“From small beginnings come great things.” – Dutch Proverb

Speaking to a client, or parent/caregiver about addiction is easier if you understand what motivates them to change. Change is not an event, but a process that is composed of several steps, all of which begin with how you approach a client or family/caregiver in need.

How you begin to speak to a client or family in trouble will often determine how well that person will understand what you have to say and how motivated he or she will be by your assessment and recommendations. Likewise, not doing this will ensure the client is lost, tunes out, become uninvolved, and uninterested in pursuing help, often early in the first session. Engaging the client from a strength-based perspective is often the best way to proceed. From such small beginnings are built the foundations of a therapeutic relationship.

This approach, Helpful Conversations, begins with a genuine interest in knowing both what is positive and working well in your clients’ lives, as well as what is not. It is important to understand that being curious about what is working well in someone’s life is not meant to minimize their pain, anger or confusion. In fact, you need to begin your conversations by understanding what the problem is, from your clients’ perspective, while remembering what they see the problem is may not be what you or the referring agency sees as the problem. This can be accomplished by following a series of simple steps.

Understanding the Problem from the Clients’ Viewpoint: Understanding the problem — the removal of children, arrest, conviction, termination of parental rights, and/or mandate to go to treatment — from the parent/caregiver’s point of view is a critical first step of a treatment intervention. Frequently when clients come to treatment, their own drinking or drug usage is not what is seen as a problem, particularly, if they are mandated.

How do we get there? The following questions can help you begin to understand your clients’ point of view. Put these thoughts into your own words, or use these questions as written, and vary them to suit your own communication style. Remember, be empathic, be curious, and do not be judgmental. You need to know how the client thinks, and understand what is important to them, so that you can engage them. Ask the client: What brought you here? What happened? How do you see this problem? Is it a good thing that you are here? How do you feel about this problem?

Approaching a problem from your client’s viewpoint allows them to feel heard and understood. It decreases their resistance and increases the possibility that you will be effective in reaching them. This is important, since one problem that caring professionals face is that by the time clients enter the child welfare, mental health, or substance abuse system, they have become defensive about what others see as wrong with them. This is because helping systems have a tendency to become focused on the problems — what is wrong with the client — and often do not spend the same amount of time focusing on the solutions, or what is right. It is important to remember that when we focus on problems, we tend to elicit more resistance, whereas when we focus on what is right we tend to be more able to engage.

Helpful Conversations begin by working with clients on their internal dialogue, what they think and feel about themselves; and culminates when you have developed a genuine interest and knowledge of their perspective about what is positive and working well in their lives. To move from a problem-focused orientation to a solution-focused one, you will need to go beyond traditional assessment techniques and determine what motivates a client. When we focus on solutions we become curious about the following:

• If the problem went away, what would be different?
• What is the first thing that you would notice that indicated to you that the problem no longer existed?
• How would you feel in this new
situation?

Determine — The Preferred View: How Clients Want To Be Seen, and The Non-Preferred View — How Clients Do Not Want To Be Seen: A key component of being able to reach your clients is the ability to understand the strengths they wish others to see and recognize. This engagement technique, based upon the ground-breaking work of Eron and Lund (1996), deals with understanding how clients are connected to other people in two scenarios: when they are at their best — that is, when others perceive the family members as they wish to be seen (their preferred view); and when they are at their worst — when the way others perceive them makes the family members uncomfortable in some way (their non-preferred view).

First, you’ll need to find out how families want to be viewed by others — their preferred view of themselves. From here, you can seek to motivate changes in their behavior by inquiring about the feelings and consequences of being seen in ways that make them feel appreciated, safe, and secure, versus ways that do not make them good, or safe. This can be helpful for clients affected by addiction, who may have a long history of deluding others and trying to delude themselves into believing that there is no problem. This approach also allows you to engage and understand clients based on how the client understands him or herself, thus also allowing room for cultural sensitivity.

The following list of questions will provide a starting point for you to begin to get to know the families you are working with in a new and more positive manner. These questions are simply a guide; you don’t need to ask all of them, and you don’t need to ask all of them at once. Helpful conversations can take place over a series of interviews. As you begin this line of inquiry, you will likely think of other questions that you want to ask that are not on this list. Go ahead. This is an engagement technique that will allow you to gain the information you need help the clients you work with move toward positive outcomes.

• What is working well now?
• How happy are you now with your life? Your family life?
• What solutions have been successfully used in the past?
• What has worked well in the past?
• Who has been helpful in the past?
• What have they done that has been helpful?
• What feels different when you are treated in this way?
• What is not working well? Who notices this? How does this feel?

Even if your responses are met initially with sarcasm or skepticism, keep going. In an interview with a woman, Mertha, a mandated client in danger of losing her children due to her crack use, I asked her to describe the best thing about her family. Mertha said it was the love she had for her children. I then asked who noticed this love for her children? “My children,” she said. I asked, How does it feel to know that your children feel loved?” “It’s so messed up,” she said tearfully. At this point I knew I had her attention. I wasn’t seeing her “just” as a crack addict, but as a mother who loved her children, even if only she and her children were of this love.

From these types of questions, move towards discovering which parts of their life reinforce their preferred view of themselves and their non-preferred view.

• What do others say is the best/worst quality you/your family has?
• How do you feel being seen this way?
• What do your friends say about you?
• What do your friends think is working well/not working well in your life?

To make this clear, list the client’s responses in the following way:

Keep listing attributes of the family until you think you have grasped their particular unique preferred view, their non-preferred view, and the gap between the two. The key is to begin where your clients are; be curious about what they see as their strengths and their challenges; speak to them with respect; speak to them about their strengths, dreams, vision for the future; point out the inconsistency between how they wish to be seen and the situations they put themselves in resulting in a less favorable light.

Begin to Motivate Change, Address The Gap: For clients and families affected by substance abuse, the key to change lies in the gap between the individual or family’s preferred and non-preferred view of themselves — that is, the difference between how they want to be perceived by others and how they do not want to be viewed. It is when an individual or a family is in the gap that they are the most uncomfortable and they most desire to do something different. The wider the gap, the greater is their distress. For Mertha, the gap was very wide. She knew she loved her children and she knew that others did not see this. To understand how large the gap is ask:

• Are there things people say about you that you do not like?
• What do they say?
• When do they say it?
• What don’t you like about what they say?
• Are there people who see you in ways that you don’t like?
• Who are they?
• What do they see?
• What do they say about you?
• How would you describe how these people see you?
• When you are perceived this way, what happens?
• How does it make you feel to be seen in this way?

Setting Goals: The next step is to understand how to work with a client or family to set a goal. For a client or family impacted by addiction, what they view is the next step in terms of creating change may not be the change step that you see for them. Remember, change is a process composed of many steps. Each step in this process — no matter how small — should be understood, recorded, and celebrated, because every step closer to the goal makes the eventual attainment of the goal more certain, and less frightening. Sometimes change may be in terms of actions.

1. What does change look like from your client’s viewpoint?
• Are there things you are doing now that you would like to change?
• How do you want to be seen?
• What will you be doing when you are seen in this way?
• What do you want to do differently?
• How do you think it will feel when you are doing this?
• How well are you accomplishing what you would like as a family or an individual?
• What would you like to accomplish in the next year?
2. What social supports does the client have?
• What do your friends think you should do?
• When do they think you should take this action?
3. What resources does the client have for change?
• What is one thing that would bring you closer to your goal?
• Who could help you move closer to your goal?

Other times change will begin internally, with a shifting of thoughts or feelings. Ask the client:
• Are there thoughts and feelings you would like to change?
• If you changed these things, who would you like to notice this change?
• What effect would this person’s noticing your change have on you?

This type of inquiry allows you to speak with the client or family and understand not just how the family would like to be seen and treated, but also how they do not like to be seen, and how they do not like to be treated — important components to understand in determining a treatment and motivation approach. It also allows you to understand change from the client and family’s perspective, so that you may work with them in shaping and encouraging change, and not adding to their resistance by demanding more than they can conceive of doing.

Editor’s Note: This article contains information first published in The Lowdown on Families Who Get High by Patricia O’Gorman, PhD and Phil Diaz, MSW, Copyright 2004, Child Welfare League of America. Reproduced with special permission of the Child Welfare League of America, Washington, DC.

Philip Diaz, MS.W., past CEO of Gateway Community Services, Inc., in Northeast Florida, is the co-author of The Lowdown On Families Who Get High: Successful Parenting for Families Affected by Addiction. For more information or to contact them directly visit www.ogormandiaz.com.

Patricia O’Gorman, PhD, Chief Psychologist of Berkshire Farm Center and Services for Youth in Canaan, N.Y., is the co-author of The Lowdown on Families Who Get High: Successful Parenting for Families Affected by Addiction.

References
Eron, J and Lund, T. Narrative Solutions in Brief Psychotherapy, New York: Guilford, 1996.
O’Gorman, P. and Diaz, P. The Lowdown on Families Who Get High, Washington, DC: 2004.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2006, v.7, n.2, pp.48-51.

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