to increase commitment or help person reengage.help person reengage.

Five Principles of MIFive Principles of MI

• Express EmpathyExpress Empathy

• Develop DiscrepancyDevelop Discrepancy

• Avoiding ArgumentsAvoiding Arguments

• Roll with ResistanceRoll with Resistance

• Support self-efficacySupport self-efficacy

Strategies for working through resistance Strategies for working through resistance and arguments with children/adolescents:and arguments with children/adolescents:

PrecontemplationPrecontemplation

Client is unaware, unable, or unwilling to Client is unaware, unable, or unwilling to change. change.

Counselor can:Counselor can:

• Establish rapportEstablish rapport

• Raise doubts about patterns of troubled Raise doubts about patterns of troubled behaviorbehavior

• Give info on risks, pros and cons of behaviorGive info on risks, pros and cons of behavior

• Don’t rub client the wrong wayDon’t rub client the wrong way

• Keep interview informalKeep interview informal

ContemplationContemplation

The client is ambivalent or uncertain,The client is ambivalent or uncertain,

considering the possibility of change.considering the possibility of change.

Counselor can:Counselor can:

• Discuss and weigh pros/cons of Discuss and weigh pros/cons of behaviorbehavior

• Emphasize client’s free choice and Emphasize client’s free choice and responsibilityresponsibility

• Elicit self-motivational statementsElicit self-motivational statements

PreparationPreparation

The client ask questions, indicates The client ask questions, indicates willingness and considerations willingness and considerations options to make specific changes. options to make specific changes. Counselor can:Counselor can:

• Clarify goals and strategiesClarify goals and strategies

• Offer menu of optionsOffer menu of options

• Negotiate contract or planNegotiate contract or plan

ActionAction

The client takes steps toward change, but is The client takes steps toward change, but is still unstable. Counselor can:still unstable. Counselor can:

• Negotiate action planNegotiate action plan

• Acknowledge difficulties and support Acknowledge difficulties and support attemptsattempts

• Identify risky situations and coping Identify risky situations and coping strategiesstrategies

• Help client find new reinforcesHelp client find new reinforces

• Support perseverance (“Sticking to the Support perseverance (“Sticking to the plan”)plan”)

MaintenanceMaintenance

Client has met initial goals, made Client has met initial goals, made changes in lifestyle and now practices changes in lifestyle and now practices coping strategies. Counselor can:coping strategies. Counselor can:

• Support and affirm changesSupport and affirm changes• Rehearse new coping strategiesRehearse new coping strategies• Review goalsReview goals• Keep in contactKeep in contact

• The fundamental Assumption of family The fundamental Assumption of family centered work is that the best way to centered work is that the best way to help a troubled child/adolescent is to help a troubled child/adolescent is to support, strengthen, and empower his support, strengthen, and empower his or her family.or her family.

• Many children’s problems are centered Many children’s problems are centered on family relationships or are played on family relationships or are played out in family. Residual effects are out in family. Residual effects are expressed in mood and behavior in expressed in mood and behavior in other environments.other environments.

• An individuals problems are more easily An individuals problems are more easily understood and more effectively treated or understood and more effectively treated or influenced within the context of his or her influenced within the context of his or her interpersonal relationships.interpersonal relationships.

• The understanding of adolescent The understanding of adolescent development began in the sixties and early development began in the sixties and early seventies. The idea during these times seventies. The idea during these times were that the adolescent developmental were that the adolescent developmental task was to establish identity and task was to establish identity and autonomy through emancipation.autonomy through emancipation.

AcknowledgmentsAcknowledgments

• The following presentation uses as its primary source:

• Empowerment, Effective Helping Practices and Family-Centered Care, Dunst Carl, Trivette Carol; Pediatric Nursing/July-August /1996/Vol. 22/No.4

• Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery by Neal Adams and Diane M. GriederEnhancing Enhancing

• Motivation for Change in Substance Abuse Treatment Motivation for Change in Substance Abuse Treatment (TIP 35)(TIP 35)

• Multidimensional Family Therapy For Adolescent Multidimensional Family Therapy For Adolescent Cannabis Users (Volume 5)Cannabis Users (Volume 5)