Instructions: Looking at the techniques you learned in this chapter, decide what techniques and skills would
be best to use in each of these situations.
- Kelly has talked and talked about getting a divorce from her husband who abuses her occasionally and has always been remote and uninvolved in their marriage. You feel strongly that she should leave because you see the abuse escalating. (a) What are some interviewing techniques you might use to help Kelly decide what she should do from here? (b) How responsible is Kelly for making a change and how responsible is the case manager?
- Marlo wants to stop drinking and get her children back. They were removed from her home a year ago after Marlo had her fourth DUI and caused an accident on a city street. She has been in jail and is now in a halfway house while on parole. (a) What are some interviewing techniques you might use to help Marlo decide what to do now? (b) What can Marlo do to help herself? How do you get Marlo to begin to talk about what she can do?
- Ben has been sober for 2 years and is now working consistently on a job he likes. He divorced his wife during the time he was in rehab because she could not give up her drinking and seemed to "want to pull me down." Now she has returned, intoxicated, and begging him to take her back. They talked into the night about "old times" and both of them got drunk. (a) What are some interviewing techniques you could use to help Ben at this juncture? (b) Who makes the final decision about what to do about Ben's ex-wife? (c) Construct a response you might give Ben that accurately and matter-of-factly reflects his ambivalence.
- Elmer does not want to be abusive to his wife and wants his marriage to resume. His wife left and is staying in a shelter where she has indicated that she will not come home until Elmer gets some help. Elmer admits to you that abusing his wife was "probably wrong" but seems to resist any ideas about how to go about changing his behavior. (a) What are some interviewing techniques you might use to help Elmer at this point? (b) How responsible is the case manager for Elmer changing his behavior? (c) Should the case manager be actively involved in getting Elmer to change and the wife to come back home? Yes? How active? No?
- Elise is using alcohol to self-medicate. She suffers from debilitating depression, but since adolescence she has turned to alcohol and street drugs to alleviate the symptoms of this depression rather than take her medication. Her reasons for doing so are that the medication is too expensive, coming in every time she needs a prescription is "a pain," and she can go to the liquor store and buy cheap liquor without the inconvenience. Lately she seems to be thinking that maybe using alcohol is not the best idea, but she is defensive about why she has used alcohol in the past. (a) What are some interviewing techniques you can use at this point to help Elise? (b) Does the case manager have an obligation to explain the negative effects of alcohol on depression or is there a way to get Elise to describe these? How would you get Elise to do that?
- Christy has a diagnosis of schizophrenia. She believes, when she is ill, that she is related to the president of the United States and she has made her way to Washington on several occasions. Both times Capitol police have arrested her and then had her hospitalized in Washington. Christy has returned home now and is talking to her case manager. She realizes when she is on her medication consistently that she is not related to the president, but she tells her case manager that she gets an overwhelming desire to see the president to warn him about "all the bad people out there." She goes on to give an elaborate description of how she is related to the president through her "earth mother." (a) Should the case manager explain to Christy how she is not related to the president? (b) Are there other interviewing techniques that the case manager could use? (c) Is the case manager responsible for making sure that Christy does not return to Washington? If yes, to what extent?
I am confused on questions 1-6 on this assignment. The textbook for this course is FUNDAMENTALS OF CASE MANAGEMENT PRACTICE chapter 12.
Here are some excerpts from the book: "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.
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.
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.
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.
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.
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.
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."
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