Strategies for Work with Involuntary Clients 9780231544283

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Strategies for Work with Involuntary Clients

Strategies for Work with Involuntary Clients Third Edition

EDITED BY

Ronald H. Rooney and Rebecca Mirick

Columbia University Press New York

Columbia University Press Publishers Since 1893 New York Chichester, West Sussex cup.columbia.edu Copyright © 2018, 2009, 1992 Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Names: Rooney, Ronald H., 1945– editor. | Mirick, Rebecca, editor. Title: Strategies for work with involuntary clients / edited by Ronald H. Rooney and Rebecca Mirick. Description: Third edition. | New York : Columbia University Press, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017038571 (print) | LCCN 2017046234 (e-book) | ISBN 9780231544283 (e-book) | ISBN 9780231182669 (hardcover : alk. paper) | ISBN 9780231182676 (pbk. : alk. paper) Subjects: LCSH: Social service—United States. | Involuntary treatment— United States. Classification: LCC HV91 (e-book) | LCC HV91 .S735 2018 (print) | DDC 361.3/20973— dc23 LC record available at https://lccn.loc.gov/2017038571

Columbia University Press books are printed on permanent and durable acid-free paper. Printed in the United States of America Cover image: © iStock

Contents

List of Illustrations

Preface

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Part I: A Foundation for Work with Involuntary Clients 1. Introduction to Involuntary Practice Ronald Rooney 2. Legal and Ethical Foundations for Work with Involuntary Clients Ronald Rooney

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3. Effectiveness with Involuntary Clients Ronald Rooney

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4. Influencing Behaviors and Attitudes Ronald Rooney

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5. Oppression and Involuntary Status Glenda Dewberry Rooney and Joan M. Blakey

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6. Trauma-Informed Care with Legally Mandated Involuntary Clients Joan M. Blakey

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Contents Part II: Practice Strategies for Work with Involuntary Clients 7. Assessing Initial Contacts in Involuntary Transactions Rebecca Mirick

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8. Initial Phase Work with Individual Involuntary Clients Rebecca Mirick

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9. Task-Centered Intervention with Involuntary Clients Ronald Rooney

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10. Work with Involuntary Families Rebecca Mirick

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11. Work with Involuntary Groups Michael Chovanec

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Part III: Practice Applications with Involuntary Problems and Settings 12. Work with Men in Domestic Abuse Treatment Michael Chovanec 13. Integrated Care and Health Disparities: Critical Patient-Provider Considerations Tamara S. Davis and Adriane Peck 14. Strengths-Based Strategies for Improving Quality of Life Among Dementia-Affected Older Adults and Their Care Partners Justine McGovern

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15. Substance Abuse Treatment: A Field in the Midst of Change Katherine van Wormer and Laura Parker

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16. Work with Unmotivated Clients Per Revstedt

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17. Bringing Up What They Don’t Want to Talk About: Use of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Alcohol Misuse and Depression in a Community College Health Center Melinda Hohman, Christine Kleinpeter, and Tamara Strohauer 18. Involuntary Clients in Public Schools: Solution-Focused Brief Therapy Interventions Cynthia Franklin, Laura Hopson, and Samantha Guz 19. Work with Involuntary Clients in Child Welfare Settings Rebecca Mirick, Julie Altman, and Debra Gohagan

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Contents 20. Work with Involuntary Clients in Corrections Chris Trotter 21. Applying the Involuntary Perspective to Management and Supervision Carol Jud and Tony Bibus 22. The Nonvoluntary Practitioner and the System Ronald Rooney Appendix

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About the Editors Contributors Index

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540 571

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Illustrations

Figure 4.1

Coercion methods

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Figure 4.2 Punishment

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Figure 4.3

Inducement or reward

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Figure 5.1

Client base and involuntary status

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Figure 5.2

Intersection of involuntary status and oppressed groups

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Figure 8.1

Preparation for initial contact

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Figure 8.2

Initial phase steps

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Figure 8.3

Socialization phase steps

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Figure 8.4 A confrontation continuum Figure 8.5 Figure 9.1

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Voluntary contracts, semivoluntary contracts, and involuntary case plans

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Advantages and disadvantages of task-centered approach in work with involuntary clients

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Figure 9.2 Adaptations of the task-centered approach to involuntary settings

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Figure 9.3

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Task-centered contract

Figure 9.4 Task implementation sequence

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Figure 9.5

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Completion of disagreeable tasks

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Illustrations Figure 9.6 Considerations in completing practitioner tasks

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Figure 9.7

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Guidelines for the middle phase

Figure 9.8 Obstacle analysis

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Figure 10.1 Initiating contact in a potentially nonvoluntary situation

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Figure 11.1 Pregroup preparation

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Preface

This book is about practice with involuntary clients, both those clients required to see a helping practitioner, such as juveniles on probation, and those pressured to “seek help,” such as an alcoholic threatened with desertion by his spouse if he does not get help. “Involuntary practitioners” are also included in the book, which includes those who may be as reluctant to work with involuntary clients as the clients are to work with them. When I (Ron Rooney) began work as a social worker, I intended to work with clients who wanted to work with me, who would be thankful for the insights I gave them, and who would pay my receptionist on the way out. The reality was that few of my clients, either then or later, were excited to work with me and they were often more interested in escaping the clutches of my agency and the law than in gaining an insight into their personalities. Most of the intervention theory I was taught ignored these clients or considered them exceptions to the rules that apply when working with voluntary clients. When I became an instructor, I continued the tradition of teaching voluntary client methods to students who worked with involuntary clients. Independent-thinking students would ask, “But how does this apply to the people who don’t want to see you?” and I would improvise answers adapting voluntary methods. This book is written in answer to those students and practitioners working with involuntary clients who strug gle to apply voluntary practice theories to involuntary practice. In fact, I suggest that involuntary clients are the rule in practice rather than the exception.

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Preface The book is written for students, instructors, and practitioners. While probably few students become members of helping professions hoping to work with people who don’t want to work with them, many experience less than voluntary client contact through their field placement and internship experiences. Students should find the book useful in explaining and guiding involuntary practice on its own terms. Such practice often appears to be undertaken as a rite of passage to provide experience and toughness before graduating to work with voluntary clients. Students may also find parallels to their own situations as “involuntary” students: if they wish to graduate, they must take some required courses “for their own good” in addition to choices in elective courses. The book is also intended for practice methods instructors who wish to add material about involuntary contact to balance sources that assume solely voluntary contact. Instructors teaching courses about social problems and practice settings that often include involuntary clients, such as child welfare, criminal justice, and chemical abuse programs, will also find the book a useful practice supplement. Finally, the book is written for practitioners who work with involuntary clients. While the book is based in the social work profession, the content is useful to other helping practitioners such as psychologists, psychiatrists, nurses, probation officers, employment counselors, child welfare workers, and youth workers. The book addresses public-agency practitioners with legal mandates, large caseloads, feelings of being unappreciated, overworked, and underpaid, as well as private-agency practitioners who may not recognize that many of their clients are, in fact, involuntary clients. The book is designed to help both involuntary practitioners and involuntary clients become at least semivoluntary. Guidelines are aimed at providing legal, ethical, and effective intervention. While involuntary clients differ from one another as much as they do from voluntary clients, involuntary clients share the fact that they did not willingly enter contact with the practitioner. Consequently, the book focuses most extensively on the socialization and contracting phase that tends to be similar for many involuntary clients. Guidelines for interventions after the contracting phase are more tentative, since there is much variation based on the specific problem and setting. The book will help practitioners prepare for involuntary contacts by providing them with realistic role expectations so that they can make clearer decisions about when they must act and when they should not act. The guidelines should lead to less hostile and uncooperative encounters, to more successful contracts, more collaboration between practitioner and client, and less “burnout” on both sides of the involuntary transaction. Finally, the book reviews the philosophical debate about the conflict between social control and caring roles, and between rehabilitation and criminal justice goals. The issues are reviewed with an aim toward increasing awareness

Preface without proposing to resolve those issues herein. The book is designed to help practitioners currently engaged in the ongoing debate. Involuntary clients sometimes have fantasies that their practitioners will leave them alone, or forget about “helping” them. Practitioners also fantasize that they can make involuntary clients change if they can just find the right magic to make those clients think differently, or if they exert enough force. This book supplies neither magic nor force. It will not provide the practitioner with a blueprint for making involuntary clients do what they do not want to do, continue to do it after intervention, and like it. The book does not provide a “laying on of hands” whereby the involuntary client is transformed into a “born again” voluntary client, thankful for insight and eager to modify his or her life patterns. It is not a manual for brainwashing or hypnotizing involuntary clients to bring them to their senses—or to the practitioner’s point of view. Nor will the guidelines eliminate the need for professional judgment in making decisions. Guidelines are based on available evidence about interventions that can be used legally, ethically, and effectively across involuntary settings and populations. Where that evidence is limited or inconclusive, alternatives are presented to help practitioners make informed choices. The book also draws on the practice literature from different involuntary populations and helping professions and on my case experiences and those of my students. Practice guidelines are frequently illustrated with selections from transcriptions derived from training videotapes, some of which were conducted with actual clients. In all cases, practitioners and clients provided informed consent and client identities are disguised. The book raises questions for further study and suggests ways to test those questions. The book is aimed at increasing understanding of the involuntary transaction and knowing how to act within it. As practitioners need to be able to explain to themselves and others why they carry out an intervention, part 1 provides a foundation with a conceptual framework for understanding the involuntary transaction and influencing client behavior and attitudes in a legal, ethical, and effective fashion. It draws widely from sources in law, ethics, intervention effectiveness across helping professions and problem areas, and social psychology. Chapters are organized around brief summaries of relevant theory and research. This third edition of the book revises, condenses, and updates the second edition. Rebecca Mirick joins me as an author and editor of this edition. She has much practice, research, and teaching experience related to involuntary clients in child welfare, outpatient mental health, and the juvenile correction system. Each chapter closes with questions to guide discussion in classes and work groups. Part 3 contains chapters written by contributing authors that cover specific areas, populations, and fields of practice in which involuntary clients are frequently encountered. We have added new chapters related to

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Preface involuntary clients with substance use disorders, with diagnoses of dementia, who are survivors of trauma, and who are seen within the context of behavioral health care. This book would not have been completed without the support and encouragement of colleagues, students, practitioners, and clients from many settings. The support of Departmental Chair Jim Reinardy from the University of Minnesota School of Social Work was essential. We want to thank our spouses, Glenda Rooney and Seth Mirick, for their patience and support during this process. We want to thank the contributing authors for their persistence and commitment in supporting the completion of this project and Jennifer Perillo of Columbia University Press for her encouragement and inspiration in completing this project. Finally, we want to thank reviewers from Columbia University Press for their helpful comments.

Strategies for Work with Involuntary Clients

Part I

A Foundation for Work with Involuntary Clients

Helping professionals often assume that their clients want to work with them. Practice with clients who do not seek a helper but rather acquiesce to pressure to seek help requires different assumptions. Practitioners need to know when and why to act with involuntary clients as well as how to work with them. Part 1 lays a foundation for legal, ethical, and effective practice with involuntary clients by providing concepts and assessing empirical evidence about effectiveness. Chapter 1 introduces involuntary practice and work with clients across a continuum of voluntarism. Chapter 2 builds a foundation of legal and ethical principles for involuntary practice. Intervention principles based on evidence of effectiveness are discussed in chapter 3; and principles of behavior and attitude change are found in chapter 4. Chapter 5 puts work with involuntary clients into the context of clients often being members of oppressed groups and presents theoretical frameworks, such as reactance theory, to help assess initial interactions between practitioners and involuntary clients. Chapter 6 adds the lens of trauma-informed care to such work.

Chapter 1

Introduction to Involuntary Practice

Ronald Rooney

Involuntary ser vice users, recipients, or clients experience limited choices for accepting ser vice. Those contacts often occur in a context of distrust between ser vice users or clients who are often culturally, racially, or economically different from ser vice providers and their agencies. This chapter describes work with two types of involuntary clients. Many involuntary clients are legally mandated to see a helper. Others experience pressure that is no less real, but is not legally mandated. As the practitioners who work with involuntary clients are often as reluctant as the clients, I also introduce the concept of the involuntary practitioner and describe the transactions between involuntary clients and practitioners. Since clients can be more or less voluntary at various times or depending on the issues, a continuum of involuntary contact is presented. The implications for members of an oppressed group are also introduced. The chapter concludes with questions for prac titioners to ask about their work with involuntary clients.

Definition of “Involuntary Client” According to Merriam-Webster Online, a client is “a person who is under the protection of another, one who engages the professional advice or ser vices of another, or a person served by or utilizing the ser vices of a social agency.” The definition best fits the circumstances of a voluntary client who recognizes a problem, is willing to tell someone about it, is willing to give that person

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A Foundation for Work with Involuntary Clients permission to advise, and, finally, is willing to change in some way (KeithLucas 1972). A voluntary client does not experience external pressures to participate in ser vices and is free to select helpers or “fire” them if ser vices are not acceptable. Some practitioners raise concerns about connotations of the term “client.” Some maintain that it can imply a relationship with an assessing expert and that the client needs that expert’s advice (McLaughlin 2009). Terms such as “consumer” or “customer” have been used to emphasize the recipient’s power to be a partner and to choose among ser vices. However, such terms can appear to represent a hollow power if an involuntary ser vice recipient is pressured to accept ser vices. For example, a mental health ser vice recipient commented that he consumed mental health ser vices the way that cockroaches consume poison (Barker and Pack 1996)! Such unwilling recipients have been described as refusers of ser vices (McLeod 2007; Smith et al. 2012). These authors recommend the term “involuntary ser vice user” to describe persons who utilize ser vice under pressure. We will refer to involuntary recipients of service as “involuntary ser vice users” or “involuntary clients,” defining the latter as persons who accept contact with helping professionals under pressure. Involuntary clients or ser vice users are individuals who are forced by those around them, such as parents, spouses, neighbors, and police, to seek assistance from official helpers (Murdach 1980). They also include persons who must deal with helping professionals because they have behaved in ways considered annoying or troublesome to society (Cingolani 1984). Involuntary clients feel pressured to seek or accept contact with a helping professional. The aforementioned definitions contain the term “client” while recognizing constraints on free choice. To retain the use of the term “client,” there must be an effort to engage persons in involuntary circumstances as informed participants in constrained circumstances. Change is not targeted at the person as a whole, but rather at his or her illegal, harmful behavior. A sexual predator may find that there is a nonnegotiable focus on his dangerous, illegal behavior toward others; but he or she can be engaged as a client around other goals, such as how to increase his freedom. If the person in involuntary circumstances has no opportunity to engage in actions to identify and increase self-defined goals, then he or she is an involuntary target rather than a client. The Social Work Code of Ethics provides guidance for ser vice to clients, but no guidance is available for targets (National Association of Social Workers 1999). Involuntary clients can be subdivided further into legally mandated clients and nonvoluntary clients, according to the source of pressure experienced. Legally mandated clients must work with a helping practitioner as a result of a current or impending legal mandate or court order (Hutchison 1987). Mandated clients comprise the majority of those seen in many public social service settings, human services departments, child welfare, probation and parole, and psychiatric wards. The helping practitioners who work with them come from

Introduction to Involuntary Practice professional fields such as social work, psychology, psychiatry, counseling, marriage and family counseling, nursing, correctional counseling, and chemical dependency training. Many others are paraprofessionals with on-the-job training. Practitioners working in public settings with mandated clients are usually aware of the involuntary nature of their client contact since legal mandates describe practitioner responsibilities and often specify client rights. In common parlance, all involuntary clients are legally mandated clients. I suggest that they are not the only ones. Some involuntary clients can be described as “nonvoluntary.” Nonvoluntary clients have contact with helping professionals through sources other than a legal mandate. For example, a referral from a doctor, a school official, or an employer can represent formal pressure to seek assistance. Referral from a spouse, partner, or family member represents informal pressure to seek help. Nonvoluntary clients include those who accept services under pressure because valued ser vices are unavailable elsewhere (Slonim-Nevo 1996). For example, though prospective adoptive parents generally might be considered voluntary, the adoptive children they seek are a scarce and valued resource. Hence, they might consider their contact with helpers, such as attending required training to qualify as potential parents, as “jumping through hoops.” Similarly, women who seek refuge in a shelter for victims of domestic violence may voluntarily seek safety from possible abuse, yet chafe at the “package deal” of requirements implicit in the acceptance of the offer of ser vice. They might prefer relief with no strings attached and object to restrictions against telephone contact with their partners or the requirement to attend groups. Nonvoluntary clients are more difficult to count because they are not defined by a legal status yet may represent the majority of clients seen in public schools, hospitals, outpatient mental health settings, day treatment programs, group homes, shelters, drug and alcohol treatment programs, youth ser vices, and family ser vice agencies. Nonvoluntary clients include persons who are not required to participate in a ser vice but are encouraged to do so if such encouragement contains pressure (Altman 2004). Nonvoluntary clients may exert their freedom by refusing to accept ser vices when their perception of their own needs does not reflect that of the referral source (Barlow et al. 2005). Informal pressures also come from the referrals of community members who attribute problems to persons whose behavior they consider inappropriate or deviant. For example, persons with dementia may be pressured to work on concerns of family members rather than attend to their own expressed concerns (McGovern 2015). Nonvoluntary clients are often cited as unable or unwilling to accept responsibility for their problems. For example, service users with substance abuse issues are frequently alleged to deny responsibility for the concerns of others (see chapter 15 in this volume). Voluntary clients are typically identified by

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A Foundation for Work with Involuntary Clients the fact that they have acknowledged their problems and sought help. An attributed problem is one that others say that a client has (Reid 1985). Involuntary clients, both mandated and nonvoluntary, have problems attributed to them that they may or may not acknowledge. For example, many of the clients in my child welfare practice had been found by a court to be abusive or neglectful yet did not acknowledge abuse or neglect as a problem. They did acknowledge, however, that the public child welfare agency was restricting access to their children and were willing to work to regain access. In later chapters, we will explore ways to work with both attributed and acknowledged problems. Both legally mandated and nonvoluntary clients are involuntary because they feel forced to remain in a helping relationship through physical or legal coercion, the unavailability of attractive alternatives, or both (Thibaut and Kelley 1959). Also, the individual may choose to remain in an involuntary relationship because the cost of leaving it is considered too high. For example, a ser vice user might consider violating his court order yet decide that the costs of an increased sentence are prohibitive. Finally, people are involuntary clients when they believe that they are disadvantaged in the current relationship because better alternatives are available. For example, public school youth who are referred for social skills classes because of disruptive classroom behavior may resent being singled out in this way. Factors that influencing the level of pressure felt by an involuntary client include the following: • How severe are the consequences if he or she refuses the ser vice? • How constrained are the client’s choices regarding who might provide help? • How much input can the client provide in the assistance offered by that helper (Slonim-Nevo 1996)? • Who initiated the contact: the client or others? • Does the potential client perceive a need for ser vice? • Does that potential client experience pressures to make life changes (Burstein 1988)? • How receptive are helping professionals to the client’s account of circumstances leading to contact?

The Involuntary Transaction Both legally mandated and nonvoluntary clients are participants in an involuntary transaction. An involuntary transaction is a dynamic exchange of resources among clients, practitioners, and agencies occurring in a shifting legal and normative context and power imbalance such that the involuntary client

Introduction to Involuntary Practice would prefer to be elsewhere. In addition, involuntary clients are disproportionately more likely to be members of oppressed groups. The four parts of this definition are examined separately here, and the concept of fate control is introduced. 1. The involuntary transaction is a dynamic exchange of resources (Hasenfeld 1987). It is commonly assumed that since clients want help and agencies wish to provide it, they share a common goal. In fact, the interests of the practitioner and those of the client are determined by their respective systems. Like all living systems, the agency and the client each want to maximize their own resources while minimizing the costs of attaining them. Therefore, a person becomes a client or ser vice user to obtain needed resources and tries to do so with minimal personal costs. The agency, via the worker, engages the client to obtain resources controlled by him or her while minimizing orga nizational costs. It is this exchange of resources that makes the systems interdependent. The transaction is dynamic because the involuntary client and the practitioner can become either more or less voluntary over time. For example, a legally mandated client who enters a domestic violence treatment program may begin at a point of low voluntarism. If, however, he experiences assistance in dealing with anger and avoiding prosecution, he may become more voluntary. In contrast, a client who experiences increasing restrictions on behavior may become less voluntary. An example is an adolescent who was removed for protection from a home where parents were law violators and cocaine users. She was cooperating with a plan for visitation with her parents when a violation of the plan occurred, causing the agency to suspend further visits. Her response was to run away from the foster home, becoming less voluntary, as her next placement was secure detention. 2. The involuntary transaction occurs in a shifting legal and normative context. Contacts between involuntary clients and practitioners are influenced by legal and professional mandates and by agency policies (Hasenfeld 1987). Legal mandates specify rights, responsibilities, and sanctions for law violations that govern practitioners and involuntary clients (Alexander 2003). Legal mandates are based in cultural norms for approved and unapproved behavior and are means for sanctioning unapproved behavior. Some norms are nearly universal, and others vary by culture and over time within a culture. Corporal punishment has been common in the United States and in other cultures and nations as an acceptable form of child discipline; only in recent decades has excessive parental discipline resulting in harm been identified as child abuse (Popple and Vecchiolla 2007). 3. The involuntary transaction occurs within a power imbalance such that the involuntary client would prefer to be elsewhere. While power differences are most obvious in legally mandated contacts, they take place in nonlegal

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A Foundation for Work with Involuntary Clients transactions as well. Such imbalances of power between clients, practitioners, and agencies can occur in four circumstances: (a) the agency depends more on outside resources than on those provided by the involuntary client; (b) there is greater demand for agency ser vices than there are supplies available; or (c) the agency has a quasi-monopoly over access to ser vices such that the client does not have ready access to alternatives; then (d) the client may have little choice but to accept ser vices on the terms they are offered (Hasenfeld 1987). Hence, the mental health consumer who could theoretically select from an array of attractive programs may find that attractive options are limited. 4. Members of oppressed groups are disproportionately represented among involuntary clients. Power imbalance falls disproportionately on this group (Solomon 1983), as evidenced by the following: (a) alternatives to preferences enforced by the majority society are lacking; (b) prejudice against the group is depersonalized; (c) bias is not private or narrow but entrenched in the larger society; and (d) members of the group are visible and aware of the discrimination (McGuire 1980). By these characteristics, many social groups such as the poor, the aged, the disabled, refugees, women, children, gays, and lesbians are often oppressed. Of particular concern are persons whose racial status is different from that of the majority and who are readily identifiable by that majority society. It has been suggested that professions such as social work have always played a significant role in social control while ser vice providers told themselves that they were providing disinterested help (Margolin 1997). Proponents of an antioppressive framework argue that a larger societal context must always be considered when factors such as racism and poverty play a role in the circumstances leading to social ser vice contact (Delgado 2001; Pollack 2004). Use of an antioppressive perspective suggests that deviant or criminal behaviors are explained by more than bad individual choices (Kendall and Pollack 2003). Proponents of this approach suggest that marginalized groups receiving the most punitive forms of care is not accidental (Graham 2004). Members of oppressed groups often find their own behaviors, rather than limited access to resources or care, as the focus of change. Hence, the emphasis is on their “private troubles” as caused by problems and pathologies in their personal situations rather than “public issues” or access to resources (Mills 1971). The reasons why members of oppressed groups are disproportionately likely to become part of an involuntary transaction are not clear. Does it occur as a result of a lack of access to resources? Are members of oppressed groups subject to ethnocentric pressures to comply with norms of the majority group? For example, the children of immigrant parents may come under the scrutiny of child welfare ser vices in part because child-rearing customs in their country of origin may differ from those of their adopted home (Togo 2006). (The concerns of members of oppressed groups as overrepresented among involuntary clients is described by Dewberry-Rooney and Blakey in greater depth in chapter 5.)

Introduction to Involuntary Practice Fate Control The perceived or existing fate control influences the power imbalance between clients and practitioners in involuntary transactions. Fate control refers to the degree to which one member of a dyad can coerce or constrain the future goals or actions of a second member if that second member decides to leave the dyad before the first member is ready. Involuntary clients experience different levels of fate control in their dealings with helping professionals (Thibaut and Kelley 1959). Coercive power is the practitioner’s ability to restrain or compel a client to an act or decision by force or threat. The existence of fate control or the power to coerce does not mean that either must or will be used (Kipnis 1972; Hasenfeld 1987). The level of voluntarism is influenced by the degree to which clients experience coerced or constrained choices, that is: (1) some choices are rewarded, (2) others are punished, and (3) preferred alternatives are often not available. 1. A coerced or constrained choice may be rewarded. Clients may “agree” to perform many actions to obtain rewards. For example, under the 1996 welfare reform legislation, clients could be required to participate in work readiness programs to qualify for assistance (Hage 2004). While they were legally free to discontinue their job training, the consequence of losing financial assistance for food and rent was constraining. 2. Coerced and constrained choices are sometimes made because preferred alternatives are punished. An alleged domestic violence perpetrator may prefer to be released with a warning. If he or she chooses to avoid treatment, however, that choice could lead to facing prosecution and a possible prison term. 3. A coerced or constrained choice may be made as the least detrimental alternative (Thibaut and Kelly 1959). Clients may also “volunteer” for a ser vice because the desired alternatives are too costly or unavailable, or because they believe some ser vice is better than no ser vice at all. For example, parents referred to child welfare agencies in which risk is not considered imminent may “choose” to participate in alternative response programs that are ostensibly voluntary but may contain the implied threat that failure to “volunteer” will result in a child protection referral (Pecora et al. 2009; Rooney 2000). Attempts by Involuntary Clients to Regain Power There are five options available to involuntary clients who wish to attempt to regain power in an unbalanced situation: (1) offer resources that the practitioner or agency will accept in exchange; (2) look elsewhere for the resource; (3) coerce or pressure the practitioner to provide the resource; (4) become resigned to getting along without the resource; or (5) meet the agency or practitioner’s requirements to get the resource (Emerson 1962).

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A Foundation for Work with Involuntary Clients Even when involuntary clients decide that they have no alternative to meeting the requirements of the resource, they still have control over the way they decide to comply. For example, involuntary clients can reframe the situation to some personal benefit by viewing their circumstances as an opportunity to learn how to deal with other unequal power situations, or by working on their own goals at the same time as meeting the conditions set by the sources of the pressure (Thibaut and Kelley 1959). (Methods to help involuntary clients reframe their circumstances are explored in chapter 8.)

A Continuum of Voluntarism Our discussion about perceived fate control and available alternatives suggests that clients can experience a range of voluntarism over time or at the same time on different issues. A continuum of voluntarism is defined by different sources of pressure, coercive and constraining modes of exerting that pressure, and a range of freedoms lost or threatened (Epstein 1988; Ivanoff, Blythe, and Tripodi 1994; Trotter 2015). The degree to which personal freedoms are limited is influenced by participation in institutional settings with a range of restrictiveness (Hawkins et al. 1992). For example, limits on freedom of action and choices are extensive in many correctional and in-patient hospital settings, whereas participation in a shelter or group home often involves moderate restrictions with more freedom to make choices. Hence, clients who experience legal mandates, high fate control, and high perceived loss of valued freedoms through placement in highly restricted settings might be expected to be highly involuntary. Conversely, should clients experience a legal mandate with high fate control yet low perceived loss of freedom, they might act as if they were the inaccessible involuntary. That is, if the client is willing to give up what the agency or practitioner has the power to take away, then the effect of coercive power is limited. For example, biological parents are sometimes challenged that if they do not have frequent, productive visits with their children in out-of-home care, they risk losing permanent custody of the children. If, however, the parents have lost the will or hope that their efforts can succeed or no longer feel committed to regaining custody, then such admonitions can be powerless to influence their behavior. Between the highly involuntary and the inaccessible involuntary client groups are the invisible involuntary clients whose circumstances are often not recognized by practitioners. For example, the nonvoluntary clients described earlier who do not face legal mandates, yet experience high fate control and loss of valued freedoms, can be considered the invisible involuntary. I describe them as invisible because their lack of voluntarism is often hidden from the practitioner and agency if the latter are only alert to legal mandates as a mea sure of voluntarism.

Introduction to Involuntary Practice Involuntary status can change over time: clients can become more or less voluntary. For example, if an involuntary client attains some of his or her own goals or comes to value some of the changes influenced by others, then he or she can become more voluntary. Conversely, many clients experience a widening net whereby their voluntarism decreases. An example is a family serving as kinship providers for the children of a sibling who wishes to adopt those children. At this point, they were voluntary clients in the sense that they were willingly pursuing a resource controlled by the agency: the legal custody of the children in their kinship care. In the course of assessing the clients’ readiness to become adoptive parents, the agency discovered that the man had become depressed and at one point had threatened to harm himself. Concerned about his readiness to become an adoptive parent, the agency strongly suggested that he seek an assessment of his predilection for depression and psychological assistance for the concern. The prospective adoptive parents were less enthusiastic about the process and questioned all the “hoops” they were being made to jump through, and considered withdrawing their application to become adoptive parents. Through sensitive work by the adoption worker, the parents came to see a psychological assessment as a fair part of a safety plan for both the children and the father, and their voluntarism was partly restored. (Skills in how to pursue such semivoluntary contracts are presented in chapter 8.) A client may acknowledge some issues while denying others. For example, a young mother who was accustomed to leaving her children unsupervised in the evening for a couple of hours when she went to a bar may have, on returning home, struck a child who was whining and injured him. When she took him to the hospital, her account of the injury was not convincing to medical personnel, who contacted the child protection agency. Her memory of the prior evening was not clear, but she did tell the investigator about striking the child. She deeply regretted this and acknowledged that drinking may have played a role in her behavior; she continued, however, to believe that leaving the children alone did not endanger them (Littell and Girvin 2004). The point here is that she acknowledged the harm done and the role of alcohol, to some extent, but did not acknowledge safety issues related to child supervision. Consequently, her voluntarism could be expected to vary according to the issue. (The consequences of differing levels of acknowledgment of problems are explored in chapter 8; stages of change and the role of motivational interviewing are explored in chapters 12, 15, and 17.) Legal status does not necessarily predict willingness to cooperate with helping professionals. Practitioners often believe that involuntary clients are unmotivated to achieve goals for themselves (Ivanoff, Blythe, and Tripodi 1994). However, a revealing study of motivation for change at intake did not support this assumption. As might be expected, legally mandated clients were overrepresented among those who were not initially open to pursuing

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A Foundation for Work with Involuntary Clients goals for personal change (O’Hare 1996). However, 25  percent of those who were legally mandated had already moved before first contact to considering decisions or taking action to change. Consequently, the assumption that legally mandated clients will not be motivated for change and that clients without legal mandates will be motivated for change is not well supported. For the purpose of this book, readers can assume that motivation is rarely completely voluntary in any case and can be enhanced in most cases. These combinations of objective and subjective factors of voluntarism make it difficult to predict which clients will be truly involuntary. In fact, there are little hard data available on voluntarism as a client characteristic (Clarkin and Levy 2004). Self-referral is, however, one clue to identifying voluntary clients. A meta-analysis of social work ser vices in mental health found that 18 percent of the clients were self-referred. Only 2 percent of the studies explicitly identified clients as involuntary. The remaining 80 percent are more difficult to classify because they were referred by agency staff, by staff in other agencies, or self-referred in coordination with staff referral (Videka-Sherman 1988). This group probably contains clients who are quite voluntary and others who are nonvoluntary and are experiencing a range of perceived loss of freedoms.

Involuntary Practice Issues for Practitioners Three major issues are raised by work with involuntary clients: (1) the practitioners who work with involuntary clients are often themselves at least in part nonvoluntary; (2) ignoring involuntarism creates frustration and confusion for involuntary clients and practitioners; (3) nonvoluntary practitioners often need to perform dual roles of helping and controlling. Nonvoluntary Practitioners Reluctance often occurs on both sides in the involuntary transaction. While involuntary clients are frequently plotting to escape, physically or psychologically, practitioners can also imagine more desirable working conditions than struggling with persons who are opposing their efforts to help. Helping professionals in these circumstances may therefore be termed “nonvoluntary practitioners.” These practitioners often understandably prefer working with voluntary clients who ask “Who am I?” rather than with the involuntary client who wonders, “Who are you, why are you here, and when will you leave?” Practitioners who work with involuntary clients come from all the helping professions. For example, psychologists and psychiatrists sometimes evaluate and provide treatment to nonvoluntary clients who do not wish to be evaluated or treated. Similarly, nurses often engage in discharge planning with patients who feel that their choices are limited. Family therapists frequently

Introduction to Involuntary Practice work with families in which at least some members are ambivalent about participating in treatment (Anderson and Stewart 1985). Since social workers often work in both public and private agencies, they frequently work with mandated as well as nonvoluntary clients. Counselors placed in hospitals, schools, clinics, and prisons are also likely to work with involuntary clients (Ritchie 1986). Finally, practitioners in private agencies and private practice also have frequent contact. For example, clients may be required to obtain an assessment or seek out treatment from a practitioner who does not have a mandated relationship with the client. Ignoring Involuntarism Assumptions based on voluntary clients can complicate involuntary practice (Cingolani 1984). The helping perspective can break down at the very beginning of treatment because of conflicting assumptions between clients and practitioners about who “owns” the problem. Frustration because involuntary clients frequently deny responsibility for problems attributed to them by others can contribute to practitioners blaming clients and labeling them as resistive or unresponsive. For example, maintaining silence or limited speech in initial contacts could be an expected response in an involuntary situation in which contact came under outside pressure. Such persons normally might be talkative under less pressured social circumstances. Similarly, expectations that clients will be honest and candidly share their experiences ignore the reality of consequences for such candor for involuntary clients (Ivanoff, Blythe, and Tripodi 1994). Rein and White have suggested that ignoring the involuntary circumstances in which some client contact takes place has been pervasive in social work practice: “We mistakenly assume that clients always come voluntarily to the professional relationship in order to get help . . . [and that] the help . . . is not coercive and does not get into questions of private faith, morals, or politics” (1981:624). They further describe practitioner beliefs that there is no conflict between individual and social needs, that power is not used, and that selfdetermination is always pursued as myths of the profession. In fact, social workers control many important client resources and frequently act to represent the agency, the community, and others, rather than the client (Hasenfeld 1987). Rein and White (1981) described three solutions practitioners use to deal with the dissonance created by the gap between the reality of power and professional myths of equality. One solution to the dilemma is to say “I am one with the client” while ignoring that other interests are also represented. A second is to maintain that “everyone really agrees” by focusing on compromise and ignoring the fact that differences of interest often remain. The third solution maintains that “I have a set of skills,” which avoids consideration of

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A Foundation for Work with Involuntary Clients differing interests between the client and the agency by focusing attention on those areas the practitioner alone can affect. Rein and White suggest, however, that these so-called solutions do not eliminate the dissonance, and a malaise results from the unsuccessful efforts to implement them. Cingolani (1984) suggests that a social conflict approach is more congruent with the circumstances of involuntary contact. In this view, therapy is a political process in which society sanctions use of power in a context of conflict of interest. Lacking such a social conflict approach or a view of involuntary transactions, practitioners often blame involuntary clients for noncompliance and for sabotaging plans made for them by others. These practitioners often express a preference for working with a more appreciative clientele. We will go beyond these three solutions in this book. While at times performing the coach or advocate role, practitioners are rarely “one with the client” and in fact often perform dual roles. (Negotiating and contracting strategies to clarify available choices is the focus of chapters 5 and 6. The focus is on practitioner skills and attempts to avoid myopia about the client’s broader environment and situation.) Performing Dual Roles Practitioners who work with involuntary clients play dual roles. On the one hand, they have responsibilities to enforce the law and to protect society and other persons. On the other hand, they have responsibilities to coach and assist clients in problem solving. These responsibilities can overlap or conflict (Burman 2004; Trotter 2015). Settings influence how these dual roles are performed. For example, a practitioner in a private setting may be able to focus extensively or exclusively on the helping or coaching role. Practitioners in public settings, however, have protection responsibilities. As noted by Regehr and Antle, “social workers are often placed in the role of working for the greater good—for example, balancing the needs of a child with the individual rights of one or both parents, or balancing the risk to society of freeing someone charged with a criminal offense with the rights of the accused” (1997:301). Hence, while social work practitioners may find themselves serving vulnerable voluntary clients who require resources and efforts to empower them to protect their rights and safety, they also often find themselves working with involuntary clients who are a threat to others. (How to play multiple roles, including representing authority and acting as a coach, is presented in chapters 7 and 8.) Involuntary clients are abundant, whether defined by legal status or response to coerced or pressured contact. Voluntarism varies on a continuum that shifts over time or at the same time according to the issue and source of pressure.

Introduction to Involuntary Practice

Discussion Questions The following questions are addressed to readers of this book who are practitioners with involuntary clients, students, supervisors, or instructors. 1. How often do the clients and ser vice users in your setting arrive with problems attributed to them by others? What are the implications for making ser vice plans based on attributed problems rather than concerns acknowledged by clients? 2. Where do the clients and ser vice users in your setting fit on the continuum of voluntarism? For those who would report that their clients are voluntary, do some of those clients make constrained choices to accept ser vices? 3. Can you think of client experience examples that support the idea of a continuum of voluntarism? For example, have you noticed clients who vary in their level of voluntarism at one time depending on the issue? 4. Have you noticed ser vice recipients whose level of voluntarism increases or decreases over time? For example, have you noticed the widening net phenomenon, whereby an initially voluntary client becomes less so over time as a result of new pressures being brought to bear? 5. Have you experienced work with clients whose voluntarism begins at a low point and increases over time? 6. What are the implications for the fact that some issues regarding involuntary status relate to observable factors such as legal mandates and others relate to subjective responses? 7. How do you respond to the concept of the invisible involuntary client? What are the implications for practitioners of ignoring pressures experienced by nonvoluntary clients and failing to distinguish them from voluntary clients? 8. What are the implications of the fact that involuntary transactions frequently occur between members of oppressed groups and social ser vice agencies in which the practitioners who serve clients often differ from them in terms of race, culture, and social class? 9. Have you experienced fate control in which choices you would prefer to be punished are rewarded or selected because they are the least detrimental alternative? 10. How are students like and unlike involuntary clients? How do their constrained choices differ from those of clients? For example, do students experience choice limitations to fit degree requirements? 11. What are the implications for practitioners of performing dual roles of protecting society and supporting clients self-determined goals?

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A Foundation for Work with Involuntary Clients 12. How can helping professionals be like or unlike involuntary clients? Have you experienced feeling as if you were an involuntary practitioner? How does that experience affect job satisfaction? How have you experienced constrained choices in that process and attempted to increase your voluntarism by making the most of your choices?

References Alexander, R. 2003. Understanding Legal Concepts That Influence Social Welfare Policy and Practice. Pacific Grove, CA: Brooks- Cole. Altman, J. C. 2004. Engagement in Neighborhood-Based Child Welfare Services: Final Report. Garden City, NY: Adelphi University School of Social Work. Anderson, C., and S. Stewart. 1985. Mastering Resistance: A Practical Guide to Family Therapy. New York: Guilford. Barker, I., and E. Pack. 1996. “User Involvement: A Decade of Experience.” Mental Health Review 1 (4): 5–13. Barlow, J., S. Kirkpatrick, D. Stewart-Brown, and H. Davis. 2005. “Hard-to-Reach or Out-ofReach: Reasons Why Women Refuse to Take Part in Early Interventions.” Children and Society 19 (5): 199–210. Burman, S. 2004. “Revisiting the Agent of Social Control Role: Implications for Substance Abuse Treatment.” Journal of Social Work Practice 18 (2): 197–210. Burstein, B. 1988. “Involuntary Aged Clients: Ethical and Treatment Issues.” Social Casework (October): 518–524. Cingolani, J. 1984. “Social Conflict Perspective on Work with Involuntary Clients.” Social Work 29 (5): 442–446. Clarkin, J. F., and K. N. Levy. 2004. “The Influence of Client Variables on Psychotherapy.” In Handbook of Psychotherapy and Behavioral Change (5th ed.), ed. M. J. Lambert, 194–226. New York: John Wiley. Delgado, M. 2001. Where Are All the Young Men and Women of Color? Capacity Enhancement Practice and the Criminal Justice System. New York: Columbia University Press. Emerson, R. 1962. “Power-dependency Relations.” American Sociological Review 27:31–41. Epstein, L. 1988. Helping People: The Task- Centered Approach. Columbus, OH: Merrill. Graham, M. 2004. “Empowerment Revisited: Social Work, Resistance and Agency in Black Communities.” European Journal of Social Work 7 (1): 43–56. Hage, D. 2004. Reforming Welfare by Rewarding Work. Minneapolis: University of Minnesota Press. Hasenfeld, Y. 1987. “Power in Social Work Practice.” Social Service Review 61 (3): 469–483. Hawkins, R., M. Almeida, B. Fabry, and A. Reitz. 1992. “A Scale to Mea sure Restrictiveness of Living Environments for Troubled Children and Youths.” Hospital and Community Psychiatry 43: 54–58. Hutchison, E. 1987. “Use of Authority in Direct Social Work Practice with Mandated Clients.” Social Service Review 61(December): 581–598. Ivanoff, A., B. Blythe, and T. Tripodi. 1994. Involuntary Clients in Social Work Practice: A Research-Based Approach. New York: Aldine de Gruyter. Keith-Lucas, A. 1972. Giving and Taking Help. Chapel Hill: University of North Carolina Press.

Introduction to Involuntary Practice Kendall, K., and S. Pollack. 2003. “Cognitive Behavioralism in Women’s Prisons: A Critical Analysis of Therapeutic Assumptions and Practices.” In Gendered Justice: Addressing Female Offenders, ed. B. Bloom, 69–96. Durham, NC: Carolina Academic Press. Kipnis, D. 1972. “Does Power Corrupt?” Journal of Personality and Social Psychology 24 (1): 33–41. Littell, J., and H. Girvin. 2004. “Ready or Not: Uses of the Stages of Change Model in Child Welfare.” Child Welfare 83 (4): 341–365. Margolin, L. 1997. Under the Cover of Kindness: The Invention of Social Work. Charlottesville: University Press of Virginia. McGovern, J. 2015. “Living Better with Dementia: Strengths-based Social Work Practice and Dementia Care.” Social Work in Health Care 54 (5): 408–421. McGuire, D. 1980. A New American Justice. Garden City, NY: Doubleday. McLaughlin, H. 2009. “What’s In a Name: ‘Client,’ ‘Patient,’ ‘Customer,’ ‘Consumer,’ ‘Expert by Experience,’ ‘Ser vice User’—What’s Next?” British Journal of Social Work 39 (6): 1101–1117. McLeod, A. 2007. “Whose Agenda? Issues of Power and Relationship When Listening to Looked-after Young People.” Child and Family Social Work 12 (3): 278–286. Merriam-Webster OnLine, s.v. “client,” accessed August  19, 2017, http://www.m-w.com /dictionary/client. Mills, C. W. 1971. The Sociological Imagination. New York: Penguin. Murdach, A. 1980. “Bargaining and Persuasion with Non-voluntary Clients.” Social Work 25 (6): 458. National Association of Social Workers (NASW) Code of Ethics. 1999. https://www .socialworkers.org /About/Ethics/Code-of-Ethics/Code-of-Ethics-English (accessed October 17, 2017). O’Hare, T. 1996. “Court-ordered versus Voluntary Clients: Problem Differences and Readiness for Change.” Social Work 41 (4): 417–422. Pecora, P., J. Whittaker, A. Maluccio, R. P. Barth, D. DePanfilis, and R. D. Plotnick. 2009. The Child Welfare Challenge: Policy, Practice, and Research. New Brunswick, NJ: AldineTransaction. Pollack, S. 2004. “Anti-oppressive Social Work Practice with Women in Prison: Discursive Reconstructions and Alternative Practices.” British Journal of Social Work 34: 692–707. Popple, P., and F. Vecchiolla. 2007. Child Welfare Social Work: An Introduction. Boston: Pearson. Regehr, C., and B. Antle. 1997. “Coercive Influences: Informed Consent in Court-mandated Social Work Practice.” Social Work 42 (3): 300–306. Reid, W. 1985. Family Problem Solving. New York: Columbia University Press. Rein, M., and S. White. 1981. “Knowledge for Practice.” Social Service Review. 55 (1): 1–41. Ritchie. M. 1986. “Counseling the Involuntary Client.” Journal of Counseling and Development 64 (8): 516–518. Rooney, R. H. 2000. “How Can I Use Authority Effectively and Engage Family Members?” In Handbook of Child Protection Practice, eds. H. Dubowitz and D. DePanfilis, 44–46. Thousand Oaks, CA: Sage. Slonim-Nevo, V. 1996. “Clinical Practice: Treating the Non-voluntary Client.” International Social Work 39: 117–129. Smith, M., M. Gallagher, H. Wosu, J. Stewart, V. Cree, S. Hunter, S. Evans, C. Montgumery, S. Holiday and H. Wilkinson. 2012. “Engaging with Involuntary Ser vice Users: Findings from a Knowledge Exchange Project.” British Journal of Social Work 42: 1460–1477. Solomon. B. 1983. “Value Issues in Working with Minority Clients.” In Handbook of Clinical Social Work, eds. A. Rosenblatt and D. Waldfogel, 866–877. San Francisco: Jossey-Bass.

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A Foundation for Work with Involuntary Clients Thibaut, J., and H. Kelley. 1959. The Social Psychology of Groups. New York: John Wiley. Togo, P. 2006. The Nexus of Parenting Practices and Acculturation. Challenges Among African Immigrants and Refugees in the United States. PhD diss., School of Social Work, University of Minnesota. St. Paul. Trotter, C. 2015. Working with Involuntary Clients: A Guide to Practice. 3rd ed. London: Sage. Videka-Sherman, L. 1988. “Meta-analysis of Research on Social Work Practice in Mental Health.” Social Work 33 (4): 325–337.

Chapter 2

Legal and Ethical Foundations for Work with Involuntary Clients

Ronald Rooney

Practice with involuntary clients or ser vice users requires a legal and ethical foundation. The legal foundation determines the conditions under which practitioners can restrict behavior. Practice with involuntary clients often entails carrying out legal mandates or investigating harm to self or others. For example, child abuse and vulnerable adult investigations are designed to determine whether serious danger has or might be imminent. This chapter presents guidelines concerning legally mandated investigations. The ethical foundation guides practitioners in areas not covered by law. For example, the practitioner or employing agency may believe that harm is imminent but has not yet reached a legal threshold wherein involuntary intervention is appropriate. Practitioners need to know how to support maximum feasible self-determination. They also need to know when paternalistic or beneficent action can be in the client’s best interests. This chapter provides guidelines for ethical intervention with involuntary clients and offers practitioners assistance in answering questions about legal and ethical intervention with involuntary clients such as the following: • How can I act to support due process and informed consent for involuntary clients? • What are my responsibilities related to confidentiality? • How do I avoid malpractice and reduce liability? • How do I perform the dual roles of helping clients and protecting society?

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A Foundation for Work with Involuntary Clients • How can I support maximum feasible client self-determination and empowerment while acting to protect vulnerable persons and society? • When am I justified in acting to limit self-determination or acting paternalistically in the client’s best interest?

The Clash Between Legal and Helping Perspectives Helping professionals have often been ambivalent about the expanding role of the legal system in protecting client rights (Alexander 2003). For example, practitioners often learn new legal procedures that can become obsolete by the time they appear in training texts (Sadoff 1982). In fact, the law plays such a large role in practice with legally mandated clients that practitioners have been urged to “think like lawyers” (Dickson 1998) and they have complained of being “belegaled” (Madden 1998:4). Attorneys and mental health professionals often approach the same situations from different perspectives, such that lawyers are more concerned with the sanctity of legal principles and advocacy of civil rights, while mental health professionals are more inclined to provide help regardless of issues of loss of liberty (Melton et al. 1987; Cull and Roche 2001). Some attorneys argue that this commitment to help often means that practitioners act as if client rights are forfeited on entry into a program (Martin 1981). Further, clients with mental illness or retardation and juvenile clients who are institutionalized are often members of oppressed groups with limited power to protect their own rights. Practitioners working with involuntary clients are often caught in controversies over community and individual rights and frequently have to deal with fluctuating standards (Szmukler 2008; Rhodes 1986; Regehr and Antle 1997). The pursuit of legal, ethical, and effective practice involves conscious use of practitioner influence to affect the behaviors, attitudes, and decisions of involuntary clients in some situations and conscious efforts to avoid influence in others. Public practitioners are often mandated to act to protect the community or defenseless persons from self-harm or harm from others (Fowler 2003). Similarly, practitioners in private settings often attempt to influence nonvoluntary clients to make wise decisions by bringing to bear agency, referral source, and family, as well as their own pressures. Helping professionals are rarely trained in how to carry out their legal roles. Social workers, for instance, are advised in their professional code of ethics to “make every effort to foster self-determination on the part of clients” and to consider their responsibilities to the client as primary. Yet are also advised to “adhere to commitments made to the employing agency” (NASW 2008). As these directives often conflict, social workers are left with difficult choices (Reamer 1999). Confusion often ensues about the nature of the responsibilities

Legal and Ethical Foundations for Work with Involuntary Clients to involuntary clients, family members, the agency, and the community (Regehr and Antle 1997). One frequently cited solution to these dilemmas is for the agency-based practitioner to be guided primarily by law and agency requirements. In fact, many practitioners begin their professional work with legal in-service training or an informal trial-and-error approach to learning the law, policies, and procedures, since these areas are often inadequately covered in their academic programs. Such training contains procedural safeguards for legally mandated clients designed to curb arbitrary discretion and guarantee fundamental fairness such that constitutional rights to life, liberty, and property are not endangered without due process. The perspective presented here is in line with Martin’s observation that “rather than assuming there is an inherent conflict between rights and therapy, professionals must realize that appropriate therapeutic intervention includes client rights” (Martin 1981:9).

Principal Legal Issues in Work with Involuntary Clients Our discussion of legal issues begins with a brief survey of due process, informed consent, confidentiality, and privileged communication, followed by liability and malpractice. Due Process Under the fifth, eighth, and fourteenth amendments to the U.S. Constitution, citizens are entitled to due process of law before they can be deprived of life, liberty, or property (Alexander 2003). The fifth amendment guarantees that individuals cannot be required to testify against themselves, while the eighth amendment guarantees freedom from cruel and unusual punishment and the fourteenth amendment states that a citizen cannot be deprived of his or her civil rights without fundamental fairness. Due process safeguards include some or all of the following: the right to adequate notice of charges, an open hearing before an impartial examiner, right to counsel, the rights to cross-examine and present witnesses, the right to written decisions giving reasons based on facts, and the right to appeal decisions (Schroeder 1995). The specific forms of notice vary, and in some states there is a right to trial by jury (Saltzman, Furman, and Ohman 2016). Informed Consent Informed consent refers both to a process of continually informing clients about intervention plans and the use of forms so that those clients can provide

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A Foundation for Work with Involuntary Clients consent to proposed treatment with adequate knowledge of costs, benefits, and alternative procedures (Reamer 1987). Informed consent is not satisfied by the mere completion of a written form (Rozovsky 1987). A valid consent form is not an open-ended, blanket agreement but rather an agreement to specific procedures based on adequate information. Informed consent is relevant for conditions such as legally involuntary mental commitment, chemical dependency, use of restraints, aversive treatment, isolation, abortion, contraception, sexual disorders, and sterilization (Reamer 1987). Mental patients also have the right to be informed about treatment, to refuse treatment on religious grounds, and to participate in experimental treatment or research only after providing informed consent. Valid informed consent must be obtained without coercion or undue influence such that a person is able to refuse or withdraw consent. However, according to Melton et al., “the available research raises substantial doubt as to whether most consent in health and mental health care is truly voluntary” (1987:255). For example, Saltzman, Furman, and Ohman note that some hospitalizations called “voluntary” are in fact only agreed to under the threat of commitment (Saltzman et al. 2016). There have been court rulings that institutionalized mental patients are in inherently coercive situations. If release from the institution depends on patient cooperation, they may provide informed consent to intrusive procedures such as psychosurgery (ibid.). Circumstances do exist, however, in which informed consent is not immediately required: (1) when actions must be taken in genuine emergencies to preserve life and (2) when a person has a mental illness or incapacitating chemical or alcohol dependency such that he or she is currently incapable of providing such consent (Reamer 1987). The ability to provide consent cannot be determined by membership in a general class of persons such as those with severe mental illness, but must be based on a mental status examination. If mental status fluctuates, it may be possible to give or withdraw consent during lucid phases. Standards used to determine competency include the ability to comprehend relevant facts, appreciate one’s circumstances, understand and manipulate information, and test reality. Research on implementation of informed consent suggests, however, that the spirit of informed consent is often violated. Consent forms are often drafted in legal terms incomprehensible to clients or presented as a mere formality, alternative forms of treatment are rarely presented, and full information about negative or harmful side effects is often omitted (Lidz et al. 1984). Rather than treating informed consent as pro forma, it should be an opportunity to engage in a collaborative relationship consistent with a therapeutic philosophy of basic respect for all people (Melton et al. 1987). There are inherent difficulties in appropriately supporting the principle of informed consent. For example, the risks and benefits of an assessment can-

Legal and Ethical Foundations for Work with Involuntary Clients not always be determined in advance. The power imbalance between practitioners and clients undermines free consent. Client ability to provide valid consent can also be reduced because of language or cultural barriers, diminished capacity, or the developmental capacity of juveniles (Regehr and Antle 1997). It is recommended that the practitioner clarify his or her role when serving two or more people, and not use interviewing skills to “trick” a client into disclosing information that might harm the client (ibid.). Another challenge for supporting informed consent is the fact that practitioners cannot precisely describe the outcome of contact, predicting all contingencies. Finally, while practitioners may offer choices within treatment, the treatment itself may occur because of coercive pressure (Ryder and Tepley 1993). Confidentiality and Privileged Communication Confidentiality refers to the obligation of helping professionals not to reveal without permission records or client information obtained in the course of practice (Saltzman et al. 2016; Dickson 1998). Privileged communication refers to a client’s right to prevent a helping practitioner from testifying the client in a court of law without permission (Albert 2000). Some helping professions do not have privileged communication and others have it in some states but not in others (Schroeder 1995). Consequently, practitioners should be prepared for possible subpoena of records. Confidentiality of records such that the records or information contained therein cannot be revealed without prior client consent is a goal of the helping professions. However, some professions have more legal rights in some areas than in others and in some circumstances a court can order helping professionals to turn over records. This often leads to keeping superficial records to avoid being legally required to turn over information that might be damaging. Circumstances exist in which a practitioner is required to violate privilege. For example, if a client is currently suicidal or imminently violent toward a certain person, the practitioner is obliged to breach confidentiality for that person’s protection or issue a warning to the intended victim (Reamer 2015b; Tarasoff v. Regents of the University of California 1976). In addition, practitioners are legally required to report possible child abuse. Practitioners need to make their relationship with clients clear from the beginning so that clients understand the circumstances under which their confidentiality may be violated (Melton et al. 1987). Clients often have legal access to their own records, which should be provided in a manner that retains protection of the confidentiality of others referred to in the records.

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A Foundation for Work with Involuntary Clients Liability and Malpractice Helping professionals are increasingly faced with legal liability and malpractice concerns (Reamer 2015b). Malpractice is negligent practice, inconsistent with the standards of a prudent professional in which: (1) a legal duty existed to a client; (2) the practitioner was negligent in performing that duty; and (3) the client was harmed by that negligence (Reamer 2015b). Malpractice can be based on incorrect diagnosis or treatment, harmful effects of treatment, poor results, failure to consult or refer appropriately, injury resulting from violation of confidentiality, or a failure to warn (Saltzman et al. 2016). Malpractice has a longer legal history in the medical profession, in which the doctor’s responsibility to the patient is clearer. For professionals such as social workers and family therapists, a definition of the duty owed to clients is often less clear. In addition, a professional standard of care must be in place by which the action can be assessed as in accordance with a duty or dereliction of duty. The standard of care is sometimes hard to define, but practitioners are expected to act within established parameters (Madden 1998). Additional concerns have been raised, however, about the liability of public agency employees, who are less frequently protected by immunity from litigation (Saltzman et al. 2016). For example, child protection workers can be sued for failure to reopen or investigate possible child abuse, improper selection of or failure to monitor placement, wrongful removal or detention, and failure to locate permanent placements. The best protection against such suits is careful practice, following procedures that are compliant with the law, consulting with colleagues, reviewing ethical standards, obtaining necessary legal consultation, keeping good records, ensuring access to adequate supervision, and documenting decision-making steps (Reamer 2015b).

Legal Issues Applicable Across Populations and Settings The first edition of this book contained extensive information about legal issues within a variety of settings and populations. This information rapidly becomes dated and more specific information is needed to guide practice with a particular population. A more extensive discussion is presented in part 3, which deals with specific populations and settings. This chapter provides information about specific principles that apply across populations and settings. It focuses on three issues: the least restrictive alternative principle, the right to treatment, and freedom from unnecessary treatment.

Legal and Ethical Foundations for Work with Involuntary Clients Least Restrictive Alternative Some federal district and state courts have interpreted the fourteenth amendment to include rights to the least restrictive alternative—that is, when two methods are available that would achieve the same result, the individual is entitled to the least restrictive form (Wodarski 1980). For example, courts can order involuntary commitment only when less restrictive alternatives are unavailable or inappropriate (Madden 1998). Right to Treatment Some courts and state statutes, including Rouse v. Cameron (373 F.2d 451 (125 U.S. App. D.C. 1966)),. have moved to ensure that persons deprived of their liberty for purposes of treatment are entitled to adequate treatment that is not merely custodial. In Johnson v. Solomon (Fed. Suppl. 1979, 484: 278–320), Judge Robert Conrad wrote in defense of a right to treatment: “To deprive a citizen of his or her liberty upon the altruistic theory that the interference is for humane and therapeutic reasons and then fail to provide adequate treatment violates the very fundamentals of due process. . . . If adequate treatment is not provided, it is equal to incarceration.” While the Supreme Court has not ruled that under the Constitution there is a right to treatment, the Court has strongly suggested that a person cannot be confined to ensure a better living standard and that fencing in the harmless to protect citizens from exposure is not justified (Alexander 2003). Involuntary commitment must contain proper treatment that is the least restrictive, patients must be informed of their rights, and care must be monitored to ensure that progress is reviewed (Reamer 2015b). Since there is no constitutional right to medical care, those who are voluntarily admitted for treatment do not have the same access to a right for treatment as the involuntarily committed (Saltzman et al. 2016). Informed consent is relied upon to protect the rights of voluntary clients. Clients must therefore be competent to provide voluntary, uncoerced consent while knowledgeable about consequences and alternatives. Voluntary hospitalization supposedly raises few legal questions since in theory there is no unwanted restriction of individual rights. Saltzman, Furman, and Ohman note, however, that “it may be difficult to determine the voluntariness of consent in certain situations which may be coercive by nature such as when someone is required to execute a consent for the release of full medical rec ords to obtain welfare benefits” (ibid.:394). Under the schema suggested in chapter 1, this could be nonvoluntary contact based on formal pressures. Even those who are determined legally incompetent can be represented by guardians who act under the principle of substituted judgment as they believe the patient would have wanted (ibid.).

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A Foundation for Work with Involuntary Clients Freedom from Unnecessary Treatment The courts seek to protect involuntarily hospitalized persons from unnecessary treatment. In the case of extreme procedures such as use of restraints, electroconvulsive shock, and lobotomies, the least restrictive principle requires adequate justification, including informed consent from the patient or a qualified conservator or guardian. Under the rights to privacy, use of some mindaltering drugs that have harmful side effects have been opposed as prohibiting freedom of thought (Melton et al. 1987). Most nursing home residents are considered voluntary since they are treated in private facilities with the assumption that they are free to leave (Edwards and Sheldon-Wildgen 1981). Many nursing home residents, however, are placed without a hearing or adequate representation. Once again, these legally voluntary clients may be the “invisible” nonvoluntary with decisions often constrained by pressures from doctors, family members, physical inability to leave, and lack of alternatives (ibid.). However, nursing home residents who are Medicare or Medicaid recipients are protected by a bill of rights that includes, among others, the rights to be informed about their health and medical condition, to participate in planning total care and treatment, to refuse treatment, to be free from restraints except under specified conditions of care, to choose a physician, and to be free from physical or mental abuse (Omnibus Budget Reconciliation Act of 1987). Legal guidance and protection of rights for clients considered legally voluntary are much more limited (Saltzman et al. 2016). Hence, legally voluntary clients such as mental patients, health-care recipients, nursing home residents, and children frequently make decisions that are coerced or constrained by other persons, situations, and a lack of alternatives. In the absence of legal guarantees, practitioners are urged to voluntarily extend similar protections to nonvoluntary clients as are accorded legally mandated clients. Nonvoluntary clients should have a right to privacy and to be left alone unless their overt behavior qualifies them for inclusion in a program (Martin 1981). Practitioners and clients can collaborate in obtaining the information needed for a nonvoluntary client to make an informed decision (Adams and Drake 2006). Clients should have the right to their own thoughts and opinions as a basic requirement to ensure freedom of speech and should be entitled to treatment that is the least restrictive with guaranteed quality of care.

Assessment of Legal Impact on Work with Involuntary Clients The legal framework is one major element toward a goal of legal, ethical, effective practice. It is the basis for when to intervene involuntarily, when not to intervene, and how to protect the rights of clients in these circumstances.

Legal and Ethical Foundations for Work with Involuntary Clients As a result of expansion of legal guidelines for legally mandated clients, practitioners, agencies, and institutions have become much more aware of client rights and protective statutes and are engaged in a continual updating of knowledge of changing standards (see the following text box). These benefits have not been achieved without cost. For example, the expansion of due process procedures does not create more resources for direct ser vice to clients and may reduce it because of more paperwork and court appearances (Dickson 1976). Emphasis on the law and procedures may lead practitioners to be unwilling to take risks or fail to advocate for fear of being sued (Barton and Barton 1984). Decisions to act are increasingly dichotomized between coercive action when legal grounds exist or inaction when legal grounds do not (Sadoff 1982). The focus on the rights of mandated clients has overshadowed the rights of nonvoluntary clients who often face unfair coerced choices. Nonvoluntary clients whose capacity to provide informed consent is often constrained by formal and informal pressures should have their rights protected, taking those pressures into account. Finally, many helping professionals have reservations about the least restrictive principle when they consider more restrictive means to be more effective and they often question a client’s ability to judge this effectiveness (Barton and Barton 1984). Nevertheless, practitioners must work within procedural protections developed to protect the rights of legally involuntary and nonvoluntary clients (Martin 1981). Questions regarding client legal rights in treatment programs • Does the client meet program criteria? • Are client rights explained in ways that are understandable to him or her? • Are staff members aware of client rights? • Do goals reflect the least restrictive alternative? • Has written informed consent been obtained from appropriate persons? • Do clients have an opportunity to present complaints? • Are treatment plans individualized? • Are clients involved in goal development? • Do plans identify and build on client strengths? • Is adaptive behavior recorded as well as pathological? • Are plans related to those goals? • Are goals and progress reviewed periodically by an appropriate group that includes clients? • Do records adequately protect confidentiality? • Is abuse investigated? • Are staff members appropriately trained and supervised?

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A Foundation for Work with Involuntary Clients

Ethical Guidelines for Work with Involuntary Clients While law provides one foundation for legal, ethical, effective practice, it provides little guidance for practice with nonvoluntary clients whose consent is often provided under duress. In addition, laws and regulations do not cover all contingencies in work with mandated clients. An ethical foundation is needed to guide practitioners regarding client self-determination and appropriate paternalism contrary to a client’s wishes about his or her own welfare. This section provides guidelines for practitioner behavior that integrate legal and ethical perspectives. Self-Determination and Autonomy Most practitioners would agree that they are committed to their clients’ best interests. They disagree, however, about who their clients are and what constitutes their best interests (Reamer 1999). Guides for determining ethical responsibilities to clients must include a review of the concepts of selfdetermination and autonomy. Self- determination means action toward one’s own goals, wishes, and desires. The concept can be further divided into positive self-determination, which means having the knowledge, skills, and resources necessary to pursue one’s own goals, and negative self-determination, or autonomy, which refers to free acts, not coerced, or made under duress or undue influence (Reamer 1999; Strom-Gottfried 1998). For example, actions to assist a client in reaching her goal of alleviating her depression through a referral for counseling and a consultation for medication would support positive selfdetermination. Ensuring that her participation in the counseling program was not coerced would be in support of negative self-determination or autonomy. Does self-determination take precedence in all situations? A critical problem occurs when the rights of one person conflict with the rights of another. Many believe that one person’s self-determination stops where another person’s begin (Reid 1984). In fact, avoiding harm to others is generally agreed to be legitimate grounds for limiting self-determination. Concerns have been raised about whether there are different and double standards in the assessment of danger to self and others when applied to the general public and when applied to those in recovery programs (O’Hagan 2012). According to Reamer (1999), when a client acts to endanger others, the endangered person’s right to the basic preconditions to action, such as health, food, and livelihood, take precedence over the client’s right to freedom of action. Some have suggested that self-determination should be supported when the rights of others are protected; when client choices are realistic, rational, reasoned, and constructive rather than unexamined impulses; when those choices fit the law, agency, and society; and when those choices are within the client’s capacity to self-determine (Biestek 1951). However, including all of these criteria would

Legal and Ethical Foundations for Work with Involuntary Clients limit self-determination to socially acceptable, trivial goals (McDermott 1975). The NASW Code of Ethics adds “socially responsible” as a qualifier for client self-determination of goals (NASW 1999). Commitment to self-determination does not mean that the practitioner must support unwise client choices. Persuasive influence toward making better choices can be ethical in such circumstances (ibid.; Clark 1998). Clients can also be helped to distinguish between circumstances that are changeable and those that are not and they can be helped to review their full range of choices (Bernstein 1960). Meaningful self-determination includes acknowledging the client’s perspective and examining available choices (Britton, Williams, and Conner 2008). Paternalism and beneficence. There is less agreement on limitations to selfdetermination when such interference is justified solely by judgment of the client’s best interest apart from immediate danger to others. Paternalism refers to limitations on client self-determination for a person’s own good rather than the good of a third party (Reamer 1983). Paternalism may take three forms: (1) opposing client wishes, (2) withholding information from the client, or (3) providing deliberate misinformation, thereby manipulating the client to the practitioner’s viewpoint. Paternalism is obvious when the client’s explicit wishes for his or her own good are directly contradicted. Less obvious is paternalism in which information is withheld or the client is manipulated to concur with the practitioner’s viewpoint. Paternalism is frequently practiced with clients who are not considered entirely rational, including children and those who have been judged to be mentally incompetent (Abramson 1985). Practitioners who practice paternalistically usually assume that they are acting for the client’s own good, that they are sufficiently qualified to judge that good, and that client welfare justifies their action. Four client attributes are routinely used to justify paternalism: (1) that clients lack information that would lead them to consent to interference; (2) that clients are temporarily or permanently incapable of comprehending relevant information; (3) that clients have given prior consent to paternalism; and (4) that such consent is likely to be given later in any event (Reamer 1999). Reamer suggests that clients may give invalid prior consent to paternalism under duress of a threat of withdrawal of service. Similarly, some chemical dependency programs have norms to prevent impulsive decisions to leave treatment (ibid.). Three situational attributes are also used to justify paternalism: (1) that harmful consequences are likely to be irreversible without interference; (2) that a wider range of freedom can be preserved by restricting it; and (3) that there is an immediate need to rescue (Reamer 1999). This discretionary range in determining potential harm contributed to the legal movement to ensure due process. Paternalism is subject to abuse because paternalistic acts are often as motivated by organizational needs as they are by client interest (Abramson 1985). For example, confining patients to their rooms for a rest period might be motivated by staff shortages during shift changes.

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A Foundation for Work with Involuntary Clients In addition, once a decision is made to limit self-determination through paternalism, the way is often paved for further limitation. Frederic Reamer suggests that because of the potential for paternalistic abuse, practitioners and organizations are responsible for providing a compelling case for the need for paternalism rather than holding the client responsible for proving that paternalism is not needed (1999). He suggests that ethics committees can be helpful for consulting on difficult cases and for educating practitioners and administrators and developing agency guidelines. Reamer (1999) further proposes guidelines for making paternalistic decisions. Temporary interference to determine whether the conditions of informed choice have been met is justified when clients threaten or actually engage in behavior, such as self-destructive actions or severely debilitating alcohol or drug use, that results in harm to themselves. This interference is justified long enough to determine whether: (1) the action would be incapacitating or fatal; (2) the choice is made voluntarily, knowledgeable of consequences, circumstances, and alternatives; and (3) the proposed interference would not cause physical or economic dependency on others or endangerment. Beneficence refers to protective interventions made despite a patient’s objections in order to enhance his or her quality of life (Abramson 1989). For example, limited beneficence refers to carefully circumscribed interventions designed to protect a patient that do not interfere with his or her civil liberties (Murdach 1996). For example, accompanying a patient who is hearing voices on a shopping trip could help the patient exercise his or her freedom to shop while assisting in dealing with the environment. Selective beneficence refers to more extensive intervention in specific areas such as temporary hospitalization for those who threaten or attempt suicide. Extensive beneficence refers to protective intervention in all principal aspects of a patient’s life, which may be required for persons experiencing major psychoses, severe disabilities, or brain trauma. Such decisions raise conflicts between autonomy and decisions in best interest. The principle of the least restrictive alternative would suggest that the level of beneficence proposed must be justified by meeting accepted standards and reduced when the need declines. There are no clear guidelines for such judgements. Reamer (1983) comments that, “If we err in the direction of too much intrusion, we risk alienating our client and the sins of commission. If we err in the direction of leaving too much alone, we risk nothing less than neglect and the sins of omission” (p. 268). As a process to protect clients and ensure that practitioners and agencies act appropriately, Reamer suggests that when policies are considered, the groups that are likely to be effected by the policy should be identified, the potential risks and benefits for different courses of action considered, colleagues and experts appropriately consulted, and then the decision made and documented (Reamer 1999). Congress suggests the acronym ETHIC to prescribe a process whereby one considers the problematic situation:

Legal and Ethical Foundations for Work with Involuntary Clients • Examines pertinent values (personal, societal, agency, client, professional) • Thinks about which ethical standard of a professional code of ethics applies • Hypothesizes about consequences of decisions • Identifies who will benefit and who will be harmed in light of commitment to most vulnerable • Consults with supervisor and colleagues about ethical choice (Congress 1999). • Reamer (2015b) would add a final step: evaluation to incorporate a review of the actual outcomes of the decision. Finally, Reamer proposes an ethics audit of practices that includes assessment of the clarity and comprehensiveness of summaries of client rights such as confidentiality and privacy, release of information, informed consent, access to ser vices, access to records, ser vice plans and rights to participate in their development, options for alternative ser vices, policies regarding termination of ser vices, grievance procedures, and evaluation (Reamer 2015b).

Legal and Ethical Guidelines for Work with Involuntary Clients While the legal guidelines described in the preceding text are sometimes consistent with ethical guidelines, they often point the practitioner toward different decisions. This section considers four general guidelines that integrate the two perspectives for practitioner behavior with involuntary clients for which legal and ethical guidance is consistent. These are followed by more specific guidance in a matrix of legal and ethical influences when these influences indicate different directions.

General legal and ethical guidelines • Facilitate informed consent and due process. • Facilitate empowerment, co-planning, and contracting. • Communicate honestly and avoid manipulation and deception. • Advocate for social justice and fair treatment practices.

1. Facilitate informed consent and due process. As each citizen is constitutionally entitled to due process before rights can be endangered, all clients are

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A Foundation for Work with Involuntary Clients entitled to be informed about their rights and programs for which they are eligible, as well as limitations to those rights and programs. But some therapists have argued that persons who have violated the rights of others forfeit the right of informed consent (Ryder and Tepley 1993). Practitioners do not have a societal mandate to determine whether a client has forfeited informed consent. Even if an involuntary client has perpetrated harm on others, that person is still entitled to be informed of alternatives, risks, benefits, and consequences. If the client is not competent to provide informed consent, such consent can be sought from proxies who can act to consider the issue as the person judged incompetent would have done, in line with their life goals and preferences. Practitioners should describe their own limits and obligations such that clients know about circumstances both in which they are legally entitled to confidentiality and in which practitioners might have to violate that confidentiality or act against client wishes. 2. Facilitate empowerment, co-planning, and contracting. One solution to the dilemma of determining who the client is entails facilitating the empowerment of involuntary clients within legal limits. Legal requirements do not preclude affirmation of the worth, dignity, and uniqueness of involuntary clients and their ability to resolve problems (Clark 1998; Adams and Drake 2006; Brophy and McDermott 2013). Respect for individual worth and empowerment can be enhanced through the use of contracts. Contracting is a consensual agreement and acceptance of reciprocal obligations and responsibilities to perform certain tasks and deliver goods within a specific time frame (Simons and Aigner 1985). Contracts are similar to involuntary ser vice agreements used in mandated situations that specify target problems, goals, and client expectations. Ser vice agreements, however, are often “corrupt contracts” imposed on captive clients without negotiation. Such ser vice agreements are less contracts and more “notices of agency intent” or “notices of consequences” analogous to the citation a motorist receives when stopped by a police officer for speeding (Seabury 1979). Such a citation is not negotiated, though it may offer a coerced choice such as paying a fine or appearing in court. Contracts with mandated clients are obviously not entirely consensual, as legal requirements are not negotiable. Other areas, however, are open to discretion and negotiation such that clients can participate in decisions affecting their rights and their range of choices can be broadened (Raynor 1978). Contracting entails negotiation on such discretionary issues and exploring work on voluntary issues beyond mandated requirements. The practitioner can also help mandated clients be aware of areas that are not covered by their legal restrictions. As nonvoluntary clients, by definition, do not face legal limitations, contracting is a particularly appropriate way to ensure that there is informed consent to proceed on agreed-upon problems without duress. Agency policies may specify that clients be aware of constraints involved in their decision to

Legal and Ethical Foundations for Work with Involuntary Clients accept ser vices. Specific guidelines for contracting with involuntary clients are explored in chapter 6. 3. Communicate honestly and avoid manipulation and deception. Professional codes of ethics proscribe exploitation of clients for the practitioner’s own gain or satisfaction, and practitioners are urged not to use their expertise to dominate or manipulate clients. Manipulation, however, often occurs through keeping plans hidden, maintaining a mysterious distance, and not raising questions an unquestioning client should raise. As Keith-Lucas notes, “Some clients are still given the illusion of free choice when in fact they have been pressured or manipulated into a formal contract that has nothing to do with their real wishes” (1972:334). In addition, there may be superficial agreement with client goals, masking a commitment to a hidden goal. The motto for such efforts might be: “Start where the client is in order to get him or her to where you want to go!” Clients should be informed of the outcome of discussions, including the input of relatives and other related to their welfare (Ostherholm, Taghizadeh, and Olaison 2015). Withholding information “for the client’s own good” is paternalism, which should only be used within the narrow ethical guidelines suggested earlier. Should voluntary clients choose to remain in a counseling relationship that utilizes deceptive methods, their continuation may be based on agreement concerning the overall goal of contact and satisfaction with progress in counseling. Mandated and nonvoluntary clients, however, suffer consequences in leaving such relationships, and should be protected from the use of deceptive methods when they have not agreed to or have been pressured to accept goals set by the practitioner (Harris and Watkins 1987). Hence, practitioners working with mandated and nonvoluntary clients should avoid use of deceptive methods. Such methods constitute an unethical paternalism and, because of manipulative practitioner behavior, do not lead to the development of a trusting working relationship. 4. Advocate for social justice and fair treatment practices. While the above guidelines refer to comportment with individual involuntary clients, practitioners also have ethical responsibilities to advocate for fair treatment for all involuntary clients in their setting. The ethical practitioner should challenge demeaning, unfair, discriminatory practices and institutional restraints that limit client opportunities for change. The spirit of self-determination can be sought by attempting to enhance client participation in decision making whenever possible (Cook and Jonikas 2002; Juhila et al. 2015; Van Bijleveld, Dedding, and Joske 2015). Ethics committees can develop guidelines and training for the use of informed consent, which embodies the spirit of client protections, rather than pro forma use of written releases. Such practices may call for efforts to reform policies from within and form alliances with outside professional groups (Rhodes 1986; Clifford and Burke 2005). Unfortunately, many practitioners are better trained in methods for influencing personal

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A Foundation for Work with Involuntary Clients rather than structural change and engaging in advocacy. If they do not engage in efforts to humanize ser vices, they are susceptible to providing “social control with a smiling face.”

Integrating Legal and Ethical Perspectives in a Matrix The four guidelines described in the preceding section can be applied generally in involuntary transactions. To help the practitioner think about both legal and ethical issues simultaneously, an integrative perspective is needed that asks both legal and ethical questions and suggests possible actions based on those questions. The guiding issue in this perspective is to determine whether there are legal and ethical grounds for restricting client freedom. For such action to be legal and ethical, two sets of criteria need to be satisfied. The legal questions are: (1) Do you have delegated legal authority to restrict freedom in this instance? (2) Does client behavior fall within the domain of that delegated authority (Keith-Lucas 1972)? (3) Is the decision to take action and limit client freedom based on clear, unbiased criteria? The principal ethical question is whether there is imminent danger to self or others. Ethical action to limit client freedom is justified when irreversible, clear, and present danger will occur if prompt and positive action is not taken. Also, when one person acts to endanger others, the endangered person’s rights to health, food, and livelihood take precedence over the client’s right to act freely. Table 2.1 describes the legal-ethical matrix. When the answers to these four questions are affirmative, then action to at least temporarily limit freedom can be both legal and ethical (see cell 1). Cells 2 and 3 refer to unbalanced situations in which legal criteria are met but ethical criteria are not (cell 2), or situations in which ethical criteria are met but legal criteria are not (cell 3). Finally, cell 4 refers to circumstances in which there are neither legal nor ethical grounds for interference. Specific guidelines for each cell are proposed below, with case studies to illustrate their use. Cell 1: Limitations on Client Freedom to Act Are Both Ethical and Legal To explore legal and ethical limitation of freedom, let us consider the following situation. Police have reported to a Minnesota public child welfare agency that two children, one and two years of age, were found home alone while the mother, Agnes Jones, nineteen, was found across the street in a bar. 1. Does the practitioner have legal authority? Following the sequence of legal and ethical questions suggested in table 2.1, we ask first whether the child protection practitioner has authority and domain over the alleged action. Child

Legal and Ethical Foundations for Work with Involuntary Clients Table 2.1

Legal Criteria Met

Legal Criteria Not Met

Legal-Ethical Matrix Ethical Criteria Met

Ethical Criteria Not Met

Cell 1: Legal, Ethical Intrusion

Cell 2: Intrusion Is Legal, but Not Ethical

1. Clarify rights, responsibilities, roles 2. Distinguish nonnegotiable requirements from free choices

1. Advocate for change in law or policy through internal a dvocacy or external organization 2. Overt or covert resistance of policy 3. Choose to leave agency or setting

Cell 3: Intrusion Is Ethical, but Not Legally Based

Cell 4: Restrictions on Freedom Are Neither Legal Nor Ethical

1. Practitioner must be guided 1. Act according to negative selfby informed consent and determination; avoid coercion self-determination if legal of choices criteria or grounds for ap2. Consider positive selfpropriate paternalism do determination in assisting to not exist reach goals 2. Attempt ethical persuasion 3. Offer an incentive to influence choice 4. Advocate that harm be made illegal

protective ser vice does have legal authority and domain over allegations of child abuse, neglect, and sexual abuse, and hence the child protection practitioner does have legal authority to investigate the allegation. 2. Does client behavior fall within the domain of that authority? Mr. Brown, the child protection worker, consulted agency criteria for assessing danger and found that leaving small children unattended is a behavior that justifies investigation. 3. Is the decision to limit client freedom based on clear, unbiased criteria? Agency criteria for assessing risk in such conditions include the following: (a) the child is exposed to dangerous surroundings and (b) infants or very young children are left alone or in the care of other children too young to protect them. Criteria are less specific in determining what constitutes dangerous surroundings. Less objective criteria require more discretionary inter-

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A Foundation for Work with Involuntary Clients pretation and hence may be more subject to bias. For example, the agency’s own criteria in this case guided Mr. Brown to rate the situation as low-risk if the “parent is remorseful; this is a first incident; the parent seeks help and there were extenuating circumstances” and to rate the situation as high-risk if the parent is “denying responsibility and blaming others.” Ms. Jones responded to the investigation by saying that she was out of the home for only a few minutes and was nearby, across the street. In addition, a neighbor was supposed to be checking in with the children. She raged that she should not have to spend all of her young life with babies and she had a right to go out occasionally and have a drink. Ms. Jones went on to say that she felt cooped up and wanted to get out to get her GED and a job. By the agency’s parental response criteria, Ms. Jones’s children would have been considered at high risk. Such criteria emphasize parental motivation rather than considering normal situational responses to threatening situations. (Alternative explanations for responses to threatening situations are presented in chapter 4.) For now, it is sufficient to consider that a negative response to the possible threat of removal of children can be a normal situational response. On the other hand, superficial cooperation may indicate use of ingratiating strategies of self-presentation to neutralize a threat in a less than sincere fashion (see self-presentation strategies in chapter 4). As a consequence of the difficulties in attributing the “real” motivation for hostile and cooperative behaviors, practitioners should place higher emphasis on more objective criteria, such as the fact that the children were left alone, rather than on parental responses that may be aggravated by the involuntary nature of the transaction (Reamer 2005). 4. Is there imminent danger to self or others? Leaving small children unattended would also justify ethical action to limit Ms. Jones’s freedom if such behavior endangered them. Norms vary in different cultures about childrearing and child safety practices. For example, the age at which children are considered old enough to care for others varies, the length of time they can be left unattended varies, and the responsibility entrusted to an older child for getting adult help in times of possible danger also varies. It is sufficient here to note that there may be a conflict between what Ms. Jones and her neighbors might consider unsafe practices and the definition of such by the investigating agency. When the practitioner is employed by a legally mandated agency and a legal threshold of danger to others is reached, the client’s right to self-determine is temporarily superseded by the rights of others to act freely. In this case, the small children’s rights to adequate supervision take precedence over Ms. Jones’s right to free action. Can such intervention to limit freedom be done in a way that maximizes self-determination within legal limits? General guidelines toward this goal follow and more specific guidance is provided in chapter 5.

Legal and Ethical Foundations for Work with Involuntary Clients The first task in ethical and legal intrusion is to clarify rights, responsibilities, and roles. First, the reason for contact should be explained clearly and nonjudgmentally, including the specific criteria that led to contact. Second, Mr. Brown should clarify what the authority invested in him requires that he and Ms. Jones do. Third, Mr. Brown should clarify Ms. Jones’s legal rights. Fourth, any requirements for behavioral change should be interpreted narrowly and should not include implied conditions or threats. Finally, should those behavioral requirements entail work on goals that Ms. Jones does not share, she is entitled to an explanation of the rationale for them. Next, the practitioner distinguishes nonnegotiable requirements from choices the client can make. Mr. Brown can promote self-determination within legal limits toward the goal of achieving a semivoluntary contract by including nonnegotiable requirements, negotiable items, and voluntary concerns of the client. Self-determination in mandated situations can be promoted in at least four ways: (1) reframing the client’s own concerns to blend with mandated requirements; (2) emphasizing freedoms untouched by requirements; (3) clarifying areas for discretion and negotiation; and (4) addressing additional client concerns voluntarily or referring them to others. As some mandated clients may not wish to explore these voluntary concerns with a mandated practitioner, referral to other practitioners and the freedom not to work on any additional concerns should be emphasized. In sum, the mandated client can be helped to a measure of self-determination by clarifying choices to (1) not comply with nonnegotiable requirements and risk consequences; (2) comply with nonnegotiable requirements; and (3) work on additional concerns with the practitioner or someone else. In Agnes Jones’s case, while maintaining the children safely was a nonnegotiable priority, establishing whether she could keep custody of them in her home with assistance was negotiable. Mr. Brown noted that he could see that she did care for her children and would not wish them harmed and that it was also true that the police report indicated that her small children were at home unsupervised and hence were by agency standards at acute risk. He asked how might the children have been able to take care of themselves if there had been a fire or other emergency. Since keeping the children safe from harm was a goal they both shared, he suggested that they could plan together for ways to improve her child care relief, including arrangements with friends and relatives, day care, and drop-in centers. Mr. Brown also noted that indeed her drinking that evening and getting out of the house was her own business as long as it did not endanger the children. He also empathized with her feeling cooped up, taking care of babies all the time, and that it was also true that they were entitled to be in a safe place. He could refer her to others who might help with her goals of getting a GED and a job if she wished. She could also handle these concerns alone or choose to do nothing about these goals at this point. As the nonnegotiable

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A Foundation for Work with Involuntary Clients requirement was that the children be in a safe environment, court intervention that might involve removal of the children from the home could be avoided if they could agree on a plan for safety. Cell 2: Limitations on Client Freedom Are Legal but Not Ethical The preceding example assumes that the practitioner has the appropriate authority and that the behavior falls within the domain of that authority. A different circumstance of authority and domain would occur if during the course of a conversation between Ms. Jones and her counselor at a mental health clinic, she mentioned that she had left the children alone briefly while she took a “stress break.” While the counselor would lack the authority or domain to directly intervene, the counselor is legally mandated to report allegations of possible child abuse and neglect to child protective ser vices. Although making such a report is legally mandated, is it always ethical to do so? Reamer (1999) suggests that if the mandated reporter considers the child to be at substantial risk, then the danger should be reported. However, Heymann (1986) suggests that reporting some allegations of abuse may be harmful if the loss of control happened once rather than as a pattern, if it happened several years ago rather than currently, and if it depends on an assessment of what will happen to the parties and the working relationship as a result of reporting. Both Reamer and Heymann describe situations in which reporting resulted in greater harm for clients than not reporting might have done and therefore suggest that there are instances in which following legal requirements to report alleged abuse or neglect would be unethical. How does a practitioner determine when it is unethical to obey the law? Reamer suggests that while the obligation to obey laws to which one has freely consented ordinarily overrides one’s rights to freely violate those laws, circumstances exist in which an individual’s rights to well-being may override obedience to those laws (Reamer 1999, 2005). The problem occurs when the practitioner determines that individual rights override laws. In the preceding abuse or neglect reporting example, Reamer and Heymann seem to be suggesting that the mandated reporter may be able to assess intuitively whether behavior or conditions meet objective standards for abuse and neglect as well as or better than trained child protection workers. Bergeron and Gray (2003) report a complex situation of conflicting loyalties. In the first session of a support group of caregivers for the elderly, a caregiver reported that she was a single woman caring for her eighty-five-year-old mother as an only child with no relatives or friends to help her with caregiving. She was under high stress and said her doctor told her she needed to attend a support group or she would have a ner vous breakdown. She reported that she had recently raised her voice to her mother on several occasions and

Legal and Ethical Foundations for Work with Involuntary Clients was afraid that her frustration and exhaustion would lead her to hit her mother. In the following weeks, Edith indicated some reduction in stress and thanked people for supporting her. Should the facilitators have filed an elder abuse report after that first session? The authors developed an informed consent process including a confidentiality statement to manage such dilemmas. That statement noted that confidentiality would be honored except to seek supervision or in a case in which the facilitator suspects the caregiver has intentionally or unintentionally abused or neglected the care receiver. Such cases of suspected abuse would then be reported for investigation and intervention (Bergeron and Gray 2003). Failure to make a mandated report of possible abuse or neglect is illegal. Practitioners should not make such determinations to violate the law unilaterally. Since clients should be appropriately informed at the beginning of contact about circumstances in which client confidentiality must be violated, they can be informed that a circumstance has occurred in which the practitioner is legally required to make a report. An appropriate ethical and legal response would be to make the mandated report and include, with client permission, any mitigating information if the practitioner does not feel that current conditions indicate serious danger. While such reporting may well be harmful to the working relationship with the client, there is also danger when that relationship is valued more highly than risk to a vulnerable person. Practitioners have at least three alternatives in situations in which intervention appears to be legal but unethical. First, they can advocate for changes in the law or policy either through internal advocacy or working with outside professional and client organizations. Similarly, those who consider current reporting laws too broad and require reporting in circumstances that are not considered harmful have alternatives to failure to report. They can advocate that reporting requirements be made more specific to include more serious evidence of harm. Second, the practitioner may choose to overtly or covertly resist the law or policy. As suggested above, there may be instances in which obeying a law or policy appears to be unethical and some practitioners have chosen to violate the policy openly or covertly. For example, in a school program to assist students who were in danger of dropping out, practitioners discovered a policy that required students who missed more than six days in a semester for any reason to be expelled. Some practitioners chose to violate this policy by not reporting some absences that they considered justified. There can be no firm guidelines about when the line between protection of client interest and obeying laws and policies is crossed. Practitioners are urged to attempt to deal with changing the law or policy openly. Should they choose to resist the law or policy covertly, they should do so with full knowledge of the potential consequences for themselves, their agencies, and their clients. They should consult with supervisors and other colleagues because a

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A Foundation for Work with Involuntary Clients choice not to follow the law leaves the burden of proof to justify the decision on the practitioner. Finally, practitioners can choose to leave the agency or setting. There are some instances in which the law or policy that the practitioner considers detrimental to client interest appears to be unchangeable. Practitioners who consider practices to be unethical may choose to leave the setting and perhaps advocate for change more freely from the outside. Cell 3: Limitations on Client Freedom May Be Ethical but Are Not Legal Intervention to influence client choices can be ethically appropriate in some situations in which a legal threshold to limit such choices has not been reached. A neighbor contacted a county agency requesting that an investigation be made about the safety of Alice Donat (whom we met in chapter 1). Under the state law to protect vulnerable adults, a practitioner (Ms. James) was mandated to visit Ms. Donat and determine whether she might be in danger. Ms. Donat was forty-five and intellectually challenged, and had lived alone in a poorly heated rural shack since her mother died the year before. Specifically, there was concern that she might not have adequate heating in the winter, and her habit of eating off the same plates as her cats might be contaminating her food. As Ms. Donat had lived alone through two previous winters and was informed about heating resources available to her, Ms. James assessed that danger from this source was not imminent. Similarly, the cats had not contaminated her food and her health was good. Consequently, Ms. James decided there were insufficient grounds to support a petition to declare Alice incompetent. Following table 2.1, while the practitioner did have the authority and the case fell within her domain, criteria for legal intervention were not met. Is Ms. James’s job complete with the determination that coercive action is not justifiable? When paternalism is not justified, Gadow (1981) suggests guidelines to assist clients in making informed choices: (1) helping clients clarify their own values and intentions; (2) asking clients what information they need in order to decide; (3) clarifying the practitioner’s own position; and (4) stepping back and avoiding interference with client decisions once this process is complete. The client has a right to learn from experiences and even to fail when those actions are not incapacitating. Four guidelines are suggested to influence practitioner decisions in situations such as the ones in the preceding text in which action seems ethically compelling but that cannot be required legally. 1. If the behavior is not illegal, the practitioner cannot require the client to change and should be guided by informed consent and self-determination.

Legal and Ethical Foundations for Work with Involuntary Clients If harm to self or others has not met legal criteria, then the practitioner cannot coerce the client to change. However, coercion or ignoring the client are not the only alternatives. The practitioner does not have to support dangerous or unethical actions that are not illegal, and noncoercive influence may be attempted. A first step with Ms. Donat would be for Ms. James to assure her that she cannot be forced to leave her home or accept ser vices if her situation does not meet legal criteria for acute or imminent danger. 2. The practitioner can act ethically to attempt persuasion. Persuasion means helping clients consider the possible consequences of their choices and exploring alternatives in terms of their own best interests. Persuasion is not the same as coercion when the influence attempt is open, does not resort to threats, and ultimately respects the client’s power to decide (Clark 1998). In reviewing the alternatives and consequences, the practitioner may share his or her own opinions about the client’s self-interest. The practitioner can explore voluntary concerns of the client and share the concerns of referring sources as a context for decision making. At the end of this exploration, the practitioner should accept the client’s decisions about his or her own behavior rather than insist on following the practitioner’s advice (Clifford and Burke 2005). Should the client express no concern for which he or she wants help, the practitioner should leave, having assisted the client in informed consent through awareness of options and consequences. Ms. Donat was understandably suspicious of an offer from a person she suspected could take away her freedom. She said that she did not want to be put in a hospital and made to give up her home and her cats. Ms. James clarified that there was not sufficient danger to make Ms. Donat leave her home and she could choose to continue at home without ser vices. She asked Ms. Donat what she thought might happen to her and her cats if there were insufficient heat or if she became ill from contaminated food. To avoid such a situation, Ms. James was willing to help her become safer in her home. In this regard, she mentioned Supplemental Security Income (SSI) benefits and emergency fuel assistance as resources that might help Ms. Donat provide better food and heat for herself and her cats. 3. The practitioner can offer an incentive to influence a client choice. Incentives are consequences that are used to strengthen or increase a behavior (Simons and Aigner 1985). Use of incentives is more intrusive than persuasion but less so than coercion. Inducement should not be used to barter for basic necessities, but rather as an additional benefit that the client can choose to select or ignore. In this regard, informing Ms. Donat about her possible rights to SSI benefits should not be used as an incentive. Ms. James might, however, offer to accompany her to Social Security or to have her talk with other clients who received SSI benefits without having to go into the hospital. 4. Finally, the practitioner can advocate that the legal threshold for harm should be expanded. If the practitioner thinks that client safety is in fact endangered

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A Foundation for Work with Involuntary Clients despite not reaching legal thresholds for coercive intervention, he or she can advocate that the legal threshold be changed. Cell 4: Limitations on Client Freedom Are Neither Legal Nor Ethical Situations occur in which practitioners are pressured to intervene with clients who have not done anything illegal or endangered the well-being of themselves or others. For instance, while Alice’s current situation was assessed as not presenting an immediate danger to her, her choice to live with twenty cats in a dirty home conflicted with community sensibilities. In such situations, commitment to the principle of negative self-determination applies first. Voluntary choices that do not cause serious danger to self or others, or lead to physical or economic dependency, or violate laws should not be subject to undue influence. As stated earlier, the practitioner may register her disagreement with a plan and help the client explore alternatives, but the client ultimately has the right to decide. Hence, Alice could be reassured that she has the right to determine where and how she will live and is not required to accept ser vices so long as those decisions do not harm her or violate laws. Second, positive self-determination should be considered. In addition to not opposing or coercing client choices, how can those choices be positively supported? Ms. James could offer a contract to Alice to help her maintain her independence, protect herself and her cats through the winter, or attain other goals that Alice desired. Part of self-determination is respecting that Alice has every right to decline this offer, however well intentioned and potentially supportive of Alice’s interests it may be.

Conclusion This chapter has described legal and ethical foundations for work with involuntary clients. While legal and ethical issues with involuntary clients deserve books of their own, practitioners have limited time to review the relevant issues thoroughly in a turbulent, demanding environment. Confronted with decisions that need to be made quickly, and reports that must be written, practitioners need flexible guidelines for making decisions. The proposed guidelines are not precise prescriptions but move beyond impotence and indecision in the face of dilemmas. While these guidelines should assist practitioners in making difficult decisions and improving local conditions, they cannot provide the kinds of changes needed to ameliorate prejudicial societal conditions, such as inadequate resources, which may engender deviance and hence produce involuntary clients. Entire treatment institutions have been found to violate both legal rights to adequate treatment and the most basic ethical standards of respect for

Legal and Ethical Foundations for Work with Involuntary Clients human dignity. While practitioners do not have the legal power to close down such institutions, they can advocate for better conditions, greater access to resources, and better treatment for clients. It may feel safer for practitioners to report illegal or unethical methods in another institution rather than their own. While it may be harder for an employee of an institution to risk his or her job security to report unethical or illegal methods, working with institutional ethics committees can reduce the risk to an individual who reports such matters. If practitioners ignore issues of prejudice and unfair conditions in the larger society, they run the risk of providing social control with a smiling face: using other wise ethical means to pursue unethical goals. Many practitioners resolve these conflicts by following orders and leaving concern for law and ethics to others, while others attempt to resolve the tension by “fleeing” to private practice. Consent under duress, however, is a pervasive problem that will still follow them in work with nonvoluntary clients despite the setting. The choice to pursue legal, ethical practice means making judgments and decisions committed to both law and ethics. Pursuit of such a course does not avoid conflicts. Involuntary clients have negative reactions when freedoms are limited, however ethically or legally done. Similarly, pursuit of such a legal and ethical course may conflict with agency practices that are unduly paternalistic, which include corrupt contracts or notices of consequences rather than legitimate contracts. Such pursuit may also mean advocating that legal thresholds be changed to include more people who are in clear and present danger. While pursuing a legal and ethical course will bring conflict, it may also ensure personal self-respect and integrity as no small benefit. In addition to legal and ethical practice, effective practice is the third foundation for work with involuntary clients. Hence chapter 3 reviews evidence about effectiveness in work with involuntary clients.

Discussion Questions 1. What is your agency’s position on client rights, legal responsibilities, and actions related to confidentiality and privileged communication? Are these positions clear to clients and service users? How do you know? 2. What are agency policies relating to alerting clients and ser vice users to their rights regarding access to records? 3. Under what conditions is client self-determination supported in your agency? 4. Some practitioners have negative conceptions about paternalism, and yet they and their agencies often act to protect their perception of client best interest. Are you clear about the lines that can be drawn

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A Foundation for Work with Involuntary Clients around appropriate paternalism and beneficence and unethical intervention into client choice? 5. Can you apply the legal ethical matrix to help guide decision making? 6. Are informed consent forms explained in such a way that they support genuine informed consent or are they merely procedural guidelines?

References Abramson, M. 1985. “The Authority-Paternalism Dilemma in Social Work Practice,” Social Casework 66 (7): 387–393. Abramson, M. 1989. “Autonomy vs. Paternalistic Beneficence.” Social Casework 70: 101–115. Adams, J., and R. Drake. 2006. “Shared Decision Making and Evidence Based Practice.” Community Mental Health Journal 42 (1): 87–105. Albert, R. 2000. Law and Social Work Practice, 2nd ed. New York: Springer. Alexander, R. 2003. Understanding Legal Concepts That Influence Social Welfare Policy and Practice. Pacific Grove, CA: Brooks- Cole. Barton, W., and G. Barton. 1984. Ethics and Law in Mental Health Administration. New York: International Universities Press. Bergeron, L., and B. Gray. 2003. “Ethical Dilemmas of Reporting Suspected Elder Abuse.” Social Work 48 (1): 96–105. Bernstein, S. 1960. “Self-Determination: King or Citizen of the Realm of Values.” Social Work 5 (1): 3–8. Biestek, F. 1951. “The Principle of Client Self-Determination.” Social Casework 32:369–375. Britton, P., Williams, G., and K. Conner. 2008. “Self-determination Theory, Motivational Interviewing and the Treatment of Clients with Acute Suicidal Ideation.” Journal of Clinical Psychology 64 (1): 52–66. Brophy, L., and F. McDermott. 2013. “Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders.” Australian Social Work 66 (1): 72–85. Clark, C. 1998. “Self-Determination and Paternalism in Community Care: Practice and Prospects.” British Journal of Social Work 28:387–402. Clifford, D., and B. Burke. 2005. “Developing Anti-Oppression Ethics in the New Curriculum.” Social Work Education 87 (2): 677–692. Congress, E. 1999. Social Work Values and Ethics. Chicago: Nelson-Hall. Cook, J., and J. Jonikas. 2002. “Self-determination Among Mental Health Consumers/Survivors. Using Lessons from the Past to Guide the Future.” Journal of Disability Policy Studies 13 (2): 88–96. Courtney, M., and N. Moulding. 2014. “Beyond Balancing Competing Needs: Embedding Involuntary Treatment Within a Recovery Approach to Mental Health Social Work.” Australian Social Work 67 (2): 214–226. Cull, L., and J. Roche. 2001. The Law and Social Work: Contemporary Issues for Practice. New York: Palgrave Dickson, D. 1976. “Law and Social Work: Impact of Due Process.” Social Work 22 (4): 274–279. Dickson, D. 1998. Confidentiality and Privacy in Social Work. New York: Free Press.

Legal and Ethical Foundations for Work with Involuntary Clients Edwards, K., and J. Sheldon-Wildgen. 1981. “Providing Nursing Home Residents’ Rights.” In Preservation of Client Rights, eds. G. Hannah, W. Christian, and H. Clark, 319–344. New York: Free Press. Fowler, J. 2003. A Practitioner’s Tool for Child Protection and the Assessment of Parents. Philadelphia: Kingsley Gadow, S. 1981. “Advocacy: An Ethical Model for Assisting Patients with Treatment Decisions.” In Dilemmas of Dying, eds. C. Wong and J. Swazley, 135–142. Boston: G.K. Hall. Harris, G., and D. Watkins. 1987. Counseling the Involuntary and Resistant Client. College Park, MD: American Correctional Association. Heymann, G. 1986. “Mandated Child Abuse Reporting and the Confidentiality Privilege.” In Psychotherapy and the Law, eds. L. Everstine and D. Everstine, 332–354. New York: Grune and Stratton. Juhila, K., C. Hall, K. Gunther, S. Raitakari, and S. Saario. 2015. “Accepting and Negotiating Ser vice Users’ Choices in Mental Health Transition Meetings.” Social Policy and Administration 49 (5): 612–630. Keith-Lucas, A. 1972. Giving and Taking Help. Chapel Hill: University of North Carolina Press. Kvarnstrom, S., B. Hedberg, and E. Cedersund. 2012. “The Dual Faces of Ser vice User Participation: Implications for Empowerment Processes in Interprofessional Practice. Journal of Social Work 13 (3): 287–307. Lidz, C., A. Meisel, E. Zerubavel, M. Car ter, R. Sestak, and L. Roth. 1984. Informed Consent: A Study of Decision Making in Psychiatry. New York: Guilford. Madden, R. G. 1998. Legal Issues in Social Work, Counseling and Mental Health. Thousand Oaks, CA: Sage. Martin, R. 1981. “ Legal Issues in Preserving Client Rights.” In Preservation of Client Rights: A Handbook for Practitioners Providing Therapeutic, Educational and Rehabilitative Services, eds. G. Hannah, W. Christian, and H. Clark, 3–13. New York: Free Press. McDermott, F. 1975. Self-Determination in Social Work. London: Routledge-Kegan Paul. Melton, G., J. Petrala, N. Poythress, and C. Slobogin. 1987. Psychological Evaluations for the Courts. New York: Guilford. Murdach, A. 1996. “Beneficence Re-examined: Protective Intervention in Mental Health.” Social Work 41 (1): 26–32. National Association of Social Workers (NASW) Code of Ethics.1999. https://www .socialworkers.org /About/Ethics/Code-of-Ethics (accessed October 10, 2017). Omnibus Budget Reconciliation Act of 1987. P.L. 100–203. http:www.sa.gov. Österholm, J., Larsson, A., and A. Olaison. 2015” Handling the Dilemma of Self-determination and Dementia: A Study of Case Managers’ Discursive Strategies in Assessment Meetings.”, Journal of Gerontological Social Work 58 (6): 613–636. Österholm, J. H., A. Taghizadeh Larsson, and A. Olaison. 2015. “Handling the Dilemma of Self-Determination and Dementia: A Study of Case Managers’ Discursive Strategies in Assessment Meetings. Journal of Gerontological Social Work 58 (6): 613–636. Raynor, P. 1978. “Compulsory Persuasion: A Problem for Correctional Social Work.” British Journal of Social Work. 8 (4): 411–424. Reamer, F. G. 1983. “The Concept of Paternalism in Social Work.” Social Service Review 57 (2): 254–271. Reamer, F. G. 1987. “Informed Consent in Social Work.” Social Work 32 (5): 425–429. Reamer, F. G. 1999. Social Work Values and Ethics, 2nd ed. New York; Columbia University Press. Reamer, F. G. 2005. “Ethical and Legal Standards in Social Work: Consistency and Conflict.” Families in Society 86 (2):163–169.

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A Foundation for Work with Involuntary Clients Reamer, F. G. 2015a. “Clinical Social Work in a Digital Environment: Ethical and RiskManagement Challenges.” Clinical Social Work Journal 43: 120–132. Reamer, F. G. 2015b. Risk Management in Social Work: Preventing Professional Malpractice, Liability and Disciplinary Action. New York: Columbia University Press. Regehr, C., and B. Antle. 1997. “Coercive Influences: Informed Consent in Court-mandated Social Work Practice.” Social Work 42 (3): 300–306. Reid, D. 1984. “Child Protective Ser vices: What Happens When Our Values Conflict with Those of our Clients. Practice Digest 6(4):15–16. Rhodes, M. 1986. Ethical Dilemmas in Social Work Practice. Boston: Routledge and Kegan Paul. Rozovsky, F. 1987. Consent to Treatment. Boston: Little, Brown. Ruggiano, N., and D. Edvardsson. 2013. “Person Centeredness in Home- and Communitybased Long-term Care: Current Challenges and New Directions.” Social Work in Health Care 52 (9): 846–861. Ryder, R., and R. Tepley. 1993. “No More Mr. Nice Guy: Informed Consent and Benevolence in Marital Family Therapy.” Family Relations 42: 145–147. Sadoff, R. 1982. Legal Issues in the Care of Psychiatric Patients: A Guide for the Mental Health Professional. New York: Springer. Saltzman, R., D. Furman, and K. Ohman. 2016. Law in Social Work Practice. Boston: Cengage. Schroeder, L. 1995. The Legal Environment of Social Work. Revised edition. Washington, D.C.: National Association of Social Workers. Seabury. B. 1979. “Negotiating Sound Contracts with Clients.” Public Welfare. 38:33–38. Simons, R., and S. Aigner. 1985. Practice Principles: A Problem- Solving Approach in Social Work. New York: MacMillan. Strom-Gottfried, K. 1998. “Informed Consent Meets Managed Care.” Health and Social Work 23 (1): 25–33. Szmukler, G. 2008. “Treatment Pressures, Coercion and Compulsion in Mental Health Care.” Journal of Mental Health 17 (3), 229–231. Van Bijleveld, G., C. Dedding, and J. Bunders-Aelen. 2015, “Children’s and Young People’s Participation within Child Welfare and Child Protection Ser vices: A State-of-the-Art Review.” Child and Family Social Work 20: 129–138. Wodarski, J. 1980. “Legal Requisites for Social Work Practice.” Clinical Social Work Journal 8 (2): 94–97.

Chapter 3

Effectiveness with Involuntary Clients

Ronald Rooney

With a basis in the legal and ethical foundation, we move to consider effectiveness. We discuss the evidence-based practice movement and its implications for work with involuntary clients, ethics of research with involuntary clients, and reviews of effectiveness with involuntary clients including summary generalizations. Finally, we review the transtheoretical model of stages of change and motivational interviewing to work with two involuntary populations: sexual offenders and domestic violence perpetrators.

Evidence-Based Practice Helping practitioners should make practice decisions and recommendations to clients based on the best available information (Sackett et al. 2000). This tenet of the evidence-based practice movement, originating in the medical and nursing fields, is designed to ensure that clients and patients receive diagnoses and treatment guided by the best available information. Consequently, evidence-based practitioners can help clients in making informed decisions by sharing what is known about the efficacy of different treatment options (Social Work Policy Institute 2010; McNeece and Thyer 2004; Adams and Drake 2006). Such practitioners would be most influenced in their treatment recommendations by evidence generated through randomized, controlled trials. Even when such studies are lacking, practitioners should persist in seeking the best available information to guide decisions and recommendations.

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A Foundation for Work with Involuntary Clients Evidence-based practice values informed consent in assisting clients in assessing alternatives in reaching their goals (Gilgun 2005). Many of the assumptions about evidence-based practice appear to assume that the client is voluntary. Involuntary clients have fewer treatment choices (ibid.). When involuntary clients have acted to harm or endanger others, the community is entitled to be informed about the evidence on whether interventions are likely to be helpful in making society safer (Bloomberg and Wilkins 1977). Consequently, there is a role for evidence-based practice with involuntary clients as well. Even when client choices are limited, treatment options should be based on the best available evidence (Golder et al. 2005). Meanwhile, involuntary clients are entitled to know that the methods used with them are effective and humane. Intervention effectiveness has been studied in several fields of practice and problem areas in which we can assume that many clients are involuntary. For example, in studies of intervention with domestic violence perpetrators, probationers and parolees, recipients of child welfare ser vices, and persons with substance abuse issues, we can safely assume that most clients have not sought ser vices of their own accord. However, such studies usually focus on a particular problem and client group and rarely on the clients’ involuntary status. Despite these limitations, it is essential that we probe for the best available information to guide interventions with involuntary clients.

The Ethics of Research with Involuntary Clients A fundamental tenet of research ethics is that human subjects should be protected from harm caused by participation in research (Kelty 1981). Consequently, research with human subjects is governed by the principles of informed consent described in chapter 2. There are special problems in the application of informed consent principles to involuntary clients since their ability to provide consent without force or duress cannot be assumed. Concern for dignity and respect of individual participants in research is central to research ethics (Antle and Regehr 2003). Informed consent is central. Researchers must consider conceivable risks for participants such that they do not face harm or undue hardship. If inclusion in experimental treatment is one of the benefits, participants need to be assured that they would have equal access to that treatment whether or not they consent to participation in the research. Other kinds of benefits could include monetary compensation or supplying funds for babysitting and transportation costs. The concept of beneficence requires that the potential benefits outweigh potential harm (ibid.). Research on effectiveness can, for instance, determine whether restriction of freedom is necessary to reach desired outcomes or is actually cruel and unusual punishment. Hence, research on effectiveness may both protect clients

Effectiveness with Involuntary Clients from serving as “guinea pigs” for untested interventions and aid institutions and agencies in discovering effective and eliminating ineffective interventions. Research with involuntary clients must address costs and benefits and define acceptable risk for individuals and society (Bloomberg and Wilkins 1977). These questions need to be addressed in a way that protects involuntary clients from danger and society’s right to discover methods that are safe, humane, and effective. Guidelines that consider costs and benefits to involuntary clients and to society include the following: 1. Informed consent must be sought from persons competent to provide it. When competence is questionable, then consent must be sought from surrogates such as parents, guardians, and legal representatives (Reynolds 1982). The request for consent must include an appraisal of possible discomforts, risks, benefits, and alternate procedures. 2. Consent must be voluntary and free from coercion or undue influence. A review panel should assess potential for duress in securing consent in both mandated and nonvoluntary settings. Such an assessment should include the following: a) Use of inducements must avoid an unwarranted effect on the decision to participate. b) Implied influence should be avoided by making sure that the person requesting research participation does not have an authority relationship with the client. c) It should be explicit that the treatment will not be more favorable for those who agree to participate in research or unfavorable for those who decline (Kelty 1981). d) Participants must be free to withdraw consent at any time. e) Confidentiality of information shared in research must be guaranteed. f) The research should yield results not obtainable in less obtrusive ways such that any discomfort or risk to participants must be outweighed by benefits to society (Bloomberg and Wilkins 1977; Reynolds 1982). g) Deception should be avoided or minimized by debriefing participants after research participation. Employment of these guidelines should provide involuntary clients with a fair opportunity to decide if they want to participate in research or not. Since involuntary clients perceive restriction of freedom as part of the definition of involuntary status, it should be expected that many involuntary clients may exercise one of their limited freedoms by sometimes choosing not to participate in research. Hence, involuntary clients who voluntarily choose to participate in research may not be representative of the population. As Videka-Sherman noted in her review of social work effectiveness in mental

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A Foundation for Work with Involuntary Clients health settings, “It is also true that involuntary social ser vices are underrepresented in this sample since human subjects review and the ethics of social research depend on clients’ willingness to participate in the research. This willingness is, in all likelihood, associated with willingness to participate in treatment” (1985:40).

Studies of Effectiveness with Involuntary Clients It has been conventional wisdom in social work; other helping professions; and fields such as corrections, treatment of alcoholism, and child maltreatment that outcomes with involuntary clients are less successful than those with voluntary clients. The social work profession’s pessimism about the effectiveness of work with involuntary clients was partly based on broader reviews of social work effectiveness. When Fischer examined experimental studies of social work practice conducted between 1930 and 1972, he found that none of the eleven studies reviewed clearly showed positive, significantly mea surable changes, and concluded that “at present, lack of evidence of the effectiveness of professional casework is the rule rather than the exception” (1973:19). While Fischer’s review is well known in social work, the fact that five of the eleven studies reviewed were conducted with predelinquent, probably involuntary clients is less so. None of the five studies suggested that social work services prevented delinquency (Powers and Witmer 1951; Miller 1962; Craig and Furst 1965; Berleman and Steiner 1967). Katherine Wood reviewed the studies of Fischer, as well as eleven additional studies that included quasi-experimental designs. She concluded that “the outcomes of these studies indicate that group work or psychotherapeutically oriented casework used alone or as the major intervention, have not been effective in preventing or ameliorating delinquency” (Wood 1978:438). Wood also identified a major clue to effectiveness in work with involuntary clients: lack of fit between client and practitioner motivation as a factor in the low outcomes of earlier research. Since the studies did not begin with the adolescent’s perceptions of their own concerns, the intervention did not come from a contract about issues of concern to the adolescents. Consequently, there was little motivation to work on goals determined by others (ibid.). The negative findings concerning delinquency prevention in social work were similar to other findings on treatment of delinquents such that it became conventional wisdom that “nothing works.” This contention was further supported by Martinson’s conclusion in his 1974 review of 231 research studies completed before 1967 that with few exceptions, efforts at rehabilitation had little effect on recidivism (Lipton, Martinson, and Weeks 1974; Martinson 1974). Shireman and Reamer objected to Martinson’s conclusion that nothing works because many programs with at least quasi-experimental designs

Effectiveness with Involuntary Clients had been shown to be effective (Shireman and Reamer 1986). While the “nothing works” conclusion might have been overdrawn, there was little reason to believe that a clear way had been found to reduce recidivism among delinquents. Shireman and Reamer echoed Wood’s theme about a lack of motivational fit: “Subjects have quite commonly been drawn into programs intending to produce change in their attitudes, behaviors and life styles and life situations without regard as to whether they wished to be targets of intervention. We are only now beginning to realize the frequent futility of such endeavors” (1986:88).

Summary Generalizations Regarding Effective Interventions with Involuntary Clients Summary generalizations about research evidence regarding involuntary clients include: (1) court-ordered clients can achieve results with the same degree of success as legally voluntary clients can; (2) pro-social modeling has been associated with positive outcomes in corrections; (3) voluntary clients are rarely distinguished from nonvoluntary clients in data collection; and (4) clues to more positive outcomes appear to be based in client-practitioner interaction including motivational congruence. 1. Court-ordered clients can achieve outcomes as successfully as legally voluntary clients can. Some authors have suggested more positive outcomes with court-ordered clients than the generally gloomy predictions expressed earlier. For example, Videka-Sherman found in her review of social work studies in mental health that clients’ motivation for intervention as indicated by voluntary participation was not associated with different results as indicated. In fact, studies of clients with mixed or involuntary motivation yielded better results for the more severely impaired population.” Brehm and Smith came to a similar conclusion in their review of involuntary outcomes in the psychology literature: “Though many therapists and counselors are firmly convinced that successful therapeutic outcomes are substantially more difficult to achieve with nonvoluntary client populations, the results of applied (and therefore, necessarily correlational) research on this issue have not provided support for this belief” (1986:88). It has been long thought that some form of coercion can be useful to motivate change among drug users (Rosenberg and Liftik 1976; Flores 1983). It was, however, believed that coercion should not be overemphasized since longitudinal studies suggested that mandated alcohol abuse patients often ceased treatment when their court orders ended, regardless of how favorably they may felt about the program (Ben-Arie, Swartz, and George 1986; Foley 1988).

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A Foundation for Work with Involuntary Clients More recently, problem-solving courts have been developed to address psychosocial issues around problems that impose significant costs on the community (Berman and Feinblatt 2015; Casey and Rottman 2005; Tyuse and Linhorst 2005). For example, courts have been developed to address diverse social problems such as domestic violence, veterans’ issues, use of illegal drugs, and hazardous mental health conditions. Such courts have been hailed as a means for getting drug offenders to seek and benefit from treatment whatever their original motivation for seeking help. The court’s coercive power is used to induce “participants” to take part in rehabilitation to avoid incarceration (Hennessy 2001). Typically, the drug court program requires regular court dates, random drug testing, and full treatment compliance. Graduation can occur after twelve or more months of program attendance and sobriety. Failure to comply fully with the program can result in fines, additional court appearances, or incarceration (Hennessy 2001). Drug courts have had promising program completion rates, including graduation from the court process and retention in treatment programs (Sanford and Arrigo 2005). For example, in a review of thirty-seven programs, Belenko (2001) found that the average graduation rate was 47 percent and retention in treatment averaged 71  percent. Such measures of progress through the program are important because the rates of recidivism for graduates and nongraduates differ: 37  percent for drug court graduates and 75  percent for nongraduates (Peters and Murrin 2000). However, even those who do not complete programs but participate for extended periods have lower re-arrest rates than those who participate more briefly (Peters, Haas, and Hunt 2001). The level of threat of coercion measured by expected incarceration time has been associated with treatment retention and engagement (Rempel and DepiesDiStefano 2001). Offenders participating in the drug court programs have been described as voluntary, while acknowledging that avoiding incarceration is a strong incentive (Goldkamp 2000). We would describe such clients as nonvoluntary given the balance of available punishers and incentives for compliance. Court participation is, however, considered collaborative in that all parties work together to seek treatment and avoid incarceration. Problem-solving courts have also been developed for dealing with domestic violence. These courts are unlike the drug courts in that they are adversarial. In domestic violence courts, judges may confront violent perpetrators when they perceive them to be avoiding responsibility by assigning blame to victims (Levey, Steketee, and Keilitz 2001). Use of courts with domestic violence perpetrators has been useful in inducing them to seek treatment; however, treatment results themselves have been equivocal (Jackson et al. 2003). As with drug courts, program completion is key. Dropout rates are high and recidivism among dropouts is common. As Chovanec notes in chapter  13 of

Effectiveness with Involuntary Clients this volume, women can be put at risk if they choose to stay with partners on the basis of the latter enrolling in a treatment program (Gondolf 1988). In conclusion, in some problem-solving court situations, the threat of coercion and the inducement of avoiding prison and receiving treatment appear to have been effective means for helping some involuntary clients to engage in treatment. Reduced recidivism rates over one to two years are promising but more follow-up study is needed to determine whether changes achieved through “coerced voluntarism” last for a longer period. 2. Pro-social modeling has been associated with improved outcomes with involuntary clients in corrections. Pro-social modeling refers to reinforcing and modeling noncriminal values such as support and care for others and not supporting criminal or antisocial values (Trotter 2015). Practitioners supporting this principle would clearly identify the values they support and encourage them through modeling and praise. Conversely, they would challenge antisocial or pro-criminal values. For example, in drug abuse treatment, this refers to explicitly rewarding nonuse of chemicals (Barber 1995). Identifying inappropriate parent-child interaction and rewarding positive interaction has been a consistent factor in child protection programs based on social learning theory (Gough 1993). Andrews et al. (1979) found that when probation officers modeled and reinforced pro-social comments and were empathic, their clients offended less frequently than the clients of other probation officers (Trotter 2015). Similarly, Trotter (1990) found that the clients of volunteer probation officers who were more pro-social offended less than did clients of less pro-social volunteer officers. A later study also found that professional officers who used pro-social modeling were more effective than those who did not use the approach (Trotter 1993, 1996b). The clients of practitioners using the pro-social approach were half as likely to be imprisoned over four years than those who used the approach infrequently (Trotter 1996b). Similar positive results were reported for use in child protection (Trotter 2002). The pro-social modeling principle fits best with settings that have a clear educative mission about client values. Such a goal is prominent in education and corrections work with sexual offenders and perpetrators of domestic violence. The argument that client failures occur as a result of not internalizing pro-social values appears less applicable to some populations. For example, it appears the designers of welfare reform in the United States assumed that the values and beliefs of unemployed persons were a major obstacle toward their obtaining and keeping employment (Anderson, Halter, and Gryzlak 2004). Research has suggested, however, that many recipients of Temporary Assistance for Needy Families (TANF) ser vices already shared pro-social values about employment, in part, and training attention to such values did not address contextual variables such as availability of support, health insurance, and job availability. Thus, while inculcating pro-social values could be seen

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A Foundation for Work with Involuntary Clients as a useful tool to help TANF recipients in acquiring and keeping jobs, additional factors were also important (ibid.). The pro-social modeling principle focuses extensively on an internal change of orientation on the part of the client. Such a focus may be particularly useful in settings in which there is a consensus about pro-social values. Practitioners using this principle should be mindful of contextual variables in addition to pro- and antisocial values in less educationally focused settings. 3. Voluntary clients are rarely distinguished from nonvoluntary clients in the conduct of research. Research on treatment effects has evolved from concerns about whether intervention is generally effective to more specific questions about which form of intervention works with which sort of client and problem under which conditions (Reid and Hanrahan 1982). Reid and Hanrahan reported that the proportion of social work effectiveness studies based in public settings, and hence more likely to include involuntary clients, decreased from an earlier review by Fischer in 1973. Videka-Sherman noted in her review of 142 studies of social work intervention in mental health that client characteristics tended to lack adequate description (1985:188). Even when client voluntarism is considered as a variable, comparisons are usually made between court-ordered clients and legally voluntary clients whose participation in treatment has been coerced. These “voluntary” clients may in fact be the nonvoluntary clients described in chapter 1. Comparisons between involuntary and voluntary clients in settings such as psychiatric hospitals and residential treatment might be better seen as comparisons between mandated and nonvoluntary clients who may have received ser vices as a result of constrained or coerced choices. There are similar comparisons between court-ordered clients and legally voluntary clients in studies of coerced intervention in alcoholism, drug treatment, and child maltreatment. For example, Flores notes in his study of the effectiveness of coercion with DWI participants that “voluntary clients” in the study were influenced by coercive, but nonlegal pressures. For example, unhappy spouses, worried friends, concerned doctors, and disgruntled bosses all make up a contingency that often uses subtle pressure to force individuals with different types of problems into counseling when those individuals do not agree that they have a problem. (1983). Similarly, Irueste-Montes and Montes (1988) note that the so-called voluntary clients in their study of court-mandated ser vice for child maltreatment were all involved with child protective ser vices. The clients did not have legal consequences, but they were “encouraged or pressured to attend” (ibid.:38). In addition, other studies of voluntary clients may, in fact, include many nonvoluntary clients. For example, Edleson reports that men participating in a study of a domestic abuse program were voluntary while also reporting that all came in at a time of crisis, frequently involving a separation from the spouse

Effectiveness with Involuntary Clients (Edleson et  al. 1985). As discussed earlier, in reference to participants in problem-solving courts, “choosing” the incentive of avoiding jail time is “coerced voluntarism.” That is, when involuntary clients enter a voluntary drug treatment system with a status that is officially voluntary, yet are subject to recall by the social control system if they fail to comply, their voluntarism is coerced (Waldorf 1971; Peyrot 1985). Such programs as well as treatment programs for domestic violence perpetrators might be more accurately considered as typically involuntary, containing in some instances court ordered men and many nonvoluntary clients pressured by formal or partner-mandated, informal sources and situations. A first step to a more solid empirical base with involuntary clients in the future will be to clarify client referral status. Referral through legal mandates should be noted as such. Clients who enter contact through formal or informal pressure such that the decision to seek treatment was coerced or constrained rather than self-motivated should be noted as nonvoluntary. 4. Motivational congruence between client and practitioner is an important clue toward effective intervention with involuntary clients. Reid and Hanrahan (1982) refer to this fit between client motivation and what the practitioner attempts to provide as motivational congruence. They updated Fischer’s earlier review by assessing twenty-two additional studies conducted between 1973 and 1979 and reported “grounds for optimism” based on their finding that positive outcomes were reported in eighteen of the studies reviewed. They suggested that such congruence may be a factor in the more positive results found in their review of social casework effectiveness. The lack of fit between practitioner and client goals had also emerged earlier as an explanation for client dropout from casework and other forms of treatments (Mayer and Timms 1969; Maluccio 1979). Videka- Sherman explores motivational congruence as a possible explanation for her findings of similar outcomes between involuntary and voluntary clients and suggests that “the interaction between practitioner and client once the client (captive or not) arrives for treatment better captures . . . motivational congruence than whether the client was voluntarily or involuntarily referred” (1985:40). Congruence can be enhanced by (a) emphasizing choices and a sense of self-control, (b) socialization to role expectations, (c) behavioral contracting, and (d) supporting treatment adherence by facilitating client commitment and participation in task design and selection. a. Enhancement of choices and sense of control. Perceived lack of voluntarism can be reduced by emphasizing choices and a sense of control. Brehm and Smith suggest that “while the specific determinants of perceived choice to receive treatment are far from clear and may not parallel official status as voluntary and nonvoluntary, there is some support for the inference that once perceived, personal choice to remain in treatment has a beneficial effect on treatment effectiveness” (1986:88). Mendonca and Brehm conducted

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A Foundation for Work with Involuntary Clients an experiment in a clinical setting designed to test the impact of perceived choice (Mendonca and Brehm 1983). Half of the children enrolled in a weight loss program were randomly assigned to a “take control” condition in which choices were enhanced. The control group in fact received the same treatment program as the “enhanced choice” group but without being offered choices in the structure of the program. At the termination of treatment, children in the enhanced choice group had lost significantly more weight than the children in the no-choice group. Mendonca and Brehm (1983) concluded that this was the strongest evidence to date of treatment benefits accrued through providing clients with a choice of treatment. In fact, studies have indicated that gains can be accrued though the illusion of control as well as the reality (Langer 1975). That is, the perception that one is in control can be beneficial, even when the reality would suggest much less actual control. Since the research suggests that a client does not have to actually be in control in order to perceive control, should the practitioner stimulate an illusion of control while maintaining control over outcomes with involuntary clients? Some therapists advocate encouraging an illusion of control while maintaining real control over the process themselves (London 1969; Wathney and Baldridge 1980). I believe that real choices need to be separated from outcomes that the client cannot influence. For example, while mandated clients may not be able to avoid treatment, they may be able to make choices about the type of treatment they receive. For example, Miller notes that court-ordered status is not inconsistent with choices for participants in alcoholism treatment programs: “Even with a population required to seek treatment (e.g., drunk driving offenders), it is feasible to offer a choice among a variety of alternative treatments and to foster the perception of personal control over the change process” (1989:72). Sense of control can be enhanced with nonvoluntary clients by reminding them that they can choose not to be in treatment. Personal control and a sense of personal responsibility should be encouraged when such client efforts are likely to succeed. Even in potentially successful situations, enhancing responsibility can have negative side effects, such as increased anxiety, if clients are not confident of their ability to choose. In addition, should their choice fail, self-esteem can suffer. b. Socialization methods may assist in enhancing motivational congruence. Socialization for treatment has been found to be a powerful intervention. Videka-Sherman found socialization methods to be the one intervention technique predicting better outcomes in all subsets of her review of social work mental health studies: “The better-informed the client is concerning what will occur during treatment and what the client should be doing for his or her part of the treatment process, the more likely the client is to derive benefit from the experience” (1988:328). Similarly, pretherapy training to clarify expected behavior has proven to be an effective deterrent for premature termination in psychotherapy (Heitler 1976).

Effectiveness with Involuntary Clients Socialization methods have received less study with involuntary clients but results are promising. Brekke (1989) found that men in a domestic abuse treatment program who attended an intensive workshop at the beginning of contact were more likely to stay in treatment than men who did not attend the workshop. Similar to socialization, role clarification has been proposed as a key principle in work with involuntary clients (Trotter 2015). Practitioners who are specific about client and practitioner expectations are likely to have more success than those who are not specific. The research on socialization methods reinforces the earlier findings about the efficacy of pro-social modeling by practitioners working with involuntary clients. c. Behavioral contracting enhances motivational congruence. Contracting refers to an agreement between the client and practitioner that sets forth the purpose of the interaction and processes through which the goal is to be achieved (Kravetz and Rose 1973). Similar to pretherapy training and socialization, contracts have been suggested as a means of preventing premature dropout (Mayer and Timms 1969). Reid and Hanrahan identified behavioral contracting as an important variable explaining the more positive results in their review of casework effectiveness: “The technique of behavioral contracting has shown considerable potential . . . in which the practitioner secures from clients commitments to undertake specific problem-solving action” (1982:338). Rubin echoed this conclusion in his updated review of the next five years: “A prominent commonality among the studies was the use of highly structured forms of practice that were well-explicated and specific about the problems the social workers sought to resolve, the goals they sought to accomplish and the procedures used to achieve these ends” (1975:474). Nonvoluntary clients in the child welfare system were included among the studies that led to these conclusions. For example, Stein, Gambrill, and Wiltse (1978) found that parents engaged in a behavioral contracting approach were significantly more likely to have their children returned to their custody than families who received traditional child welfare ser vices. Seabury (1976) suggested, however, that involuntary clients are among the most difficult groups with which to establish a contract. Seabury concluded that it is more difficult to establish common agreement when the client fails to recognize a problem or does not view the worker as a person who can help. In addition, he suggests that the rational competence required to engage in contracting may rule out extremely disturbed, disabled, or brain-damaged clients and young children, though secondary contracts may be negotiated with family members and advocates (Seabury 1979). Seabury considered contracting to be problematic but possible with involuntary clients: “It is crucial that the terms of the legal arrangement be distinguished from the stipulations of the social work contract” (1979:36). Hence, we find a theme similar to that of enhanced choices; that is, the critical importance of separating negotiable from nonnegotiable items.

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A Foundation for Work with Involuntary Clients d. Treatment adherence can be facilitated through client participation in goal and task selection. Adherence is defined as the extent to which patient behavior corresponds to medical advice (Weiss 2003). The term adherence is often preferred to compliance because it implies greater patient autonomy in following treatment regimens (ibid.). Meichenbaum and Turk (2012) suggest that the term “noncompliance” means failing to follow through with the practitioner’s instructions. It implies that the patient or client is at fault. Adherence is more likely with chronic conditions than with diet or behavioral changes designed to reduce risk. Most specifically, adherence with medication for psychiatric disorders often begins at a low rate and declines over time, contributing to relapse (ibid.). A positive, collaborative relationship between doctor and patient that includes information about medication and its side effects is associated with greater adherence (Weiss 2003). Meichenbaum and Turk (2012) suggest that nonadherence may refer to a variety of types rather than a single problem behavior: those who never adhere may be different than those who do so occasionally and also from those who adhere, but do so inappropriately. Whatever the cause, nonadherence is a very frequent occurrence among the seemingly voluntary population of persons with physical illnesses. Six factors have been suggested as helpful in increasing treatment adherence: (1) specific requests instead of vague ones, (2) overt commitments from clients to comply, (3) training in performing the task, (4) positive reinforcement of the task, (5) tasks that require little discomfort or difficulty, and (6) client participation in the selection and design of tasks (Levy and Carter 1976). Given such high rates of nonadherence on the part of voluntary patients, nonadherence with involuntary clients can be expected to be as high. In the absence of studies about facilitating treatment adherence with involuntary clients, the aforementioned factors are suggested as provisional guidelines to enhancing treatment adherence. In the following section, we explore the stages of change approach and motivational interviewing as particularly promising sources of future adaptation to work with involuntary clients.

Stages of Change and Motivational Interviewing with Involuntary Clients The transtheoretical model of stages of change attempts to explain how people consider changing behaviors without therapy. The model initially addressed cigarette smoking and later was adapted to alcohol use, overeating, and safesex practices (Wahab 2005). The model proposes that there are predictable steps in the process of making intentional changes (Prochaska, Norcross, and

Effectiveness with Involuntary Clients DiClemente 1994; Hanson and Gutheil 2004). Specifically, it is posited that most people do not immediately identify a need for change and readily adopt lifestyle changes. Rather, they progress through stages including appearing to be oblivious to the problem, being aware of a concern but undecided about whether to take action, deciding to act but not knowing what action to take, and so on. The precontemplation phase sounds familiar to those who work with involuntary clients. Persons in this stage do not link their behavior to adverse consequences, do not consider their behavior a problem, and may not be confident that they could change should they choose to do so (Hanson and Gutheil 2004). A person in the contemplation stage takes the problem seriously but has not determined to act to change the behavior. Persons in this stage may have begun initial steps on their own to modify or change a behavior, such as reducing drinking. In the preparation or decision-making stage, a person is taking small behavioral and mental steps necessary to begin a change (Peterocelli 2002). In the action stage, a person is taking more decisive action over a period of time to address the problem behavior. Efforts then follow in the maintenance stage to solidify gains and prevent a lapse to earlier problematic behavior. While the transtheoretical model assumes voluntary change efforts, stages such as precontemplation and contemplation have ready applications to clients who approach contact under mandated or nonvoluntary pressure. As noted earlier, involuntary clients frequently have problems attributed to them that they do not acknowledge as legitimate, similar to the behavior described as precontemplation in this model. Awareness of the client’s stage of change can be useful to the practitioner in determining how they might best direct their efforts. For example, frequently practitioners assume that clients were at the action phase and were ready to modify their behavior when in fact they had neither decided that they had a problem nor decided that they wished to change it. Motivational interviewing is a client-centered intervention method designed to assist the client in exploring ambivalence about change and enhancing commitment to taking action (Miller and Rollnick 2012). Through empathic listening, the practitioner helps the client assess behaviors and consequences and consider options for change. Even in precontemplation, an involuntary client pressured to explore treatment can be made aware of available choices. For example, a practitioner might say, “Considering the pressures you are facing, you decided to come in and take a look at what was available: I am impressed that you made that choice” (Peterocelli 2002). Stages of change and motivational interviewing are appropriate for use with specific involuntary problems and populations, such as sexual offenders and perpetrators of domestic violence.

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A Foundation for Work with Involuntary Clients Treatment of Sexual Offenders Sexual offenders are usually legally coerced to participate in treatment, and therefore are legally mandated clients (Glancy and Regehr 2002; Knox 2002). Given the harm to victims and society, the community is often considered the primary client rather than the sexual offender with primary goals of preventing future victimization and ameliorating harm caused by offenders (Colorado Sex Offender Management Board 1999). Consequently, treatment has often focused on confronting offenders with errors in thinking, developing empathy with victims, and with taking responsibility for the consequences of their actions. Groups have often been used to assist in confronting secrecy and denial (McGrath 1995; Knox 2002). Treatment may also attempt to redirect sexual arousal toward appropriate partners and activities, to improve social competence, and to address potential for relapse. Finally, there is often a clarification process whereby the offender is led to accept full responsibility for his or her actions, often in the form of a letter to the victim (Knox 2002). Treatment effectiveness has been measured in terms of recidivism (Kim, Benekos, and Merlo 2016). Methods have emphasized cognitive behavioral techniques to reduce thinking error and increase empathy. Results have been assessed as proven and promising with solid evidence criteria such that there could be shown to be a 10 percent reduction in recidivism. Kear- Colwell and Pollock (1997) have suggested that a treatment style that aims to confront offenders and seek admission of guilt and penetration of defenses does not engage the offender as an active participant in his treatment. By adapting the stages of change approach, offenders can be met at their stage of motivation and engaged in a decision analysis of alternatives in situations of risk (ibid.). Similarly, Yates (2003) suggests that a punitive style focusing on having the offender take responsibility for his or her actions results in an aggressive style of relating to the offender and creates power struggles. This style makes it less likely to engage clients, and those who do not complete treatment are more likely to reoffend. Yates suggests that a style of work that emphasizes active listening, pro-social modeling, and reinforcement allows practitioners to challenge offenders around risk areas and also to engage them actively in positive self-management, not just attempting to avoid relapse. These developments suggest that even when the community can be considered the primary client, engaging sexual offenders as persons capable of making decisions that help or harm them through adaptations of motivational interviewing and recognition of stages of change can make motivational congruence more feasible and choices can be emphasized.

Effectiveness with Involuntary Clients Work with Domestic Violence Perpetrators Persons who commit violence on others are not necessarily involuntary clients. However, it would appear that most treatment participants are at least nonvoluntary in the sense that they respond to pressures to enter treatment. According to Chovanec (chapter  12 of this volume), approximately 60 to 80  percent of men who complete violence treatment programs end their violent behav ior; a smaller number reduce their threats and verbal abuse (Gondolf 1997). However, the dropout rate is at least 22 percent (Daly and Pelowski 2000), and women who remain with partners expecting them to complete programs may be in greater danger (Gondolf 1988). While intervention models have often emphasized confrontation and taking responsibility for one’s behavior (Chovanec, chapter 12 of this volume), concerns have been raised about whether confrontational models may inadvertently reinforce beliefs about power and control that those with more power may exert their will over those with less power (Murphy and Baxter 1997). According to van Wormer and Bednar (2002), the assumption that power and control are the sole or primary motivation for domestic violence is now under question. Such an approach may marginalize other concerns raised by men. As with sexual offenders, some researchers suggest that assaultive men can better be addressed at their stage of change. Perpetrators who find that the goals of treatment do not match their own goals are likely to drop out (Cadsky et al. 1996; Daniels and Murphy 1997). A recent study of assaultive men suggests that the majority are in precontemplation or contemplation in which efforts to engage will be crucial (Eckhardt, Babcock, and Homack 2004).

The Contribution of the Transtheoretical Stages of Change Model and Motivational Interviewing to Work with Involuntary Clients Critics suggest that people may not progress through the stages in the orderly way suggested by the model (Davidson 1998; Littell and Girvin 2002). That is, they may move forwards and backwards and jump stages rather than progress in the orderly fashion implied by the model. Also, involuntary clients may have multiple issues or concerns such that they are at different stages on different issues. For example, a parent may be taking action on securing better child care at the same time as he or she may be in precontemplation related to the consequences of his or her own child care under the influence of drugs. In addition, Littell and Girvin suggest that involuntary clients may have a vested interest in portraying themselves as ready for change when in fact they see no reason for it, but rather understand the consequences of failure to acknowledge a problem (Littell and Girvin 2004). For example, if a child has

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A Foundation for Work with Involuntary Clients been removed from the home related to failure to protect the child and a parental chemical problem, parents would be unlikely to deny that they had such a problem if they wished to regain custody of the child. Finally, there are concerns about full application of the approach to social problems that are broader than health decisions. For example, child welfare concerns may include health care issues but often include other concerns related to environmental resources and lack of support. The stages of change model and motivational interviewing do not directly address involuntary clients but instead have significant implications for involuntary clients who face health decision issues. Specifically, the motivational interviewing approach is designed to guide the practitioner in making interventions that fit where the client is now in terms of motivation for change. The model does not directly approach the issue of the role of the practitioner when that practitioner has mandated responsibilities to protect clients, dependents, and the community. That is, the approach appears to assume that the practitioner’s role is to help clients with health care issues to consider alternatives and to make decisions. Sometimes mandated practitioners have to act to protect clients, dependents, and the community whether or not the involuntary client acknowledges the problem and indicates willingness to work on it. Both the stages of change model and motivational interviewing are explored more thoroughly in three following chapters. Chovanec applies the approaches for work with men who perpetrate violence in chapter 12. Van Wormer and Parker explore the utility of the approaches for work with addiction problems in chemically dependent clients in chapter 15. And Hohman, Kleinpeter, and Strohauer apply the approaches to work with adolescents in health safety issues in chapter 17.

Discussion The knowledge base for work with involuntary clients has been limited by lack of focus, varied quality of studies, and less than conclusive results. These limitations may in part reflect appropriate protections for mandated clients from participating in research against their will. Further studies are needed that specify the level of voluntarism, the extent of choices and their implementation, the nature of the treatment and involuntary client responses to it, as well as more specific applications to problems and populations. In this chapter we have suggested that intervention with legally mandated clients can achieve successful results. However, coerced intervention often produces time-limited benefits that do not last beyond the use of the external pressure. In addition, comparisons between involuntary and “voluntary” clients often appear to be comparisons between mandated and nonvoluntary clients. Further clues to effectiveness suggest that interaction between practitioner and

Effectiveness with Involuntary Clients client plays an important part in achieving these improved outcomes. Specifically, interventions designed to enhance motivational congruence between practitioner and client are promising sources for effective intervention. Motivational congruence should not, however, be construed as easily achieved with involuntary clients. Many choices are so constricted as to be negligible. In addition, as treatment adherence has been shown to be problematic with voluntary clients, there is little reason to expect it to be less so with involuntary clients. Mandated ser vice agencies and institutions have community protection goals that impose obstacles to the pursuit of high congruence. Even when the setting affirms goals of congruence, time, resources, and practitioner discretion is needed to implement those goals. Such pressures often create a reactive stance that impedes the extra efforts required to seek congruence. In addition, public opinion often pressures agencies into punitive approaches and away from approaches seen as “coddling” wrongdoers. Despite these reservations, the pursuit of motivational congruence is promising toward a goal of legal, ethical, and effective practice with involuntary clients. Such efforts deserve experimentation and study to enhance compliance while respecting involuntary client legal rights and their self-determination. Several clues to effectiveness in the pursuit of motivational congruence have been suggested. Enhancement of perceived choice is the first such clue. Since nonvoluntary clients can legally choose to refuse treatment, notification of such freedom is recommended for work with all nonvoluntary clients. As such a choice may bring some negative consequences as well as benefits, the consequences should be explored in assisting nonvoluntary clients in making such decisions. Perceived choice can also be enhanced with mandated clients when they are encouraged to make constrained choices between acceptable options, including the choice to accept legal consequences rather than participate in treatment programs. Manipulation of the appearance of choice for clients while withholding actual choices conflicts with guidelines suggested in chapter 2 regarding honest communication and restricting unethical paternalism. A more ethical choice is to make very clear the distinction between those issues that are required and non-negotiable and distinguishing them from issues in which clients have free choices or choices among constrained alternatives. We note that with some populations such as sexual offenders and domestic violence perpetrators, the community is often considered the primary client. However, by adapting a stages of change approach, it is possible to seek motivational congruence. Additional clues include socialization and behavioral contracting methods that clarify such distinctions between the negotiable and the nonnegotiable. Finally, guidelines for increasing treatment adherence including soliciting specific commitments and client participation in task selection were suggested. At this point, there is no overarching theory or model about what works with involuntary clients. Intervention methods are reported that have different

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A Foundation for Work with Involuntary Clients targets of intervention and different assumptions about the change process. Pursuit of ethical effective practice would suggest continuing the same methods in the face of less than uniform success may make less sense than exploring hypotheses from other methods and populations. Ultimate questions of whether some persons have committed crimes of such a despicable nature that they have forever forfeited the right to be treated as a client entitled to self-respect and some engagement in problem solving are not now answerable. We need to monitor the consequences of our assumptions about client status. The stages of change approach and motivational interviewing are useful tools for addressing health care behaviors with involuntary clients with the proviso that adaptations have to be made. Motivational interviewing addresses the conundrum that involuntary clients in many fields are often less immediately concerned about their problem behaviors than are others. Rather than try to pressure or influence them to take action on problems that they do not acknowledge and ending in a confrontation– denial cycle in which clients are confronted about their irresponsible behavior, they defend themselves and are labeled as in denial, leading to more confrontation, this method focuses the practitioner on assessing the level of acknowledgment of the problem and inclination to action. A number of techniques are available for helping clients to assess the costs and benefits of their behaviors and the costs and benefits of considering change. The clues to intervention effectiveness developed in this chapter are transformed into more specific practice guidelines in chapters 6 through 8. Chapter 4 reviews practitioner influence methods such as use of rewards, punishments, and persuasion.

Discussion Questions 1. To what extent have you seen such guidelines as seeking motivational congruence and enhancing choices promoted in practice with involuntary clients? 2. Since practitioners with involuntary clients frequently interact with clients who do not perceive themselves as having the problems that others see them as experiencing, how useful is a conception of precontemplation and contemplation to such work? 3. To what extent have you seen efforts to seek congruence with clients such that their own goals are pursued rather than focusing on others’ goals for them? 4. What is your experience with the concept of pro-social modeling as a conscious method for influencing involuntary clients?

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Effectiveness with Involuntary Clients Littell, J. H., and H. Girvin. 2002. “Stages of Change: A Critique.” Behavior Modification 26 (2): 223–273. London, P. 1969. Behavior Control. New York: Harper and Row. McGrath, R. J., ed. 1995. Vermont Clinical Practices Guide for the Assessment and Treatment of Adult Sex Offenders. Burlington: Vermont Center for Prevention and Treatment of Sex Offenders. Maluccio, A. 1979. Learning from Clients. New York: Free Press Martinson, R. 1974. “What Works? Questions and Answers about Prison Reform.” The Public Interest 35: 22–54. Mayer, J., and N. Timms. 1969. “Clash in Perspective Between Worker and Client.” Social Casework 50: 32–40. McNeece, C., and B. Thyer. 2004. “Evidence-Based Practice and Social Work.” Journal of Evidence-Based Social Work 1 (1): 7–25. Meichenbaum, D., and D. Turk. 2012. Facilitating Treatment Adherence. New York: Springer Press. Mendonca, P., and S. Brehm. 1983. “Effects of Choice on Behavioral Treatment of Overweight Children.” Journal of Social and Clinical Psychology 1 (4): 343–358. Miller, W. 1962. “The Impact of a Total Community Delinquency Control Project.” Social Problems 9: 168–191. Miller, W. 1989. Handbook of Alcoholism Treatment Approaches, eds. R. Hester and W. Miller. New York: Pergamon. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Preparing People for Change. New York: Guilford. Murphy, C., and V. Baxter. 1997. “Motivating Batterers to Change in the Treatment Context.” Journal of Interpersonal Violence 12 (4): 607–619. Peterocelli, J. V. 2002. “Processes and Stages of Change: Counseling with the Transtheoretical Model of Change.” Journal of Counseling and Development 80 (1): 22. Peters, R., A. Haas, and M. Hunt. 2001. “Treatment Dosage Effects in Drug Court Programs.” In Drug Courts in Operation: Current Research, ed. J. Hennessy, 63–72. New York: Haworth Press. Peters, R., and M. Murrin. 2000. “Effectiveness of Treatment-Based Drug Courts in Reducing Criminal Recidivism.” Criminal Justice and Behavior 27 (1): 72–96. Powers, E. and H. Witmer. 1951. An Experiment in the Prevention of Delinquency: The CambridgeSomerville Youth Study. New York: Columbia University Press. Peyrot, M. 1985. “Coerced Voluntarism: The Micro Politics of Drug Treatment.” Urban Life 13 (4): 345. Prochaska, J., J. Norcross, and C. C. DiClemente. 1994. Changing for Good. New York: Avon Books. Reid, W., and P. Hanrahan. 1982. “Recent Evaluations of Social Work: Grounds for Optimism.” Social Work 27: 328–340. Rempel, M., and C. Depies-DiStefano. 2001. “Predictors of Engagement in Court-Mandated Treatment: Findings at the Brooklyn Treatment Court, 1996–2000.” Journal of Offender Rehabilitation 33 (4): 87–124. Reynolds, P. 1982. Ethics and Social Science Research. Englewood Cliffs, NJ: Prentice Hall Rosenberg, C., and J. Liftik. 1976. “Use of Coercion in the Outpatient Treatment of Alcoholism.” Journal of Studies on Alcohol 37: 58–62. Rubin, A. 1975. “Practice Effectiveness: More Grounds for Optimism. Social Work 30 (6): 469–476.

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A Foundation for Work with Involuntary Clients Sackett, D., S. Straus, W. Richardson, W. Rosenberg, and R. Haynes. 2000. EvidenceBased Medicine: How to Practice and How to Teach EBM, 2nd  ed. Edinburgh, UK: Churchill-Levigness. Sanford, J., and B. Arrigo. 2005. “Lifting the Cover on Drug Courts: Evaluation Findings and Policy Concerns.” International Journal of Offender Therapy and Comparative Criminology 49 (3): 23–44. Seabury, B. 1976. “The Contract: Uses, Abuses and Limitations.” Social Work 21: 16–21. Seabury, B. 1979. “Negotiating Sound Contracts with Clients.” Public Welfare 38: 33–38. Shireman, C., and F. Reamer. 1986. Rehabilitating Juvenile Justice. New York: Columbia University Press. Stein, T., E. Gambrill, and K. Wiltse. 1978. Children in Foster Homes: Achieving Continuity of Care. New York: Praeger. Trotter, C. 1990. “Probation Can Work: A Research Study Using Volunteers.” Australian Journal of Social Work 43 (2): 13–18. Trotter, C. 1993. The Effective Supervision of Offenders. PhD diss., La Trobe University, Melbourne. Trotter C. 1996a. “Community Corrections—Punishment or Welfare. Book Review Essay.” International Criminal Justice Review 6: 121–130. Trotter, C. 1996b. “The Impact of Different Supervision Practices in Community Corrections.” Australian and New Zealand Journal of Criminology 29 (1): 29–46. Trotter, C. 2002. “Worker Skill and Client Outcome in Child Protection.” Child Abuse Review 11: 38–50. Trotter, C. 2015. Working with Involuntary Clients: A Guide to Practice. 3rd ed. London: Sage. Tyuse, S., and D. Linhorst. 2005. “Drug Courts and Mental Health Courts: Implications for Social Work.” Health and Social Work 30 (3): 233–240. Van Wormer, K., and S. G. Bednar. 2002. “Working with Male Batterers: A RestorativeStrengths Perspective.” Families in Society 83 (5/6): 557–565. Videka-Sherman, L. 1985. Harriet M. Bartlett Practice Effectiveness Project. Silver Spring, MD: National Association of Social Workers. Wahab, S. 2005. “Motivational Interviewing and Social Work Practice.” Journal of Social Work 5 (1): 45–60. Waldorf, D. 1971. “Social Control in Therapeutic Communities for the Treatment of Drug Addicts.” International Journal of the Addictions 6 (1): 29–43. Wathney, S., and B. Baldridge. 1980. “Strategic Interventions with Involuntary Patients.” Psychiatric Services 31 (10): 696–701. Weiss, R. D. 2004. “Adherence to Pharmacotherapy in Patients with Alcohol and Opioid Dependence.” Addiction 99 (11): 1382–1392. Wood, K. M. 1978. “Casework Effectiveness: A New Look at the Research Evidence.” Social Work 23 (6): 437–458. Yates, P. M. 2004. “Treatment of Adult Sexual Offenders: A Therapeutic Cognitive-Behavioural Model of Intervention.” Journal of Child Sexual Abuse 12 (3–4): 195–232.

Chapter 4

Influencing Behaviors and Attitudes

Ronald Rooney

In chapter 2, we reviewed the circumstances in which practitioners with involuntary clients have ethical or legal grounds to attempt to influence behavior. In chapter 3, we saw that problem-solving courts are among the coercive interventions that can be effective with involuntary clients. In this chapter, we explore methods designed to influence behavior and attitudes. Practitioners working with voluntary clients sometimes see themselves as helping those clients make informed choices, or facilitating their growth, rather than influencing their behavior and attitudes. The latter has connotations of manipulation that may not fit the self-image of voluntary practitioners. Such practitioners may not be aware of or acknowledge that they and their clients are engaged in attempts to influence one another’s behavior and attitudes (Perloff 1993). However, denial or unconscious use of influence by practitioners is particularly problematic in practice with involuntary clients since that influence is often evident to the involuntary client if not the practitioner and may constitute an unethical use of power. Hence, we proceed in this chapter with the view that influence attempts do occur and that practitioners are better served by being conscious of power so that such efforts to influence behavior and attitudes can be ethically guided and evaluated. Compliance-oriented methods are at the high end of a continuum of intrusiveness into client behavior, since they attempt to influence actions and attitudes directly through punishing undesirable events and rewarding desirable events. Persuasion methods are less intrusive as they influence actions and attitudes through providing information rather than manipulating rewards and

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A Foundation for Work with Involuntary Clients Figure 4.1

Coercion methods

Restriction of freedom

High

Moderate

Low Persuasion

Reward or inducement

Coercion or punishment

Compliance methods

constraints. Both compliance-oriented and persuasion methods have important roles for involuntary clients, with relatively more frequent use of compliance methods with mandated clients and more frequent use of persuasion with nonvoluntary clients. The characteristics, advantages, disadvantages, and guidelines for legal, ethical, and effective use of each form of influence are presented in this chapter. More attention is devoted, however, to persuasion methods, since their inappropriate use raises fewer ethical problems and practitioners and programs tend to be less knowledgeable about them (see figure 4.1). The following case study introduces compliance-oriented methods.

Gerald, sixteen, lived in a small residential facility for adolescents with behavior problems. As frequently occurs in such settings, the treatment program included a specific set of rules and procedures, such as rewards for approved behavior and penalties for disapproved behavior. A token economy system was used in which Gerald could earn points for good behavior that would accrue toward obtaining rewards (Morisee et al. 1996). For example, Gerald could earn one point for each hour in which positive behaviors, such as paying attention in school, were demonstrated. The system also included penalties for infractions. For example, swearing, acting in a way considered rude or sarcastic by a counselor, or failure to comply with a counselor’s request would result

Influencing Behaviors and Attitudes in a warning. After three such warnings, a punishment in the form of a half hour of work such as scrubbing windows would be administered. If, however, the form of negative behav ior included aggression toward self or others, attempts to run away, property destruction, or use of alcohol or drugs, the half-hour penalty was immediately administered. In addition, residents who were being disciplined were to “process” their punishment by discussing the reasons for the penalty with the counselor. While a punishment was being processed, residents were not allowed to watch television, interact with peers, use the telephone, or smoke. Gerald had been in the setting for three months and had been earning steady rewards as well as a normal amount of penalties for his behav ior. On one occasion, however, Gerald returned to the group home under the influence of marijuana after a weekend visit with his parents. The counselor on duty noted his dilated pupils and the distinctive odor of marijuana. When asked, Gerald acknowledged that he had been smoking marijuana. Returning to the group home under the influence of alcohol or other drugs was a clear rule violation. Gerald was told that the processing of the appropriate penalty would occur the next afternoon when he returned from school. The next afternoon, Gerald did not “process” the discussion of the rule violation calmly. He was described as sarcastic by the counselors and was assessed a time-out to calm himself. Gerald was still irate after the ten-minute time-out and a half-hour restitution penalty was inflicted. Gerald refused to comply with the penalty and threatened staff members. When staff attempted to restrain Gerald, he broke free and broke a panel in a door. After he was successfully restrained and first aid applied to his cuts, two more penalties were issued. At this point, Gerald had lost 1,000 points for aggression toward self and others, had earned five hours of restitution, and further unsupervised home visits were now suspended. In addition, he was now suspended from outings with peers for six months. Staff told Gerald that he had hurt his parents by violating the rules: they could no longer have unsupervised home visits with him. Gerald became angry and had to be restrained once again.

Reminiscent of a lyric sung by Janis Joplin, “freedom’s just another word for nothing left to lose,” Gerald had lost so many rewards and accrued so much punishment at this point, that there was little incentive for him to try to succeed in the program. With little left to lose, and the program designed

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A Foundation for Work with Involuntary Clients to influence his behavior in a positive fashion appearing to have a boomerang effect of escalating negative consequences, a reevaluation of procedures was called for. We will explore in the following sections how a compliance-oriented system can work effectively and ethically to limit behavior but can also go wrong, as in this case, acquiring its own momentum and producing results worse than the behavior that it was designed to curb. We will also explore how a better understanding of compliance methods might have led to a different result.

Compliance-Oriented Methods Compliance behavior occurs when a person accepts influence in order to escape a punishment or achieve a reward or approval (Feld and Radin 1982). Such methods can be appropriately used to protect others and to modify behavior that is dangerous to the client. The principle of pro-social modeling was described in chapter 3 as a clue for effectiveness involving a conscious, consistent plan for modeling and reinforcing behavior and attitude change (Cherry 2005; Trotter 2015). The residential program where Gerald was placed attempted to use compliance methods to reach individual and institutional goals. While complianceoriented methods are ethically neutral and are sometimes used with clients who have little input into goals and methods, use of contracts that specify negotiable and nonnegotiable items is preferred (Stolz, Wienckowski, and Brown 1975). Compliance-oriented approaches make important assumptions that can be helpful in involuntary situations. By considering behavior as learned, attention can be focused on changing contingencies, observing models, avoiding dangerous situations, and rewarding alternative behaviors rather than dwelling on unchangeable past events (Cherry 2005). While it is beyond the scope of this book to examine compliance-oriented approaches in detail or to include all the involuntary populations with which they have been used, key concepts for use with involuntary clients are reviewed. Punishment Discussion of use of punishment and coercion takes place in a context in which extreme forms of coercion best classified as torture or what has been described as “tough techniques with the worst of the worst” have become an instrument of national policy in the war against terror. Waterboarding, which induces a sense of imminent drowning through strapping persons to boards and pouring water over the nose and mouth, has occurred as an instrument of policy (Warrick and Pincus 2008). Whatever the justifications for such usage for

Influencing Behaviors and Attitudes national defense, particularly problematic has been the compliance of medical personnel contrary to the Hippocratic Oath in collaborating in the design of torture and monitoring health so that health endangering methods can be used (Dossey 2006; Miles 2006). Coercive methods have frequently been used in the context of human services with mental patients ostensibly to protect them and others, both with legally involuntary clients and ostensibly voluntary clients (Iversen, Hoyer, and Sexton 2007). Studies of coercion in mental health have suggested that recipients of coercive intervention often find it humiliating (Nyttingness, Ruud, and Rugkasa 2016) and giving patients the opportunity to engage in treatment planning and the evaluation of success had little effect on the experience (Sørgaard 2004). Coercion has been studied to include both objective coercion, which is intentional and can be observed, and perceived coercion, which includes the patient’s perception that it has occurred. Sørgaard (2004) found that both involuntary and voluntary patients perceived coercion to have occurred. In addition to objective coercion, implicit coercion can occur by failing to notify patients of rights. For example, voluntary patients on an in-patient unit have been stalled or delayed when they expressed a desire to leave if their departure was considered dangerous (Sjöström 2006). Coercion occurs despite data to suggest that it arouses negative feelings, creates negative expectations about outcomes, impedes a trusting relationship, and makes many patients less open to ser vices (Kaltiala-Heino, Laippala, and Salokangas 1997). The following presentation and discussion of coercion therefore takes place in a context of dangers as well as potential benefits. Punishment or constraint is the most intrusive compliance method. It refers to methods intended to stop or reduce an unwanted behavior through administration of adverse consequences or withholding positive consequences (Rose 1998). There are five major types of punishment. Positive punishment refers to the use of an aversive consequence when an unwanted stimulus occurs (Thyer and Myers 2000). For example, requiring a delinquent youth to wash windows as a consequence for swearing (ibid.). In the preceding example, when Gerald became violent, staff attempts to restrain him were designed to constitute positive punishment. The term “positive” should not be construed to mean that this form of punishment is pleasurable or appropriate. Response cost refers to withholding positive reinforcements when an unwanted behavior occurs (Rose 1998). Hence suspending Gerald’s outings with other residents and unsupervised home visits was a form of response cost. Negative reinforcement refers to the removal of an aversive consequence in order to stimulate a behavior (Thyer and Myers 2000). Hence, negative reinforcement is a coerced choice because some responses are rewarded. If Gerald could have immediately begun to acquire positive points toward regaining privileges following response cost, negative reinforcement would have been used more appropriately.

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A Foundation for Work with Involuntary Clients Overcorrection methods can be used to teach alternative behavior incompatible with the unwanted behavior. For example, restitution can be used to both provide an appropriate punishment and also reinforce pro-social behavior. Restitution is used in some victim-offender reconciliation programs that involve meetings between property offenders and their victims in which the form of restitution for damage done is negotiated between the two parties. Such methods may meet some of the real purposes of punishment by putting the offender in touch with the harm he or she caused (van Wormer 2004). Since the drug violation occurred while Gerald was under his parents’ supervision, a meeting with Gerald and his parents might have more directly addressed the causes of the rule violation and assisted in the construction of an appropriate response. If Gerald and his parents had been consulted in the choice and design of appropriate penalties, their belief in the appropriateness of the penalty might be greater. Finally, time-out can be used as an extinction method by withholding reinforcement in a nonpunitive environment (Rose 1998). When Gerald was sent to his room for ten minutes, this was considered a time-out. Each of these five punishment methods can be used legally, ethically, and effectively in certain situations. Legal Use of Punishment As described in chapter 2, use of coercion is legal when the practitioner has a mandated responsibility, client behavior falls within the domain of that mandate, and criteria for employment of punishment are clear and appropriately followed. Appropriate oversight boards must develop and periodically review use of intrusive procedures such as the use of restraints (Stolz, Wienkowski, and Brown 1975). In this case, the circumstances of the use of restraint with Gerald should have been reviewed by an oversight board to determine whether in fact there was immediate danger to Gerald or others. Ethical Use of Punishment Use of punishment is ethical when harmful behavior or behavior at high risk of injury to the person or others occurs, when less intrusive methods are ineffective such that few alternatives can be reinforced or reinforcers removed, and when there is a panel to review appropriate use of the method regularly (Simons and Aigner 1985). There is question here whether there was risk of any immediate injury to Gerald or whether less intrusive methods such as consultation with Gerald and his parents about restitution could have been attempted. As noted in chapter 2, punishment and other paternalistic behaviors often emerge to meet the needs of the institution rather than more limited, situationspecific penalties. It may be easier for staff to administer punishments than rewards, and an ineffective punishment system can be established that unfor-

Influencing Behaviors and Attitudes tunately models the inappropriate aggressive behavior it intends to change (Rose 1998). In addition, nonvoluntary clients in residential institutions have fewer legal protections from inappropriate use of punishment than do legally mandated clients (Iverson, Hoyer, and Sexton 2007; Surgenor 2003). Practitioners should act to protect client rights when compliance-oriented methods are used to regulate social deviance in matters that are neither dangerous to others nor illegal. Such methods are in par ticu lar danger of overuse with members of oppressed groups. For example, more punitive sentences for use of crack cocaine rather than other forms of cocaine disproportionately penalize African Americans (Sterling 2004, Coyle 2002). Effective Use of Punishment The effective use of punishment assumes that the practitioner has access to aversives that are powerful enough to stop the behavior, that the punishment is administered quickly and consistently, and that the practitioner is prepared for the drawbacks that frequently accompany its use (Simons and Aigner 1985). Punishment works most effectively when it is used to stop or reduce a harmful behavior in the short run (see figure 4.2). Hence, the penalties that Gerald received might have had an effect of immediate, though short-term, reduction in use of marijuana. Punishment tends, however, to suppress the harmful behavior rather than eliminate it and usually does not change attitudes (ibid.). Since aversives work best when they are power ful and consistent, the lack of power or consistency too often results in the client learning how to avoid getting caught for a similar offense rather than questioning the offense. If punishment was not combined with other forms of influence with Gerald, the most important thing he may have learned from this incident would be to stop smoking marijuana earlier in the day before returning to the facility, to avoid detection, rather than change his beliefs about use of the drug. Additional problems occur when aversives are neither power ful nor consistent. When this occurs, clients may learn to avoid punishment by lying, deceiving, or acting in an ingratiating fashion. Further, client beliefs in punishment as a solution to interpersonal problems may be inadvertently reinforced. They may believe that “might makes right” and punishment of them may lead to a displacement of aggression onto others outside the situation. Use of punishment is also frequently associated with increased fear, hostility, and feelings of powerlessness and helplessness. In addition, punishment does not necessarily reduce attraction to prohibited behavior but may, in fact, cause it to be more valued (Brehm et al. 1966). Finally, if the reason for punishment is not clear, it may inadvertently punish other positive, desirable behaviors (ibid). In this case, Gerald’s desire to smoke marijuana again when unsupervised may

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A Foundation for Work with Involuntary Clients Figure 4.2

Punishment

Punishment * used to reduce or eliminate a response when danger is imminent, there is a mandate to use, and other methods will not suffice

Considerations in appropriate use * with enough strength and consistency

* combined with inducement

Frequent byproducts * fear, anxiety * reactance * ingratiation * identification with the punisher * costly, often ineffective * may inadvertently act to reinforce * suppresses or “buys” behavior * often teaches avoidance * rarely leads to self-attribution

and persuasion

* retaining some choices * regular review of appropriate usage

have increased and his general collaboration in the positively oriented token economy system may have decreased. Effective use of punishment requires control of sufficient aversive resources. These resources may need to be used indefinitely if alternative behavior does not become reinforcing. Further, when a relationship begins on the basis of punishment, it is difficult to change to a relationship based on reward or persuasion as the practitioner and agency may be associated only with punishment. However, access to sufficient coercive resources contains its own dangers. Availability of coercive resources encourages their use to exercise control and exert retribution (Kipnis 1972; Stolz, Wienckowski, and Brown 1975). Continued use of punishment can contribute to alienation and distancing from clients, including labeling and blaming those clients for negative responses to its use. There is little doubt that in the circumstance described, staff response focused primarily on Gerald’s negative response to sanctions rather than questioning the appropriateness of their use. Finally, punishment may continue to be used despite evidence that undesirable behavior is not stopping and that the punishment may in fact be rein-

Influencing Behaviors and Attitudes forcing behavior. Despite ineffective use, practitioners and agencies may be inclined to use “more of the same” punishment strategies as a relief of tension for the punisher. Hence, punishment once used may be continued habitually without reexamination of its appropriateness or effectiveness (Milgram 1963). In Gerald’s case, we saw punishment escalate to produce a worse outcome than the infraction. A review should have been conducted when a clearly undesirable result had occurred from following procedures. In Gerald’s case, the immediate escalating administration of punishment with little opportunity to return to the generally positive behavior that had characterized his stay before the infraction should have been reviewed. Punishment in corrections is designed to act as a deterrent. Specific or simple deterrence refers to a sentence that makes it unlikely that an offender is likely to recidivate (Bartholomew 1994). A general deterrent is one designed to deter the general population through its harshness or other special features. Correctional boot camps were designed, for example, to be specific deterrents through exposing participants to a brief, quasi-military experience. While such boot camps may have alleviated overcrowding, questions are raised about how much it has assisted with other rehabilitative goals given the emphasis on unquestioning obedience and aggression. In any event, dropout from the experience has been reported as nearly 50 percent (Welch 1999). An comparison of boot camps in eight states showed that nonparticipants had comparable outcomes to participants (MacKenzie et al. 1995). Part of the problem with the design of sentences as deterrents may have been assumptions that decisions to commit offenses occur rationally rather than impulsively and that potential offenders perceive other alternatives to a path that leads to incarceration as readily available (Austin, Irwin, and Kubrin 2003). Meanwhile restorative justice offers promise as an option that benefits victims and fosters human dignity and mutual respect (Sullivan and Tifft 2004). It has been characterized by the offender and the victim or a representative meeting during which the offender listening respectfully while the harmed describe how they have been affected, the offender apologizing and undertaking a reparative task as an effort to make amends at least partially through a positive act (Johnstone 2004). The principles of restorative justice have been used outside of the legal system to include the educational system with participation by students and teachers (Sullivan and Tifft 2004). Restorative justice has been described as featuring at its best a reintegrative shaming process in which the offense rather than the offender is shamed with a goal of reintegrating the offender into society (Maxwell and Morris 2004). Stigmatic shaming, conversely, often occurs as a result of punishment efforts in which an offender is made to feel that he or she is a bad person. Such stigmatization does not reduce recidivism but rather may contribute to further offending (ibid.).

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A Foundation for Work with Involuntary Clients Inducement Inducement is a compliance-oriented method that occurs when a person is influenced by the hope of receiving a reward (Kelman 1965). Inducement is used to increase a behavior by providing rewards contingent on performance of that desired behavior (figure 4.3) (Simons and Aigner 1985). Use of inducements is discussed below based on consideration of the following case study.

Nathan Brown had a serious and persistent mental illness. To receive public assistance, Nathan had to demonstrate reasonable efforts to gain employment. While Nathan was faithful in making the required number of job applications, he was never selected for a job interview. One reason was the fact that Nathan did not take regular baths, wash his clothes, or shave. His public assistance worker proposed that for a onemonth period he would be offered the option of working on hygiene instead of completing job applications. Nathan acknowledged his problem regarding hygiene and wanted to get a job, but had not succeeded on his own in improving his hygiene. He agreed to a plan that called for a gradually increasing number of shaves, showers, and launderings before job interviews. He understood that at the end of this trial period he would be expected to try to maintain the new cleanliness habits in a renewed job search. Nathan’s hygiene tasks were now successful and his resumed job search began to result in actual job interviews. In addition, Nathan reported that friends had begun to compliment him on his cleanliness.

Inducement can be less intrusive than coercion by providing a choice to begin a behavior influenced by available rewards rather than stimulated by avoidance of punishment. Hence, Nathan’s task to develop good hygiene habits was reinforced by the reward of public assistance and the temporary suspension for job search expectations. However, such choices are typically constrained by limited access to alternative resources. A decision to not try the behavior desired by the persons controlling the resources often means choosing to live without the desired resource. Nathan had a constrained choice of continuing to carry out job interviews or participating in the alternative hygiene program, or choosing not to apply for assistance. The following sections explore guidelines for the legal, ethical, and effective use of inducement.

Influencing Behaviors and Attitudes Figure 4.3 Inducement or reward Inducement or reward * used to increase a behavior; effectiveness depends on how difficult it is to get desired resources in other ways

Frequent byproducts * can create dependency * can be abused with Considerations in appropriate use * with enough strength and

vulnerable populations

* often does not lead to self-attribution, hence effect may not last beyond use of reward

consistently strong enough to succeed, but not so strong as to block self-attribution * used continuously to start a behavior and intermittently to maintain a behavior * should fade to natural rewards * review of appropriate usage

Legal Issues in the Use of Inducement Institutional programs such as the one in which Gerald was placed have long used token economies in which residents can earn tokens or points toward larger rewards through performing desired behavior (Rose 1998). Courts have ruled, however, that some penal programs have started at such a low baseline level that the programs were in fact punishing rather than rewarding. Specifically, programs that used sleeping quarters and adequate food as rewards were found to constitute cruel and unusual punishment (Alexander 2003). Hence, the legal guideline here is that inducements are not to be used to negotiate or bargain for basic rights and necessities. Inducements should be an additional resource such that a person could choose not to accept the resource (Simons and Aigner 1985). Rewards are often used in nonvoluntary conditions with fewer checks and balances. The same legal guidelines for mandated clients should apply for the protection of nonvoluntary clients in institutional and other settings. Nathan could at least choose to continue to receive public assistance by rejecting the hygiene option and proceeding with job search requirements.

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A Foundation for Work with Involuntary Clients Ethical Issues in Use of Inducement On the surface, inducement seems to pose fewer ethical problems in work with involuntary clients than punishment, yet ethical problems also arise with this method. As suggested previously, inducements can be used appropriately to support alternatives when behavior harmful to the self or other is occurring. Too often, however, inducements are used to exploit vulnerable clients and reinforce dependency. For example, rewards will be more effective if clients do not have ready alternative access to them. Hence, financial rewards are effective for clients who do not have ready access to money. Consequently, rewards are more effective with vulnerable clients with limited resources. Such limited alternative access can lead to misuse and abuse of the power to dispense the resource. Does control of such resources lead to abuse with vulnerable clients? It has been suggested with behaviorally disordered schoolchildren that docility is the implicit goal (Winett and Winkler 1972). Agency or practitioner control, or a monopoly of scarce resources means that compliant behavior may be elicited through discriminating or even indiscriminate use of such resources. It should also be considered that clients who are subject to a unilateral monopoly of scarce resources may attempt to restore the balance by “cheating,” gaining access to the resource in other ways, and making coalitions with others in the same situations (Cook and Emerson 1978). Extracting more change than is necessary to meet agreed-on treatment goals violates professional values (Simons and Aigner 1985). Hence, the ethical guideline in use of inducements is that this use should empower the person and reduce dependency. Too often, however, continued dependency on the practitioner and rewards from the program occur. Effectiveness Issues with Inducement Inducement can be effectively used to begin a behavior. For that behavior to be maintained, however, inducement should be phased out and replaced by natural reinforcers and combined with other influence methods such as persuasion. Continuous reinforcement refers to the provision of an inducement each time a desired event occurs and is the best way to support a new behavior (Rose 1998). The inducement must be strong enough to reinforce the behavior and be applied consistently. Continuous reinforcement is often begun by rewarding successive approximations or shaping the desired behavior. For example, starting with requests for a small number of hygiene activities from Nathan that gradually increased follows this principle. Inducement is similar to punishment in that it is more successful at initiating a behavior than maintaining it after rewards have been discontinued.

Influencing Behaviors and Attitudes Behavior is best maintained by intermittent reinforcement schedules in which artificial rewards are decreased and natural rewards are substituted (Rose 1998). Behaviors are most likely to be maintained if the person attributes to him or herself the reasons for continuing the reward (Kiesler 1971) However, rewards can be used to enhance intrinsic interest or valuing of activities (Cameron and Pierce 1996). This can be done by identifying naturally occurring rewards while extrinsic rewards are still in effect. Should rewards be too strong, attitudes toward the changed behavior are unlikely to change because the person is likely to perceive his or her compliance as forced by the promise of gaining a reward. The person likely may not take responsibility for his or her own change because the person may perceive that his or her behavior was “bought” (Kiesler 1971). For example, while Nathan was aware that his original compliance with the new plan was “bought” with the promise of continued assistance for this behavior, the behavior was maintained by natural reinforcers when he reported that others were complimenting him on his change. The practitioner in this case had begun with an approximation of a continuous reinforcement schedule, and lessened that reinforcement as natural reinforcers began to have an effect. While programs should work toward reduced use of inducement, frequently they are continued without appropriate phasing out (Simons and Aigner 1985). If Nathan should now say to himself and others that he was carrying out a different hygiene program because it helped him get job interviews, and other people complimented him about the change, then the change would be selfattributed and would be more likely to be maintained than if he said that he persisted in the new behavior because his financial assistance was dependent on it. Following the principle of supporting self-attributed change, practitioners should use small inducements where possible, and practitioner support, praise, and encouragement for behavioral changes should not be overemphasized such that personal responsibility for changes can be supported (Simons and Aigner 1985). We have seen that punishment strategies can be used effectively in combination with inducement in negative reinforcement. In Nathan’s case, the choice to accept neither a job search nor the option of completing hygiene tasks would have resulted in denial of assistance. When the use of inducement is contemplated, the following questions are considered: 1. Does the situation involve such danger to self or others that a form of punishment would work more quickly and safely? 2. Is inducement used to exploit clients who are in a vulnerable state? 3. Has it been applied in a “package deal” to reinforce attitudes, behaviors, and beliefs that are neither illegal nor dangerous?

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A Foundation for Work with Involuntary Clients 4. Is inducement applied to limited behaviors that are clearly supportive of treatment goals agreed upon in a contract? 5. Is inducement used to reward empowerment and reduce dependence?

Use of Cognitive Methods with Involuntary Clients Cognitive methods have frequently been employed as part of efforts to influence the attitudes and behavior of involuntary clients. Such methods view behavior as influenced by mental images of the world. That is, persons are seen as not only reacting to objective events but rather to how those events are processed through mental images or schemas of those events (Berlin and Barden 2000). Cognitive methods are used to identify self-defeating or illogical or automatic patterns of thinking that inhibit pro-social problem solving (Rose 1998). Cognitive methods have been used with many involuntary populations including persons with severe and persistent mental illness, men with battering problems, parents with problems of child abuse and neglect, alcoholism, cocaine addiction, delinquency, sexual offenses, drug court ser vices, and school ser vices (Linehan 1993; Kaplan and Carter 1995; Allen, Mackenzie, and Hickman 1998; Carroll 1998; Rose 1998; Thyer and Myers 2000; Bouffard and Taxman 2004; Bradshaw and Roseborough 2004; Stalans 2004; Murphy and Eckhardt 2005). Cognitive methods are frequently part of treatment packages with juvenile sexual offenders (Craig, Browne, and Stringer 2003). Such packages have been associated with deterrence without specifying exactly what parts of treatment contribute to effectiveness (Efta-Breitbach 2004). Cognitive methods have been found in up to 75  percent of adult sexual offender programs (Stalans 2004). Such programs have included modules on anger management, enhancing empathy for victims, and prevention of relapse (Yates 2003). Most specifically, they teach awareness of thoughts surrounding offenses and employ cognitive restructuring to challenge self-statements that excuse behavior (EftaBreitbach 2004). A qualitative study of sexual offenders found that at least in the short run, such challenging of what are perceived as cognitive distortions may lead the offender to conclude that the therapist did not believe them, and they reported learning to say what the therapist wanted to hear (Drapeau et al. 2005). Cognitive methods have been used with adult offenders to enhance the ability to reason morally using moral reconation therapy as well as a reasoning and rehabilitation program that challenges thoughts and attitudes that are considered dysfunctional. Moral reconation therapy has been found to be at least minimally successful in reducing recidivism (Allen, McKenzie, and Hickman 1998).

Influencing Behaviors and Attitudes Persuasion Persuasion methods are used to influence behavior and attitudes by providing additional information or reasons for making particular choices (Simons 1982). Persuasion can include guiding a person toward an attitude through familiarity with their values and goals, presenting alternatives and evidence to support them, and supporting choices (Reardon 1991). Persuasion need not include manipulation for the benefit of the persuader, hiding crucial facts and available choices, or coercion involving threat or force (ibid.). A theme of this book has been that involuntary transactions occur between practitioners, representing agencies and legal systems, and clients. It is important to recognize that such transactions contain efforts by practitioners to influence client behavior and attitudes, and efforts by clients to influence practitioners. Such efforts occur whether or not the practitioners or clients are consciously aware of them (Frank 1973). The practitioner may consciously or unconsciously attempt to influence attitudes and beliefs by selecting certain statements to comment upon and reinforce and ignoring others (Reardon 1991). As we saw in chapter 3, the principle of pro-social modeling is one that supports being quite conscious of these efforts to support some attitudes, beliefs, and behaviors and discourage others. Persuasion methods can often be less intrusive and more helpful in promoting self-attributed change than compliance-oriented methods. The sections that follow examine principles for attempting persuasion and legal, ethical, and effectiveness implications of persuasion with involuntary clients. These principles are explored in the case study of Wilmer Jones. Wilmer had a serious and persistent mental illness that had earlier resulted in involuntary hospitalization but taking antipsychotic medication now allowed him to live in the community. There was a continual struggle with his community care practitioner, Anne, about taking his medication. She was concerned that failure to take the medication would result in a return to the hospital. Wilmer resisted persuasion attempts, saying that the medication gave him a dry mouth, grogginess, fuzzy perception, and that it deprived him of religious experiences. Anne first referred Mr.  Jones to a physician for a possible change of medication and dosage. However, Wilmer continued to dislike and distrust medications. Several persuasion principles were useful in working with Wilmer. Factors in the effectiveness of influence attempts include intimacy, dominance, benefits, consequences for the relationship, and resistance to appeals

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A Foundation for Work with Involuntary Clients (Reardon 1991). The intimacy factor entails how well the person attempting influence knows the recipient of the attempt and what they value. That is, the more the person attempting influence knows about those values, the more likely he or she is able to construct a persuasive appeal. For example, a research finding suggests that women who have suffered from domestic violence often place diminished value on their own safety, yet they often draw the line when they believe that their children’s safety is endangered (Syers-McNairy 1990). Hence, if this value was salient for a particular victim of domestic violence, efforts to explore positive and negative consequences for children might be a more effective strategy than appealing to their personal welfare. Based on her level of intimate knowledge of Wilmer, Anne knew that he greatly valued living independently in the community. Taking antipsychotic medication that had many unpleasant side effects was by no means highly valued. Dominance is a second factor in the effectiveness of influence attempts and the degree to which threats permeate the discussion. Persuasion strategies designed to enhance compliance have been cast on a matrix that include reference to positive or negative consequences for the recipient and variation in the employment of dominance (Marwell and Schmitt 1967). Promise strategies are those in which the essential argument is that, if the client complies, he or she will be rewarded by natural events, other people, or the person attempting influence. Threat strategies, meanwhile, suggest the opposite: if the client does not comply, other persons, events, or the person attempting influence will punish him or her (Reardon 1991). A third strategy is known as pregiving, whereby a recipient is rewarded by the person attempting influence before a request for compliance occurs. For example, taking a client with serious mental illness out for coffee before a discussion about taking medication would employ this principle (Angell, Mahoney, and Martinez 2006). The opposite of pregiving is a debt strategy in which it is suggested that the recipient should comply because of past favors paid by the person attempting influence. Some agencies ask that practitioners gather information from clients that the clients do not want to provide. For example, unwed mothers are often asked the names of the fathers of their children. They may wish to protect their privacy and do not see a benefit to themselves or their children in providing this information. Couching such a request in a duty to repay prior favors such as providing transportation or getting clothes for the children would employ the debt strategy. This example suggests some ethical issues with a debt strategy if it is used to cause a client to deny what they consider to be their best interests because of a debt. A more ethically sound method for discussing this need for information would be to present the request in the light of potential positive consequences, such as increased financial support for the children. A self-feeling positive strategy is one in which the person attempting influence argues that the recipient will feel better if he or she complies. Similarly, an “altercasting positive” strategy is one in which the persuader maintains

Influencing Behaviors and Attitudes that a person with positive qualities, such as a caring parent, would comply (Reardon 1991). Practitioners working with involuntary clients may be inclined to employ threat or debt strategies. In chapter 5, we explore reactance theory (Brehm et al. 1966) and how appeals based on threats to freedom sometimes result in a boomerang effect of less effectiveness. A third factor is the degree to which the client would experience personal benefits or whether the persuader would experience them from the influence attempt (Reardon 1991). Practitioners working with involuntary clients should explore personal benefits for the client and avoid such benefits for themselves. Anne discovered that Wilmer’s driver’s license had been suspended when he was hospitalized and was not renewed on his release. She recognized that Wilmer was more likely to take the medication as a means toward personal benefits such as staying out of the hospital, living independently, and being able to drive a car than valuing the medication for itself. Consequently, Anne and Wilmer revised the ser vice agreement to describe agreed-upon goals of “staying out of the hospital” and “working to regain my driver’s license.” In their revised contract, taking a different dosage of the medication in the effort to reduce side effects became an instrumental task toward reaching personal benefits that were highly valued by Wilmer. As Anne did not have the power to restore his license, she committed herself to advocating on his behalf based on his past record of safety and evidence of regular mediation. Her recommendation would be included when he would apply for a reinstated license. This agreement resulted in greatly increased regularity in taking the mediation and a successful effort to regain his driver’s license for use in restricted circumstances. A fourth factor refers to the short- and long-term consequences for the relationship of the influence attempt (Reardon 1991). This is an important factor in which use of deceptive methods may diminish trust in the long term and inhibit pro-social modeling. Resistance refers to what will happen should the first influence attempt is rejected, as recipients of influence attempts often do not agree on the first presentation of the request. Indeed some influence approaches are predicated on assuming that the first appeal will be rejected. The “foot in the door” method implies that a person will be more likely to comply with a second request after complying with a first one, especially when there are few external rewards associated with the attempt (Reardon 1991). For example, Alice Donat, the client in chapter 1 with a mental handicap who lived at home with twenty cats, believed that if she applied for Social Security benefits, SSI officials might attempt to hospitalize her. The practitioner agreed with her goal of keeping her independence. She asked Ms. Donat for a one-time commitment to visit the Social Security office for the sole purpose of gaining information. Accompanying Ms. Donat to the SSI office was a form of the “foot-in-the-door” method of securing agreement to try a new behavior in a small, experimental fashion without making a long-term commitment. By

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A Foundation for Work with Involuntary Clients going on this visit with the practitioner, Ms. Donat could check out her beliefs in a safe way. While the offer to accompany her might be seen as a small inducement, it falls short of heavy-handed efforts to force her compliance. The “door in the face” method refers to starting with a large request and, after it is rejected, returning with a smaller request. For example, a drug dealer may provide a free sample to a potential new user/addict, employing the “foot in the door method,” in hopes that if the new “client” accepts, the way is prepared for paying for the drug and becoming “hooked.” Meanwhile, a practitioner attempting to influence such a client later in the cycle when he or she has become hooked, might use the door in the face method to make a request that the user enter an intensive inpatient treatment program. If that request were rejected, the practitioner might return with a request to consider a less intensive outpatient program. The practice of low balling refers to offering a bargain and, after it is accepted, adding other costs (Reardon 1991). The low-balling method may unfortunately be used by practitioners working with involuntary clients if they hide less pleasant factors when suggesting a choice. For example, when suggesting that a victim of domestic violence consider movement to a shelter for protection, low balling could mean not calling attention to shelter rules such as no contact with the perpetrator while in the shelter. The long-term effects on the relationship are especially important for practitioners working with involuntary clients because of the emphasis on modeling pro-social values. Hence, methods such as low balling raise serious ethical issues for helping professionals as they would not enhance trust and prosocial modeling. Clients are inclined to adopt the same attitudes as people they like, consider expert, and trust, and oppose attitudes of persons not considered to possess these attributes (Heider 1958). Research on cognitive balance theories suggests that people are inclined to adopt the same attitudes as people they consider credible, likable, and expert, who have their best interests at heart (Osgood and Tannenbaum 1955). Conversely, they are unlikely to adopt the attitudes of persons they dislike or find lacking in these attributes. In Wilmer’s case, Anne had a positive reputation in the community as a supporter and advocate for persons with serious and persistent mental illness, one who treated them with respect as people rather than as targets who were not taking the right medications. These attributes undoubtedly made her more persuasive with Wilmer than might have been the case had the same arguments been made by persons he did not consider credible or supporting his best interests. Legal Use of Persuasion Informed consent was described in chapter 2 as a guiding legal principle in work with involuntary clients. Since informed consent requires that the client

Influencing Behaviors and Attitudes have access to information that would permit an informed choice, appropriate use of persuasion methods can assist in providing knowledge of available alternatives and their potential costs and benefits. Ethical Use of Persuasion Persuasion attempts can range in pressure from education to brainwashing (Singer and Lalich 1996). Hence, some persuasion methods may be effective but are ethically questionable (Perloff 1993). Deceiving clients by “hooking them” based on hiding critical facts or using inaccurate “straw man” arguments about alternatives runs the risk of modeling manipulative behavior that is the opposite of pro-social modeling (Roloff and Miller 1968). Persuasion can be used unethically around issues that are neither illegal nor harmful but violate the sensibilities of the practitioner or community. Hence, an important issue in ethical persuasion is drawing the line between behaviors that the practitioner can ethically attempt to influence and those that he or she should not. For example, the fact that Alice Donat, the client introduced in chapter 1, lives with twenty cats is not a legal issue as long as laws are not violated, nor an ethical issue unless her health or the health of others is seriously endangered. She might experience pressure from her neighbors, but it could be emphasized to her that she can choose to do something about that pressure or not. She can choose to do something about the number of cats when she is given access to accurate information about alternatives and consequences. She might be told that the number of cats was not illegal at this point. Similarly, she could be informed that if there was a danger that they could become a serious health hazard, another investigation might ensue. Such influence would be ethical. The practitioner may be tempted by pressure from the neighbor or supervisor to prey on Ms. Donat’s fears by using unethical persuasion with exaggerated, inaccurate threats of harmful consequences. Hence, threats that the health inspector would probably exterminate her cats if she did not comply would prey unethically on her fears. Ethical persuasion is very much like the conditions required for true informed consent reviewed in chapter 2. All alternatives should be explored, not just those favored by the practitioner, and the advantages and disadvantages of each should be accurately reviewed. Ethical persuasion is consistent with commitments to honest communication and is likely to be associated with greater effectiveness over time should the practitioner come to be considered likable, trustworthy, and expert. Ethical persuasion entails assisting the client in determining his or her own goals, increasing rather than decreasing options for meeting those goals (Wallace 1967). Steps toward ethical persuasion would include attempting to understand the client’s logic and rationale for his or her choices of attitudes and behaviors; identifying ways in which there is consistency between the reasoning and values the practitioner is presenting

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A Foundation for Work with Involuntary Clients and ones the client now holds; empathizing with the client’s emotions; and then gently probing inconsistencies in logic or inconsistency of behavior toward those goals (Gardner 2004). As values are slow to change, a reasonable goal might be to continue to explore possible resolution of inconsistencies rather than assume that the client will make an immediate change of behavior or attitude. For example, it is not uncommon for men alleged to have assaulted women to defend themselves by noting that they have always been good providers for the family (identifying client values). Practitioners might then affirm how significant such a role is for the welfare of the family (identifying consistency in practitioner and client values). The practitioner might note that given the value the client places on supporting the family, how troubling an accusation of assault must be (empathizing with client values). The practitioner might then gently probe how causing one’s partner to go to the emergency room is part of that goal of being a stable, reliable source of support for the family (probe inconsistencies of behavior and values). Such a question might begin to stimulate dissonance or concern with consistency of values. This might then lead to exploration of other ways of providing overall support for the family, a central value, and also avoid harm to others (Gardner 2004) (see the following text box). Dissonance may be stimulated if a central value is identified that is violated by the client’s behavior. For example, when Wilmer Jones complained of the side effects of the medication, Anne empathized with these uncomfortable experiences and asked him to describe other consequences in the past when he stopped taking his medication. Mr. Jones remembered that not taking his medication resulted in an involuntary hospitalization. Anne then asked whether Wilmer wished to risk another hospitalization. Involuntary clients can be helped through inductive questioning to see unanticipated or self-defeating consequences and to consider other alternatives in meeting their own goals. Decisions are often made because alternatives and unanticipated or negative consequences of actions have not been considered. Inductive questioning can be used to explore such alternatives and unanticipated negative consequences (Simons and Aigner 1985). The Socratic method is one form of inductive questioning. Using the Socratic method, a belief or assumption considered irrational can be challenged by asking a series of questions that explore exceptions to that irrational belief. The method can also be used to help clients clarify obstacles to goals and plans. The client is first asked to describe the goal he or she seeks and then to look at possible unanticipated consequences in questions such as “What do you think might block your plan?” Similarly, clients may be asked if they might have considered other ways of reaching their goals. The Socratic method is unlikely to cause much negative response when the practitioner’s own suggestions are added after the client’s own views have been heard. As the Socratic method can help clients be

Influencing Behaviors and Attitudes aware of the consequences of their choices, it can also increase the selfattribution of those choices. 1. Seek to understand client’s values, goals, and logic for actions in pursuit of those goals. 2. Use knowledge of clients’ values to frame appeals to values. 3. Draw attention to behavior and attitudes inconsistent with client values. 4. Seek to help clients identify their own goals and how behaviors and attitudes are consistent or inconsistent with them. 5. Clients are likely to adopt the same attitudes as persons they like, trust, and consider expert, and to oppose the attitudes of persons not considered to have these attributes. For example, when Anne discovered that Mr. Jones did not have his driver’s license and wished to regain it, she engaged in a series of inductive and Socratic questions such as: “What might prevent you from regaining your driver’s license?” When he was informed that he would need a doctor’s recommendation that he could drive safely before the suspension would be lifted, Anne asked, “What do you think will influence the doctor’s recommendation?” When Wilmer suggested that his safe driving history prior to hospitalization would be one such factor, Anne agreed. She then asked, “What about how you act now is likely to make a difference in your safety as a driver?” While Wilmer continued to note the negative side effects of medication, he did think that taking the medication might contribute to his safety as a driver and that it might influence the recommendation. As noted in this example, the practitioner might add other consequences and alternatives to the client’s list. These consequences might include informing the client of potential punishing or rewarding consequences such as rehospitalization and alternatives such as requirements for lifting the driving suspension. Information about alternatives and consequences make it possible to make constrained choices. Information about potentially punishing consequences is not itself punishment when the punishing contingencies are not manipulated by the practitioner, and the choice, however constrained, is left to the client about modifying central values. Practitioners should first attempt to identify those central values. We noted that Anne was able to identify that Wilmer highly valued staying out of the hospital, living independently in the community, and regaining his driver’s license. Clients who are undecided or have an opposing viewpoint are more likely to be persuaded by a two-sided argument than by persuasion that emphasizes only the view held by the practitioner (Simons 1982). Steps in the two-sided

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A Foundation for Work with Involuntary Clients argument include: (1) empathizing with and showing understanding of the viewpoint or preference of the client first; (2) acknowledging the limitations of one’s own position; and (3) considering the benefits and costs of these and other viewpoints. Presenting the client’s viewpoint first with the favored viewpoint last is likely to be seen as more objective by those who hold an opposing viewpoint. Use of the two-sided argument can inoculate the client against counterarguments that might be given by other influential persons in the environment (ibid.). This method is used effectively in motivational interviewing to assess the advantages and disadvantages of changing behavior in assessing decisional balance (Miller and Rollnick 2012). For example, if a client were considering the possibilities of reducing or stopping drinking, he or she might be assisted to list the advantages of continuing to drink (“it helps me relax, I enjoy drinking with friends”) as well as the costs (“it harms my health, it is a bad example for my children, it is a source of stress in my marriage”). From this point, the practitioner might assist the client to assess the advantages of making a change in drinking behavior (less family stress, more time with my children, better example for my children, more money available for other things) as well as the potential costs (I would lose something I enjoy, I might lose my friends, I might not be able to cope with stress) (ibid.). Exploring only the positive reasons for making a change runs the risk of enhancing reactance and a boomerang effect of greater attraction to drinking by taking away a valued free choice. Situations in Which Persuasion Methods May Be Used with Involuntary Clients Persuasion methods are recommended to help mandated clients who have violated the rights of others to accept ser vices. Acknowledging reluctance, conveying empathy, citing instances of success of involuntary contact, or identifying undesirable consequences of continuing present behavior can all be ethical influences toward accepting mandated contact (Simons and Aigner 1985). As nonvoluntary clients fall between the extremes of voluntary and mandated contact, they are entitled to make decisions about accepting ser vice based on information about its costs and benefits. Such choices are frequently constrained by the decisions of others and institutional policies. Helping nonvoluntary clients assess these real-life punishing and rewarding contingencies in making their constrained choices can be an ethical influence as long as those influences are not in fact controlled by the practitioner (Simons 1982). Hence, much of Anne’s efforts to influence Wilmer toward the regular taking of his medication came from assisting him in examining the costs and benefits of the medication in light of his own perceived goals.

Influencing Behaviors and Attitudes Persuasion is most appropriate in work with nonvoluntary clients since it is a less intrusive method of influence with fewer ethical and legal concerns. Persuasion can also contribute to maintenance of changes by facilitating selfattribution. Practitioners and agencies disillusioned with the lack of staying power of forced compliance might explore the combination of persuasion with other compliance methods in promoting longer-lasting change. Finally, persuasion does not use up scarce resources and can increase as the practitioner becomes a more credible source of influence. Persuasion cannot be the only or primary mode of influence with mandated clients, though it can play an important complementary role in enhancing attitude change and maintaining behavioral change. The effectiveness of persuasion also depends on the client’s ability to manipulate and process information in order to make a decision informed by knowledge of potential costs and benefits. Hence, clients who have limited ability to process information may be less influenced by persuasive methods.

Conclusion Compliance methods, including coercion and inducement, and persuasion methods have been presented along a continuum of intrusiveness into involuntary client choice ranging from coercion at the high end, inducement in the middle, and ethical persuasion at the low end. Since compliance methods often have short-term success in promoting behavioral change, their disadvantages in maintaining behavior or changing attitudes are often ignored. Rather than exploring less intrusive methods, agencies and practitioners often use “more of the same” compliance strategies by increasing their strength if they fail to reach their goals (Raynor 1978). When law violations or danger to self or others is involved, the practitioner may be ethically required to use coercive means. While inducement is a less intrusive method, circumstances in which it is not used to empower the client but rather to maintain dependence with powerless clients from oppressed groups were also discussed. Hence, efforts to use inducement in ways that empower rather than weaken clients must be emphasized. Finally, the chapter has advocated use of ethical persuasion as the primary form of influence with nonvoluntary clients and as an impor tant supporting form of influence to enhance the possibility of selfattribution for mandated clients. The possibilities for use of unethical, coercive persuasion are many, as practitioners are pressured or tempted to withhold information about choices and create incomplete arguments for less preferable choices. The practitioner should use legal, ethical, and effective forms of compliance and persuasion methods as situations arise and use simultaneous forms of influence where appropriate.

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Discussion Questions 1. Which assumptions do you and/or your program make about how behavior is changed? 2. Which assumptions do you and/or your program make about how attitudes are modified? 3. What is the practitioner’s role in terms of modification of attitudes and behaviors in your agency? 4. What is the role of practitioner confrontation in your program and what is assumed about its effectiveness? 5. What is assumed about how clients change over time in your program? 6. What are the practitioner roles in your program as the clients change over time? 7. What is your view and that of your agency about using ethical means of persuasion? 8. Have you witnessed use of “hooking” or “low ball” persuasion methods that mislead a client into making a choice without full information of the consequences of the choice? 9. What are the implications for development of a trusting relationship when using less ethical means of persuasion? References Alexander, R. 2003. Understanding Legal Concepts Practice. Pacific Grove, CA: Brooks- Cole. Allen, L., D. MacKenzie, and L. Hickman. 1998. “The Effect of Cognitive Behavioral Treatment for Adult Offenders: A Methodological, Quality-Based Review.” International Journal of Offender Therapy and Comparative Criminology 45 (4): 498–514. Angell, B., C. Mahoney, and N. Martinez. 2006. “Promoting Treatment Adherence in Assertive Community Treatment.” Social Service Review 80: 485–526. Austin, J., J. Irwin, and C. Kubrin. 2003. “It’s about Time: America’s Imprisonment Binge.” In Punishment and Social Control, 2nd ed., eds. T. Blomberg and S. Cohen, 433–440. New York: Aldine De Gruyter. Bartholomew, A. 1994. “Prisoners’ Perceptions of Punishment: A Comment on Indermaur.” Australian Psychologist 31 (1): 60–62. Berlin, S., and J. Barden. 2000. “The Cognitive-Integrative Approach to Changing a Mind.” In The Handbook of Social Work Direct Practice, eds. P. Allen-Meares and C. Garvin, 175–196. Thousand Oaks, CA: Sage. Bouffard, J., and F. Taxman. 2004. “Looking Inside the “Black Box” of Drug Court Ser vices using Direct Observations.” Journal of Drug Issues 34 (1): 195–218. Bradshaw, W., and D. Roseborough. 2004. “Evaluating the Effectiveness of CognitiveBehavioral Treatment of Residual Symptoms and Impairment in Schizophrenia.” Research on Social Work Practice 14 (2): 112–120.

Influencing Behaviors and Attitudes Brehm, J., L. Stires, J. Sensening, and J. Shaban. 1966. “The Attractiveness of an Eliminated Choice Alternative.” Journal of Experimental Social Psychology 2: 301–311. Cameron, J., and W. Pierce. 1996. “The Debate about Rewards and Intrinsic Motivation: Protests and Accusations Do Not Alter the Results.” Review of Educational Research 66 (1): 39–51. Carroll, K. 1998. “A Cognitive Behavioral Treatment Approach: Treating Cocaine Addiction.” NIH Publication No. 98–4308. Rockville, MD: National Institute on Drug Abuse. Cherry, S. 2005. Transforming Behaviour: Pro-social Modelling in Practice— A Handbook for Practitioners and Managers. Cullompton, UK: Willan Publishing. Cook, K. S., R. M. Emerson. 1978. “Power, Equity and Commitment in Exchange Networks.” American Sociological Review 43: 721–739. Craig, L., K. Browne, and I. Stringer. 2003. “Treatment and Sexual Offence Recidivism.” Trauma, Violence and Abuse 4 (1): 70–89. Dossey, L. 2006. “Where Were the Doctors? Torture and the Betrayal of Medicine.” Explore 2 (6): 473–481. Drapeau, M., A. Korner, L. Granger, and L. Brunet. 2005. “What Sex Abusers Say about Their Treatment. Results of a Qualitative Study of Pedophiles in Treatment at a Canadian Penitentiary Clinic.” Journal of Child Sexual Abuse 14 (1): 91–115. Efta-Breitbach, J. 2004. “Treatment of Juveniles Who Sexually Offend: An Overview.” Journal of Child Sexual Abuse 13 (3/4): 125–138. Feld, S., and N. Radin. 1982. Social Psychology for Social Work and the Mental Health Professions. New York: Columbia University Press. Gardner, H. 2004. Changing Minds: The Art and Science of Changing Our Own and Other People’s Minds. Boston: Harvard Business School Press. Heider, F. 1958. The Psychology of Interpersonal Relations. New York: John Wiley. Iversen, K., G. Hoyer, and H. Sexton. 2007. “Coercion and Patient Satisfaction on Psychiatric Acute Wards.” International Journal of Law and Psychiatry 30: 504–511. Johnstone, G. 2004. “How and in What Terms Should Restorative Justice be Conceived?” In Critical Issues in Restorative Justice, eds. H. Zehr and B. Toews, 5–16. Monsey, NY: Criminal Justice Press. Kaltiala-Heino, R., P. Laippala, and R. Salokangas. 1997. “Impact of Coercion on Treatment Outcome.” International Journal of Law and Psychiatry 20 (3): 311–322. Kaplan, J., and J. Car ter. 1995. Beyond Behavior Modification: A Cognitive Behavioral Approach to Behavioral Management in the Schools. Austin, TX: Pro-ed. Kelman, H. 1965. “Compliance, Identification and Internalization: Three Processes of Attitude Change.” In Studies in Social Psychology, eds. H. Proshansky and B. Sendenberg, 140–148. New York: Holt, Rinehart and Winston. Kiesler, C. 1971. The Psychology of Commitment. New York: Academic Press. Kipnis, D. 1972. “Does Power Corrupt?” Journal of Personality and Social Psychology 24 (1): 33–41.Linehan, M. 1993. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford. MacKenzie, D. L., R. Brame, D. McDowall, and C. Souryal.1995. “Boot Camp Prisons and Recidivism in Eight States.” Criminology 33 (3): 327–358. Marwell, G., and D. Schmitt. 1967. “Dimensions of Compliance- Gaining Behav ior: An Empirical Analysis.” Sociometry 30: 350–364. Maxwell, G., and A. Morris. 2004. “What Is the Place of Shame in Restorative Justice?” In Critical Issues in Restorative Justice, eds. H. Zehr and B. Toews, 133–142. Monsey, NY: Criminal Justice Press.

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A Foundation for Work with Involuntary Clients Miles, S. 2006. Oath Betrayed: Torture, Medical Complicity and the War on Terror. New York: Random House. Milgram, S. 1963. “Behavioral Studies of Obedience.” Journal of Abnormal and Social Psychology 67: 371–378. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Helping People Change. New York: Guilford Press. Murphy, C., and C. Eckhardt. 2005. Treating the Abusive Partner: An Individualized CognitiveBehavioral Approach. New York: Guilford. Nyttingness, O., Ruud, O., and Rugkasa, J. 2016. “It’s Unbelievably Humiliating”: Patients’ Expressions of Negative Effects of Coercion in Mental Health Care.” International Journal of Law and Psychiatry 49: 147–153. Osgood, C., and P. Tannenbaum. 1955. “The Principle of Consistency in the Prediction of Attitude Change.” Psychological Review 62: 42–55. Perloff, R. 1993. The Dynamics of Persuasion. Hillsdale, NJ: Lawrence Erlbaum. Raynor, P. 1978. “Compulsory Persuasion: A Problem for Correctional Social Work.” British Journal of Social Work 8 (4): 411–424. Reardon, K. 1991. Persuasion in Practice. Newbury Park, CA: Sage. Roloff, M., and G. Miller. 1968. Persuasion: New Directions in Theory and Research. London: Sage. Rose, S. 1998. Group Therapy with Troubled Youth: A Cognitive-Behavioral Interactive Approach. Thousand Oaks, CA: Sage Simons, R. 1982. “Strategies for Exercising Influence.” Social Work 27 (3): 268–274. Simons, R., and S. Aigner. 1985. Practice Principles: A Problem- Solving Approach to Social Work. New York: Macmillan. Singer, M. T., and J. Lalich. 1996. Cults in Our Midst: The Hidden Menace in Our Everyday Lives. San Francisco: Jossey-Bass. Sjöström, S. 2006. “Invocation of Coercion Context in Compliance Communication—Power Dynamics in Psychiatric Care.” International Journal of Law and Psychiatry 29 (1): 36–47. Sørgaard, K. 2004. “Patients’ Perception of Coercion in Acute Psychiatric Wards. An Intervention Study.” Nordic Journal of Psychiatry 58: 299–304. Stalans, L. 2004. “Adult Sex Offenders on Community Supervision.” Criminal Justice and Behavior 31 (5): 564–608. Sterling, E. 2004. “Drug Policy: A Challenge of Values.” Journal of Religion and Spirituality 24 (1/2): 51–81. Stolz, S., L. Wienckowski, and B. Brown. 1975. “Behavior Modification: A Perspective on Critical Issues.” American Psychologist 30 (11): 1027–1048. Sullivan, D., and L. Tifft. 2004. “What Are the Implications of Restorative Justice for Society and Our Lives?” In Critical Issues in Restorative Justice, eds. H. Zehr and B. Toews, 391– 404. Monsey, NY: Criminal Justice Press. Surgenor, L. J. 2003. “Treatment Coercion: Listening Carefully to Client and Clinician Experiences.” International Journal of Law and Psychiatry 26 (6): 709–712. Syers-McNairy, M. 1990. Women Who Leave Violent Relationships: Getting On with Life. PhD diss., School of Social Work, University of Minnesota. Thyer, B., and L. Myers. 2000. “Approaches to Behavioral Change.” In The Handbook of Social Work Direct Practice, eds. P. Allen-Meares and C. Garvin, 197–216. Thousand Oaks, CA: Sage. Trotter, C. 2015. Working with Involuntary Clients: A Guide to Practice. New York: Routledge. Van Wormer, K. 2004. “Restorative Justice: A Model for Personal and Societal Empowerment.” Journal of Religion and Spirituality in Social Work 23 (4): 103–120.

Influencing Behaviors and Attitudes Wallace, K. 1967. “An Ethical Basis of Communication.” In Ethics and Persuasion, ed. R. Johannesen, 41–56. New York: Random House. Warrick, J., and W. Pincus. 2008. “Station Chief Made Appeal to Destroy CIA Tapes.” Washington Post, January 16, 2008, p. A01. Welch, M. 1999. Punishment in America: Social Control and the Ironies of Imprisonment. Thousand Oaks, CA: Sage Winett, R., and R. Winkler. 1972. “Be Still, Be Quiet, Be Docile.” Journal of Applied Behavioral Analysis 5: 499–504. Yates, P. 2003. “Treatment of Adult Sexual Offenders: A Therapeutic Cognitive-Behavioral Model of Intervention.” Journal of Child Sexual Abuse 12 (3/4): 195–232.

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Chapter 5

Oppression and Involuntary Status

Glenda Dewberry Rooney and Joan M. Blakey

Racial and ethnic minority clients are discussed in the social work literature as members of oppressed groups. The experience of oppression is often interdependent with minority status. Oppression is characterized as having limited power, privilege, resources, and choices, which shapes individuals’ ability to participate and change the social, political, and economic structure of a society (hooks 1984; Pharr 1988; Van Voorhis 1998). Its manifestations and effects are described as a matrix in which interlocking structures and conditions often dictate an individual’s life course and trajectory (Young 2004; Hanna, Talley, and Guindon 2000; Gitterman 1995; Van Soest and Garcia 2003; Clifford and Burke 2005). Social workers are encouraged to take into count the effects of sustained oppression on the biopsychosocial functioning and the psychosocial self when assessing the behavior of members of oppressed groups (Alexander 2010, 2003; Arrendondo, 1999; Berzoff 2011; Lum 2004; Michaels 2010; Sandee 2016; Stewart 2004; Williams 1994; Van Voorhis 1998). Despite the personin-environment focus of social work, professionals may not fully examine the extent to which power, injustice, and the dominant political, social, and economic order are implicated in the array of problems experienced by those who are oppressed (Hasenfeld and Garrow 2012; Gil 1978, 1998; Dei 1996; Margolin 1997; Al-Krenawi and Graham 2001). Moreover, public policies and funding priorities, both private and public, are guided by dominant values and focus on rehabilitating or correcting individual behaviors and problems considered to be maladaptive and do not consider changes to the

Oppression and Involuntary Status structural, social, and political environment (Alexander 2010 2003; Breton 2006; Segal 2010). Understanding experiences of oppression and the associated trauma is often a difficult task for social workers as well as the agencies in which they work. In consequence, social workers and programs are less likely to be responsive to and therefore address oppression-related problems and needs; particularly the intersection of oppression and involuntary status. This chapter discusses oppression, the effects it has on oppressed groups, the sociopolitical processes that produce and reproduce oppression as well as the dynamics associated with being a member of an oppressed group coupled with involuntary status. Throughout this chapter, the similarities and differences between being a member of an oppressed group and involuntary clients will be explored along with the circumstances and behaviors that increase the likelihood that racial and ethnic minority groups will become involuntary clients.

Involuntary Status and Oppression While there is a connection between involuntary client status and being a member of an oppressed group, ethnic or racial minorities in particular; not all involuntary clients are members of oppressed groups or persons of color. Similarly, not all members of oppressed groups are involuntary clients. Even so, Figure 5.1 illustrates a point made by Rooney, that “members of oppressed groups are disproportionately represented among involuntary clients” (1992:21). This trend has not changed and it holds true for social work practice in both public and private social welfare organizations. In addition, even though

Figure 5.1

Client base and involuntary status Client base

Members of oppressed groups

Involuntary client base

Members of oppressed groups

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A Foundation for Work with Involuntary Clients Figure 5.2

Intersection of involuntary status and oppressed groups

Involuntary clients

Oppressed groups

members of racial and ethnic minorities may be a smaller segment of the client population, they are a larger portion of clients who are involuntary. In fact, these individuals and groups as well as the communities in which they live are often targeted for rehabilitative or corrective intervention ser vices. Although higher socioeconomic status is insufficient to blunt the scope of oppression, with few exceptions, social welfare clients are poor and minority, which further erodes their power and status. Given the premise that ethnic and racial minorities make up the majority of involuntary client, there is a definite intersection between involuntary client status and racial or ethnic minorities as members of oppressed groups (see Figure  5.2). Additionally, there are attributes that involuntary clients and racial/ethnic minorities have in common that have the potential to intrude upon the helping relationship. Finally, there are acts and behaviors that increase the likelihood that racial and ethnic minority groups will experience involuntary transactions within society.

Pathways to Involuntary Status As a result of systemic oppression, racial and ethnic minorities, especially those with low income, are positioned at the lower ranks of society, which almost guarantees that members of these groups will have contact with social welfare organizations and the courts. As members of a permanent underclass, oppressed groups have contact either as voluntary applicants in need of resources or, more often than not, they are required to have contact with a professional as directed by a sanctioned authority or public policy. We propose three paths to involuntary status, each of which may stand alongside and intersect with each other. The paths involve a legal mandate, the

Oppression and Involuntary Status silent mandate, and ascribed status. The consensus perception is that involuntary status is attained by a legal mandate that is considered to be a reasonable response to behavior that can only be corrected or curtailed by a court order or some form of legal sanction. A silent mandate is neither legal nor court ordered, but individuals feel they have no other choice but to comply. The final pathway to becoming an involuntary client is ascribed status. Persons are assigned status at birth that remains fixed over the individual’s life course (Foladare 1969; Linton 1936). Legal Mandate Perhaps the most familiar path to involuntary client status involves the court order or mandate, in which individuals are required to seek help for behavior or acts that they may not perceive to be problematic. In these cases, individuals are compelled by the court to engage with a professional (Calder 2008; Trotter 2013; Rooney and Bibus 2000; Rooney 1992, 2009). Legal mandates are considered to be instrumental inducements to alter or correct behaviors or actions that are outside of the realm of societal expectations and are sometimes the result of illegal acts. Some would argue that legally mandated involuntary status has little to do with oppression. This argument presumes equity within systems (e.g., child protection, criminal justice) that are charged with ensuring and protecting the public good. However, there are many examples where equity is not inherent to systems, especially as it relates poor and minority communities (Baum 2016; Stamper 2016; Alexander 2012). For example, there is widespread use of “no-knock” searches or “broken window” police practices as well as wholesale community surveillance of potential criminal behavior and illegal drugs activities in racial and ethnic minority communities despite the fact that such practices infringe on individual and community rights and privacy guaranteed under the U.S. Constitution. These practices often result in poor and minority individuals becoming legally mandated involuntary clients. Also in question are the mandatory sentencing laws that are currently being revisited. These laws eroded judicial discretion and required harsher sentences for those who used or were in possession of crack cocaine, a derivative of cocaine, than for cocaine. Possession of just a few ounces of crack cocaine is punished as a drug offense. In effect, the response to the crack epidemic in poor and minority communities primarily involved the criminal justice system as a solution. At issue was the fact that these legally sanctioned practices discriminated against poor minority men and women and resulted in harsher sentences for what was essentially the same drug. In contrast, when methamphetamines, and more recently heroin and prescription opioids, became a major concern in a cross-section of nonminority communities, politicians and professionals framed the epidemic as a public health problem. The call for

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A Foundation for Work with Involuntary Clients treatment programs was immediate and essentially emphasized that prisons were not a sustainable viable response (Cohen 2015). It is worth noting the macro similarities between minority and nonminority communities, for example, high unemployment, despair, economic hardships, structural stressors, and emotional distress (Monnat 2016; Keyes et al. 2014). For others, the connection between involuntary client status and racial and ethnic minorities is a chicken-and-egg argument. For example, does the omnipresence of the police in minority communities contribute to the propaganda narrative that minority men and woman commit crimes more often? Or is it that the potential for arrests are heightened by the often aggressive presence and tactics of the police in these communities? For example, police discretionary traffic or pedestrian stops or searches for minor infractions such a broken taillight, jaywalking, behavior characterized as loitering or gang involved, or wearing a particular type of clothing became a source of municipal revenue, the latter of which was the case in Ferguson, Missouri, and Baltimore, Maryland (U.S. Department of Justice 2015; US Department of Justice Civil Rights Division, 2016; Berman and Lowery 2015; Stamper 2016). Intense scrutiny of minority communities as an argument also can be applied to the racial visibility factor and the zero tolerance policies for certain behaviors that have resulted in a high number of school suspensions or referrals to special education or specialized behavioral groups for African American and Latino female and male youths (Artiles and Trent 1999; Townsend 2000; U.S. Department of Education 2012). Scrutiny is equally applicable to the child welfare system in which mandated reporting and decision making have in large measure led to families of color being overrepresented as involuntary clients in the child protection, juvenile justice, and adult correctional systems (Hsia and Hamparion 1997; Morton 1999; Ogawa 1999; Lane et al. 2002; Critical Resistance 2003; Derezotes, Poertner, and Testa 2005; Fong et al. 2015). The surveillance of certain groups is pervasive in the larger community. Minority youth, for example, express a mix of anger and humor, citing the irony of their being harassed by shopping mall security and followed by store personnel because of their “hip hop” clothes (a non–race-based phenomenon), when they and many of their white counterparts wear the same items purchased from the same stores. Silent Mandate Rooney and Bibus (2000) distinguish nonvoluntary and involuntary client status, citing the importance of the presence or absence of a legal mandate. Whereas legal mandates are understood as requiring compulsory contact with a professional for a problem identified by a sanctioned authority, no such authority is involved with the silent mandate. Similarly, nonvoluntary interaction with a professional occurs in instances in which an individual is pressured

Oppression and Involuntary Status to seek help, for example, from a family member or an employer. In either case, an inherent tension occurs when an individual has not sought the help that is offered and does not accept the imposed ser vice. The silent mandate in many respects bears a resemblance to both involuntary and nonvoluntary contact. But, depending on the professional’s perceived power and authority, a client can become involuntary; in which case his or her agreement or disagreement with the professional’s decision can have consequences. Trotter (2013) refers to a continuum in which people become involved as service recipients not by choice but rather as the result of a professional decision that has been made about their needs or problems. We refer to this continuum, which may include informal and discretionary pressures, as the silent mandate. In some instances, this mandate may be intertwined with one that is legal. For the most part, however, decisions about client’s needs or goals are pressured or imposed by the professional. It is the absence of a legal mandate, however, in which transitory waters to involuntary status becomes murky and raises questions about client’s rights and, ultimately, ethical professional practice. Silent mandates, whether grounded in dominant societal preferences, public policy, or professional acts, may assume a posture of best interest and good intentions, often with paternalistic overtones. On the part of the professional, the offer of care can mimic oppression, in particular when well-intentioned instincts of what is best imply that an individual is incapable of correctly judging his or her needs and related goals (Orme 2002; Wilson and Beresford 2000). Specifically, imposed ser vices may add to rather than diminish stressors and therefore, from the client’s point of view, may resemble the experience of yet another level of oppression. This section presents two cases that illustrate the force and power of the silent mandate. The first case is representative of reports from minority parents about their interactions with educational systems in which the power of the silent mandate as exercised by professionals and reinforced at the institutional level.

Jermaine attends middle school. He likes math and has frequently mentioned his dream of becoming an architect. His reported inability to sit still for extended periods in the classroom resulted in a recommendation that he be placed in a classroom for students who are described as having emotional and behavioral problems (EBD). The majority of the students in this class are minority males. In the meeting with the EBD team, his parents, who had not received prior information about the school’s concerns, were angered by the team’s recommendation

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A Foundation for Work with Involuntary Clients and demanded to know, “Why can’t you all teach our kid?” “What has been tried?” “Why weren’t we told that he had a problem sitting in his seat?” The EBD team perceived these comments as “hostile.” “How does he act in other classes?” The parents believed that his placement in an EBD classroom was a drastic step to correct a behavior that could have been other wise addressed or modified. The parents described their meeting with the EBD team as “stacked against their son, because their minds were already made up.” The parents said, “When we entered the room, there were twelve people sitting in a semicircle around the table. A man introduced himself as the team leader and informed us of the team’s decision. He then handed us parental consent papers to sign, like we agreed with what they were doing.” Another team member read a list of complaints from two teachers, “with my child sitting there listening to them, nothing positive was said; one of which was that Jermaine finds it difficult to sit for long periods.” When asked which teachers had made these statements, “The team leader snapped his folder shut and said that the information was confidential.” After visiting the area of the school in which the EBD classes were located, the parents commented that the doors were locked and it “felt like a prison.” When they said that “It seemed like [they] didn’t have a choice and that didn’t like the recommendation,” the team leader suggested that “Jermaine might be better served in an alternative school.”

In the second case, a professional’s discretionary interpretation of public policy demonstrates the way in which an individual who applies for ser vices can transition to involuntary status. The case also is an example of how a professional’s decision becomes a silent mandate in support of the prescriptive preferential lifestyle of the dominant society.

Abigail, an elderly minority female, requested ser vices from a publicly funded in-home health care ser vice. The request was denied by the social worker because Abigail’s recently divorced unemployed daughter and her four children also resided in the home. Rather than assess Abigail’s qualifying ser vice needs, which would enable her to remain in her home, the social worker advised Abigail that he would recommend that she move to a “more structured environment,” in which the needed services were readily available. This recommendation was based on the

Oppression and Involuntary Status social worker’s observation that the apartment “appeared to be a gathering place for a host of relatives and their children.” In his notes, he described the “chaos and clutter in the apartment caused by so many people” as potential risks to Abigail’s well-being as the justification for the recommendation. Like Jermaine’s parents, Abigail was presented with a nonnegotiable choice of the ser vice believed to be appropriate by the social worker, specifically, moving to a facility instead of receiving in-home ser vices.

We applied the silent mandate to both case examples, rather than referring to them as nonvoluntary contacts using the Rooney and Bibus (2000) screen; that is, the presence or absence of a legal mandate to assign involuntary status. But in each of the cases, no legal mandate was involved and there was no court order. Also, at first glance, each case resembles the pressured contact that is associated with nonvoluntary status. In silent mandate situations, however, the course of action in both cases was determined by the professionals involved. Of course, an individual may choose to more or less accept the help offered so as not to incur serious consequences. But consider the outcome if Abigail had chosen to ignore the social worker’s solution as the appropriate response to her ser vice request. In effect, her doing so meant that the in-home ser vices that she requested would not be made available. For those without power, the silent mandate the force and characteristics of one that is legal, in that it has a similar prescriptive power that is associated with constrained or coerced choice. For example, Jermaine’s parents were given a choice of accepting the EBD class or an alternative school, neither of which was attractive to them. There are policy guidelines related to EBD placements, but no law that dictates that the inability to sit for long periods should result in being placed in a remedial education class. In reality, Jermaine was entitled to have an advocate present in the meeting as well as documentation of intermediary interventions before the decision was made to place him in an EBD classroom. For example, when the parents asked “What has been tried?” the team should have been able to cite at least one intervention that addressed the situation. Similarly, in Abigail’s case there is not a law that determines the number of people who should live in a household, or the quality of that experience, unless there is evidence of a health hazard, neglect, or egregious harm that requires substantiation. In both instances, the silent mandate was supported by the authority of an organization as well by the status of the professional. Clients recognize the fragility of their power and their innate vulnerability. In most instances, it is the centrality of the power that resides in the

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A Foundation for Work with Involuntary Clients professional’s authority that will ultimately influence a client’s response (Orme 2002; Clifford and Burke 2005; Wilson and Beresford 2000). Thus, it is highly unlikely that vulnerable and oppressed clients who experience involuntary status through silent mandates will cognitively differentiate between the presence and absence of a legal mandate. Although the silent mandate lacks a legal basis, and on the face of it resembles a nonvoluntary contact, its influence has implications that are just as powerful as one that is legal. Status An unexplored dimension of involuntary status relates to the involuntariness of individuals who are members of an oppressed group (Linton 1936. These individuals are decidedly involuntary in this status. The depersonalized and stigmatized rubric of being different is not erected or sustained by those who are affected. Oppression in this regard is an involuntary transaction with society because members of oppressed groups do not willingly seek a status that has limited power and resources, and in which there is a high potential for being marginalized. The exchange between society and members of oppressed groups resembles the involuntary transaction in which the client experiences the dynamic of a legal and normative imbalance of power. In much the same way as the involuntary client would prefer to be somewhere else (Rooney 1992; 2009), oppressed individuals left to their own volition would probably not choose to be different and disenfranchised. Nor would the majority use language that is associated with being oppressed. Oppression in the classic sense is the language of professionals and social scientists who study the structural arrangements of a society. Professionals may view involuntary clients as uncooperative, ungrateful, untrustworthy, unmotivated, angry, or hostile. Clients may express anxiety, discouragement, and fear that stems from their lack of power or resources. In much the same way that stories told by oppressed individuals differ from dominant perceptions, involuntary clients’ stories would not embrace the professional paradigm that summarizes their attributes. Individuals who are members of oppressed groups would more likely describe their personal circumstances as realized in and influenced by the macro content of their lives. For instance, rather than perceiving themselves as deficient or unmotivated, client’s stories might speak to a lack of sufficient resources, of being simulta neously visible and invisible, the experience of discrimination and bigotry, and a familiarity with the day-to-day tasks of coping without the status and privilege that is available to others. Similarly, because of their status, involuntary clients perceive and understand their vulnerability and lack of power. They also appropriately view themselves as being different from clients who seek help on their own accord. Both the professional and the client experience the descriptive societal and professional

Oppression and Involuntary Status language that marginalizes client status and magnifies the power difference and social distance in the helping relationship.

Micro and Macro Nature of Oppression Oppression is rooted in racism; that is, unmerited privilege experienced by one group of people over another based on race and ethnicity, which is systemized in such a way that one group is alleged to be superior and thus has the right to dominate the powerless inferior group. In this regard, many practices and systems were designed and intended to support the superior-inferior divide and sustained racism through openly blatant discrimination and injustice, such as Jim Crow laws and subtler means including subpar educational systems, mass incarceration, and poverty (Alexander 2012). Oppression maintains racism through “institutional and economic power and control over social institutions such as schools, banks, legislative bodies, policing, and the military” (Lichtenwalter and Baker 2010:306). Oppressed individuals and communities are marginalized and subjected to the dominant group’s preferences, norms, and standards and lack the power or resources to fight and resist or create, and embrace their reality (Pharr 1988; Freire 1998). Individuals and entire communities are oppressed, which maintains and continues the inequities experienced by subordinate groups. Oppression is about the relationship between dominant superior and subordinate inferior groups—the powerful and the powerless—which ultimately fosters exclusion versus inclusion. In its scope, oppression is not limited to any one group. As such, oppression can shape the experiences of people who are different from the dominant group, renders them powerless, and exclude them from opportunities that could change the circumstances and conditions of their lives. In the United States, these groups include people of color, those with physical, mental, and cognitive disabilities, non-Christians, gay, lesbian, transgender, and poor individuals and families. In its multiple forms, oppression is an accepted, normative experience, deeply rooted in the social, economic, political, and cultural structure of a society. The intersection between involuntary client status and oppression can be understood by examining oppression at the individual (micro) and systems (macro) levels. Moreover, oppression as described by Lum (2004) is both a process and a structure. There is circuitous interaction between micro and macro factors that is seamlessly woven into oppression and hence involuntary status. The process of oppression positions members of the oppressed group in the lower ranks of society (Lum 2004). In tandem, the hierarchical structure of oppression creates and reinforces individual status at the lower ranks, and by extension, the groups to which they belong. In essence, members of oppressed groups are “a part of the whole, but outside of the main body” (hooks 1984:ix).

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A Foundation for Work with Involuntary Clients Being outside of the whole is evident in systems that obscure or disavow individual inequality, which in turn perpetuates and sustains individual and group vulnerability. Individual Level When involuntary clients become involved with social ser vice and criminal justice systems, there is a tendency to locate and interpret problems as those of an individual. Focusing on the individual allows the dominant elite to pose such questions as “Why are those people so lazy, or unmotivated?” “Why are certain people poor?” “Why are the majority of people who are incarcerated people of color?” “Why” questions inherently cast blame. Instead questions should be framed as “What are the factors that inhibit the growth and success of individuals and entire communities?” This line of inquiry would require a different course of action-focused justice, beginning first with an acknowledgment that people are oppressed and therefore disadvantaged. Social distance, combined with a lack of empathy, fosters an indifferent dissonance, and hence “why” questions, when certain individuals and groups enjoy certain privileges, yet do not recognize that this is the case. Therefore, it can be challenging to understand experiences of oppressed people and the daily challenges that they encounter and endure. Examples of Oppression 1. Many poor parents involved with the child welfare system are relegated to living in substandard housing because that is all they can afford. But they are often told by child protection ser vices that their children cannot be returned home until the parent’s living conditions have improved. 2. Funding for school systems is based on property taxes. In poor communities fewer people are homeowners, and therefore the tax base is lower so the schools remain subpar. Residents in largely minority communities pay the same municipal and sales taxes as other communities. Yet the equivalent benefits of these dollars that contribute to the livability of communities, such as routine garbage removal and amenities such as parks, for example, are seldom returned to these communities. 3. People of color are cognizant of and careful about what time they leave any place and how they are dressed because of the likelihood of being be stopped by police, an encounter that could result in their arrest, serious injury, or death. 4. The only way some women can adequately care for themselves and their children is to prostitute themselves for money. Many need drugs to cope. Their drug use leads to child neglect and to involvement with child protection.

Oppression and Involuntary Status 5. Without adequate options such as green spaces or recreational facilities in poor communities, youth and adults tend to socialize on street corners, on the sidewalks in front of their apartment buildings, or at shopping malls. This is considered deviant behavior by some and such activities increase the possibility of encounters with the police who consider socializing in this manner as outside the norm. 6. Entire communities of poor racial and ethnic minorities, disadvantaged or left behind as result of public policy, are described in negative terms. Others view them as devoid of strengths, and in particular the capacity to cope with intolerable conditions and daily challenges. Social ser vice organizations, the police, and professionals tend to embrace this point of view, and therefore seek to change or reform. These are examples of the fact that certain groups (e.g., poor, racial, and ethnic groups) cope with adverse often traumatic conditions, and live under some form of surveillance albeit the police, professionals, public policy, or the media, which ultimately can result in the status of becoming involuntary clients. Roberts (2002) characterizes the disparate enforcement of laws and the intrusion into minority communities as a matter of basic rights and freedoms. With respect to the latter, Roberts maintains that the excessive intrusion experienced by minority communities by child welfare and the police reinforces the oppressive notion that without supervision, minority individuals and communities are “incapable of governing themselves” (ibid.:20). Consequently, these systems were put in place principally to govern subordinates. Nonetheless, it is important to remember that “institutions don’t act; rather it is the people in them who act, even though these individuals may be simply following routine rules and regulations” (Lichtenwalter and Baker 2010:306). Locating the problem within the individual is a “power ful political act” that distracts from the holistic nature of system-level oppression and vulnerability (Gil 1978:61).

Systems Level Systems-level oppression operates in concert with naming the individual and entire groups as deviant. At the systems level, inequality and accompanying social issues associated with oppression are rationalized as individual attributes rather than the structural arrangement of society that affects groups as a whole. The attribution bias undermines the capacity of oppressed groups by emphasizing individual success in overcoming adversity, and the failure of others as the result of personal characteristics, cognitive abilities, motivation, and a lack of personal responsibility (Lum 2004; Lopez, Gurin, and Nagda

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A Foundation for Work with Involuntary Clients 1998). Systems-level oppression often is sustained and strengthened by strategic propaganda.

Propaganda of Oppression To maintain the status quo, specifically the marginalization of certain people or groups, strategic propaganda, a tool of oppressive societies, is routinely energized in the political and social arenas. Whether intentional or not, carefully threaded evocative narratives disavow inequality, appealing instead to emotions and fears that inform people’s cognition and ultimately their collective belief systems about people who are different. Moreover, the public and elected officials are either unable, unwilling, or unaware of the ways in which certain groups are privileged over other groups. In the absence of problem solving that addresses legitimate concerns, propaganda promotes the superiorinferior attributes. Using the superior-inferior construct, casting blame on the latter, politicians have been either unwilling or unable to solve the very real problems that address the legitimate fear, ambivalence, and uncertainty about an expected way of life that has been embraced for generations. Both the micro and macro processes and structure of oppression are grounded in a historical template that emphasizes superior and inferior groups (Pinkney 2012; Pyke 2010; Feagin 2006; Harvey, Case, and Gorsline 2004; Young 2004; Hanna, Talley, and Guindon 2000). Superiority bestows privilege and entitlement for those with certain attributes, irrespective of socioeconomic status, while limiting the privileges and entitlements of inferiors. Various systems reinforce inferior status through the manner in which problems are addressed and resources are allocated. The Flint, Michigan, water crisis exemplifies this point. State agents of the Environmental Protection Agency and the Michigan Department of Environmental Quality reportedly ignored the contaminated water supply in Flint, Michigan, a predominately minority community (Lynch 2016). Although the origins of superiority-inferior construct and hence oppression can be traced to black/white relationship during slavery, however, the ramifications of a superior-inferior construct are implicated in the relationship with other racial and ethnic groups. Hatred, blame, indifference, indoctrination, and fear threaded through political, economic, and social discourse are staples of propaganda. Narratives support the superior-inferior relationship using images and words that portray the latter as maladaptive, unworthy, untrustworthy, and, if left unchecked, threats to the safety, liberty, and rights of superiors. Consider the decades-old politically motivated image of the African American Cadillac-driving welfare queen cheating the system. The woman was real, but according to official records, the 1930 census, and family members, she was white. However, to reinforce the unworthy, untrustworthy, inferior myth the publicized photographs

Oppression and Involuntary Status were darkened to make the women appear to be a minority (Demby 2013; Levin 2013). The powerful vestige of this propaganda is revisited with certainty in any discussion about entitlement programs in which the characterization of recipients is uniformly similar to the welfare queen. In essence, this imagery would become a persuasive force that eventually influenced welfare reform legislation under the Clinton administration; the results of which were intended to end or curtail entitlements for unmotivated inferiors who refused to work and were content to live off the government and hardworking superiors. The so-called War on Drugs became a rationale for increased surveillance of minority communities and antiwar protestors to maintain law and order in the name of keeping superiors safe (Baum 2016). “Family values” promoted an idealized family as a two-parent, married, heterosexual couple, which meant that other family forms were unacceptable and therefore suspect. Lacking an understanding of or a failure to acknowledge the social and economic circumstances that supported these values meant that other family forms were marginalized in public policy (Powell 2006). African American families in particular were considered to be pathological because the majority of households were headed by single-parent mothers. More recently, rhetoric about screening, criminalization, or banning of certain immigrants and emphasis on voter fraud were intended to convince the unsuspecting and in some instances indifferent public of the threat of inferiors. The fundamental danger of propaganda about the inferiority of otherness as a deficit is that sustained rhetoric has the potential to inform and hence become codified in public policy; thereby thwarting the civil and constitutional rights of those without a voice. An associated factor is that the risks are greatest when the problems are politicized, but the properties are not holistically defined. The propaganda oratory, which to a large extent often operates in a fact-free zone, reinforces the qualities of oppression as described by Young (2004), specifically cultural imperialism, marginalization, powerlessness, control, and exploitation. Marginalization is also recognized because scant, if any, attention is paid to the fact that the end result of propaganda is harmful and in many instances can become a threat to the safety and well-being of people without power. Even seemingly progressive strategies intended to rectify long-standing inequality have been co-opted through propaganda. For example, affirmative action is often mischaracterized as a quota system in which less qualified minorities are given preferential treatment over qualified whites, essentially validating the inferior-superior divide. The United States has a long history of protests targeted at addressing inequality and seeking justice and equality. Yet when protests occurred in Ferguson, Missouri, following the death of Michael Brown, the 24/7 media cycle focused primarily on the unrest in certain parts of the community and described it as riots rather than as an uprising against decades of oppression and inequality in a democratic society. Black Lives

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A Foundation for Work with Involuntary Clients Matter, a nonviolent organized group, emerged to address these issues. It was a response to the multiplicity of injustices and national encounters with the police that resulted in the death of unarmed African American and other minority males. Ironically, American champions of democracy and equality applauded the Arab Spring, the series of antigovernment human rights protests that arose in 2011  in the Middle East, as righteous and an appropriate response to the lack of democracy and against injustice and oppression. In contrast, the members of the Black Lives Matter movement, which was organized to bring attention to racial discrimination, injustice, and human and civil rights violations, were characterized as racists, thugs, criminals, and agitators. The media had a prominent role in fostering an image of mistrust of the motives of Black Lives Matter by providing information for the public to consider, relative to the victim’s status as offenders. Specifically, in almost every situation, the media investigated and publicized the deceased victim’s prior contact with the police. For example, following the death of twelve-year-old Tamir Rice in Cleveland, Ohio, the media called attention to the fact that his father had at one time been arrested for domestic violence. In effect, irrespective of the content and context of victim’s a prior contact with the police, the public upon learning about these encounters, however minor, could remain indifferent because the individuals who died at the hands of the police were hardly upstanding citizens. Also, in response to protest events led by Black Lives Matter, the media and some public officials embraced a minimizing counternarrative. After all, don’t all lives matter? Indeed, it would seem that when oppressed people respond, they are considered to be ungrateful for the privilege of living in the United States and are characterized as dangerous to democracy and the public good.

Attributes of Oppression and Involuntary Status Members of oppressed groups and involuntary clients share common attributes that have the potential to intrude upon the helping relationship and process. There are a number of challenges in working with involuntary clients from oppressed groups. First, despite the apparent overlap between involuntary status and oppression, there is limited literature that directly connects these populations. There is a void in practice and guidance is scarce. Second, as social work professionals, we understand oppression yet we lack knowledge of ways to incorporate the complexities of oppression into our work with clients. Nagda and colleagues (1999), in articulating this dilemma, suggest that concerns related to oppression are stalled at the intuitive and emotional rather than the cognitive level. Clifford and Burke (2005) point to yet another difficulty, which is the profession’s ethical principle of embracing differences and being willing to see problems from multiple lenses, but when articulated in

Oppression and Involuntary Status Table 5.1 Shared Attributes of Oppressed Groups and Involuntary Clients Involuntary Clients

Oppressed Groups

Compliance

X

X

External locus of control

X

X

Distrustful

X

X

Constrained self-determination

X

X

Historical legacy

X

Powerlessness

X

X

Marginalized

X

X

Outsiders

X

X

practice this is often problematic. These issues become more challenging when individuals as clients are of a very different social standing, background, and culture than the professional. In examining the attributes of involuntary clients and members of oppressed groups, table 5.1 lists specific attributes that are common to both involuntary clients and members of oppressed groups. Compliance Compliance is a factor for both groups. Involuntary clients are expected to show evidence of compliance by completing the requirements of their case plans that have been set forth by legal or silent mandates. They also are required to accept the authority that has defined their problem. Similarly, it is the responsibility of the oppressed to adapt and to comply with the mandates inherent in dominant societal realities, social order, behaviors, lifestyles, and values. Both involuntary clients and oppressed people have limited choices that are inherent in their involuntary status. For oppressed groups, choice is often limited by access to resources, including desirable housing, employment, and education. Constrained self-determination is central in that there is a real or perceived feeling of powerlessness and vulnerability. For involuntary clients, the imbalance of power in the relationship is reinforced when the professional’s power is acknowledged in the mandate. Compliance as a coercive dynamic creates tension and conflict and diminishes trust when the professional authority emphasizes compliance in the helping relationship. In consequence, clients are likely to perceive the professional’s role as indicative of their collaboration with the authority that mandates their involvement.

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A Foundation for Work with Involuntary Clients External Locus of Control In describing the experience of oppression, Frye contends that oppression is “the living of life,” in a manner that is “confined and shaped by forces and barriers that are not accidental and hence unavoidable” (2004:176). Oppression is akin to “being caged in, feeling that all avenues in either direction are blocked or booby trapped” (ibid.). For the involuntary client, the expectation to behave in a certain way and to comply with a requirement or a mandate to seek help is analogous to feelings experienced by those who are oppressed. Given the experience of oppression, when it is joined by involuntary status, individuals are apt to be hypersensitive, distrustful, and suspicious. In many instances, such clients perceive contact with a professional, especially when the contact has been mandated, as oppression disguised as helping. When confronted with situations in which they feel powerless, clients may view themselves as victims of an oppressive system created by the authority that exerts control over their lives. External control combined with compliance become counterproductive forces that cast an aura over the helping relationship. Distrust Distrust is a core dynamic when clients’ problems or needs have been determined either by a mandate or other means of coercion and authority. In such circumstances, attempts on the part of the professional to establish the helping relationship can be overshadowed by the client’s fear and his or her compliance and associated feeling of lack of control (Cingolani 1984; Hutchison 1987; Rooney and Bibus 2000; Reid 2002; Trotter 2013). The relationship between professionals and those who engage voluntarily is in contrast with those with involuntary clients. In the former, relational problem solving and collaboration and general goodwill are attributed to the professional, and a collaborative, reciprocal arrangement is nurtured. For the involuntary client who is also a member of a racial or ethnic minority group, the psychological authority of the professional occurs in a vastly different social and historical context. Tensions have long existed among social welfare organizations, the police, and poor and minority communities. Social services and law enforcement have been involved as agents of control for whom a major task was to ensure societal behavior standards and, in some instances, morality (Margolin 1997). With regard to the police, minority communities want and need protection, nonetheless trust in the motto “to serve and protect” is hardly a notion embraced by poor racial and ethnic communities. In many respects in the absence of policies that address disparate social and economic conditions in these communities, the police are permitted to act as de facto change agents, the results of which is labeling the adaptive behavior associated with these conditions as

Oppression and Involuntary Status suspect or evidence of potential criminal activity. For example, lacking alternatives, youth who socialize with each other on street corners are approached, frisked, and treated as suspects and in some instances are bullied by the police. This practice is considered to be a means to stop the occurrence of unspecified safety problems. The notion of prevention adopted by police departments is based on the first level of public health intervention (Harcourt 2001; Stamper 2016). Specifically, the youths’ behavior is indicative of potential harm, and hence is to be examined and acted upon. Police are therefore a major source of distrust for many residents in communities of color. Similarly, these communities have limited trust in the ser vice delivery systems of social welfare organizations. They perceive or have experienced a disconnect in the ser vices provided relative to their needs, and therefore do not trust that professionals have their best interests at heart, in particular because of the focus on deficits that essentially reproduces the superior-inferior paradigm (Blitz et al. 2014; Reisch 2002; Yang 2008).

Constrained Self-Determination Students and some professionals may confuse compliance to a legal or silent mandate as having precedence over client self-determination. To be clear, involuntary clients have the right to self-determine. The role of the social worker, according to the National Association of Social Workers (NASW) Code of Ethics is clarified in Standard 1.03(d): “In instances when clients are receiving ser vices involuntarily, social workers should provide information about the nature and extent of the ser vices and about the extent of client’s right to refuse ser vices.” Abiding by this standard assures clients of their rights and enhances their sense of control over their lives. In the same way, oppression also constrains self-determination. Oppression gives individuals an inferior status, which limits their ability to determine a chosen path; instead the path and future are often predetermined by virtue of marginal individual or group status. Even so, instances in which the involuntary client exercises the right of selfdetermination, the professional is obligated to inform individuals of the consequences of a choice, rather than concluding that the individual is unmotivated or oppositional to change. This work may require extra effort to move beyond such an impasse, for example understanding the dynamics of involuntary status and oppression.

Historical Legacy The United States has historically oppressed various groups, particularly communities of color. Many of this country’s founders and early leaders reinforced

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A Foundation for Work with Involuntary Clients the superior-inferior construct by raiding, taking land from, and killing Native Americans, essentially dismantling the indigenous culture. Examples include acts such as the forced removal of indigenous children to boarding schools and relegating adults to reservations, a circumstance from which many tribal nations never fully recovered. Also, the enslavement of Africans created wealth and privilege for superior individuals and families that is evident today, but not for the majority of the slaves’ descendants. The treatment of Japanese, Chinese, and Mexican citizens in this country is further evidence that any nonwhite group considered to be inferior has experienced some facet of oppression. Furthermore, once overt racism became illegal as a result of the Fourteenth Amendment and civil rights legislation, many oppressive practices became covert and subtler in the form of micro and macro aggression. The fact that many oppressed groups remain at the bottom rungs of society is based on this country’s historical legacy of powerlessness that is reinforced by racism and ultimately oppressive policies and practices. Powerlessness All people are concerned about having direct and indirect control over their lives (Tyler 1989). In encounters between social workers and involuntary clients, emotional responses to a lack of power may be related to clients’ previous experiences or the extent to which they have control over the process that led to the contact. In most cases, involuntary clients who are members of oppressed groups feel powerless to change or direct their involvement with social service or criminal justice systems because they have limited, if any, control over the process and the decisions that affect their lives. Involuntary clients’ response to powerlessness may establish boundaries in their relationship and involvement with helping professionals. Being hesitant or selective about the information that is shared is a common means of regulating the relationship, and hence engagement with professionals. Therefore, lacking control, involuntary clients can be cautious about sharing any information that will influence the direction of decisions made, and in effect allows them to maintain a level of power. Marginalization There are different strategies that nations, systems, and individuals use to oppress and maintain power. Marginalization is one of those strategies. Marginalization is the process through which someone or something is intentionally forced or maintained in an undesirable position and is excluded from fully participating in society, which results in needs and desires being ignored (Jenson 2000). Indications of the ways in which oppressed groups are mar-

Oppression and Involuntary Status ginalized are economically, educationally, politically, and socially. According to Jenson, “marginalization is perhaps the most dangerous form of oppression. A whole category of people is expelled from useful participation in social life and thus potentially subjected to severe material deprivation” (2000:2). Involuntary clients are marginalized in many of the same ways. They are marginalized by organizational and professional labels that disregard their personhood, and instead define them as at risk, abusive parents, criminals, prostitutes, crazy, unstable, homeless, and offenders. In many cases, these labels justify the mistreatment and denial of rights of certain client groups. Moreover, systems and practices ignore the circumstances of involuntary clients, and in consequence rarely consider the client’s version of events or consider a client’s wishes and desires as part of the helping process. Instead, social workers and other professionals are authorized to interpret or deny the validity of involuntary clients’ reality or experience, and in some instances impose or restructure reality based on the professional’s world view (Johnson 2006; Wilson and Beresford 2000). Outsiders and Stigma The relationship of social work to the involuntary client from an oppressed group is subjective. The behavior and attitude of both the social worker and the client are informed by their experiential and cognitive world views. Members of oppressed groups, especially those with low income have often experienced a social welfare legacy that comingles the person and the problem. Thus, rather than receiving help focused on the problems that clients experience, the objectives of change approaches target the person. As outsiders, involuntary clients are detached and isolated from society and its organizations, and their experience with oppression is rarely acknowledged (Freire 1970, 1998; Van Voorhis 1998). In contrast, social workers hold a position of privilege that is derived from education, status, power, social class, world view, and in some instances race, all of which are factors that contribute to an asymmetrical client-professional relationship. Professional status is further bolstered by policies and ser vices that empower professionals to interpret and diagnose client problems. The stigma of labels attached to racial and ethnic minorities is in fact an oppressive double bind. Members of these groups are in need of ser vices and resources, yet are stigmatized for seeking help by the language of organizations and professionals. For example, they may be considered as at-risk or high-risk (Orme 2002; Weinberg 2006). Involuntary clients are labeled and stigmatized for their acts or behaviors, which in essence denies their personhood. For example women who are arrested for a prostitution-related event are prostitutes. Men who are engaged in abusive relationships are considered batterers.

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A Foundation for Work with Involuntary Clients In any case, neither the involuntary client nor a member of an oppressed group is likely to willingly become involved in an unequal relationship. As outsiders, they appropriately react to the professional with whom they interact and who are perceived as lacking an understanding of or are disinterested in the circumstances of an identified problem. Like oppressed racial and ethnic minorities, involuntary clients are outsiders. Involuntary status essentially ranks them in a hierarchy of the willing and unwilling, the latter of which is perceived to be outside of the norm. The dynamic of reactance may reinforce their marginal status, effectively separating them from clients who acknowledge or self-identify a need or problem and thus are motivated to change. In the following case situation, many involuntary client and oppressed group attributes may be observed. Given the intersection of the shared attributes between involuntary status and membership in an oppressed group, working with such clients is an additional obstacle that must be crossed in order to establish a productive relationship. Furthermore, as in observed the case, involuntary individuals from racial and ethnic minority groups in effect create social distance between themselves and professionals by speaking in the abstract, for example, using they, them, or the system or in the case of individuals as he, she, or they when referring to the individuals and entities they view as exerting control over their lives. In the latter, the use of pronouns is indicative of the professional a client perceives to represent the system. In general, clients do not make distinctions between professionals and systems with whom they are required to interact. For example, note that when the social worker asked Mrs. Walker to explain “they” she replies, you know, “them.”

The Case of Mrs. Walker client: They told me to come and see you about getting my son back. It seems like with black people, we are always being told to go see somebody about something that they say ain’t right. They [are] always messing with our kids and us. social worker: When you say they, it would be helpful for me to understand whom you are talking about. client I don’t know, but you know them. All I know is they said I wasn’t taking care of my son. When she came into my house with the police, I was mad. I cussed her out. She don’t know nothing about me, and here she is in my face talking s. . . . about neglect. Two big old policemen held me back while she took my child—he was crying and all she did was look stupid. Everybody was out in the hallway looking. Then, I got real scared. They ain’t never gonna let me have my child, you know what I am saying. This is messed up!

Oppression and Involuntary Status social worker: I understand you’re feeling scared and angry. I also imagine that it was traumatic for your child to be removed from your care. Would it be helpful for me to explain why you were asked to see me? client: Well, maybe, but you know the system works this way. My sister, my cousin and one of my friends all had their children taken for crazy reasons. For us black people, they use any excuse to take our children. It’s always some b. . . . s . . . about neglect, like we don’t care about our kids. social worker: I hear that you believe that African American kids are removed from their homes and that the system is unjust. I also hear that you believe that your son was removed from your home because you are African American. client: Yeah, how are you gonna help me get my child back? social worker: I work for Pegasus. This agency contracts with the county child welfare agency to work with parents so that they can complete their case plans and be reunited with their children. It would help me to understand your situation if you told me what happened. client: I am sick and tired of people messing with me, you know what I mean. I work, try to keep my head up, but things just keep coming at me. My son Darnell has asthma. I stopped smoking because the doctor said this would help. One night he was really bad, so I took him to the emergency room. We had to take the bus. The doctor, he asked me a bunch of ignorant questions, like I didn’t care about my child. (She mimics the doctor) “Mrs. Walker, why did you wait so long to bring your son to the ER?” I just stood there and looked at him like he was some kind of fool. Then he said that I would have to see the social worker and left the room. I was tired, cold, and scared. All I wanted was for them to help my child. social worker: Then what happened? client: She [the hospital social worker] came in and asked me more stupid questions, just like the doctor, and begin filling out this form. She said something about being required to complete a risk something or other. social worker: Yes, the social worker would complete a risk assessment. Perhaps I could explain this to you if you are interested, but first, tell me what happened next. client: I got mad. When Darnell got better, I went into the room, took him, and left. Next thing I know, they were at my house to take him away, saying that I was neglecting him. Then she wrote a report saying that my apartment was unsafe because she saw the traps that I had for mice and roaches. Everybody in the building has mice and roaches. The garbage is always overflowing cause he [the landlord] don’t pay the private contact garbage people for regular pickup. I would not know the man if he was in this room; his name is Mister something or other. We send our rent to a post office box. I have called him to fix the water leaks—the building is a mess— where am I gonna go that’s gonna be better?

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A Foundation for Work with Involuntary Clients The crazy thing is that I was doing the best that I could. I got a cat from a friend and that helped. I don’t keep a lot of food in the house, that’s why I go mad when they [the police] opened my cabinets and said that there was no food in the house. Then, you know what she had the nerve to say—the cat was making my son sick. I tried to tell that b. . . . that Darnell’s doctor said that having a short-haired cat was okay. It’s like they were looking for a reason. When we got to court, the judge said that I needed to find another apartment. When she talked to the judge, she didn’t tell him anything about me or what I had done, because she don’t care or know nothing about me. Just playing games with me, and there is nothing I can do about it if I want to get my son back. What are the connections between involuntary client status and oppression in this case? First, throughout Mrs.  Walker’s narrative, she alerts the social worker to her lack of power, and that of people like her. For example, comments that speak to her lack of power and that of an invisible power were, “It seems like with black people, we are always being told to go see somebody about something that they say ain’t right.” In addition, the issues of power and external locus of control are reflected in the client’s dispirited statement, “I am sick and tired of them messing with me. . . . I work, try to keep my head up, but things just keep coming at me.” Choudhuri proposed that in interactions with professionals that “it is in the spirit” that impact of oppression can be observed (2005:133). When the social worker empathized with the client, she plunged ahead with her story, of being “caged in” as suggested by Frye (2004) and a victim of the “roadblocks” of an unspecified system. Allowing the emotionally charged catharsis of Mrs. Walker is important at this point in the contact, she is unwilling or unable to hear and to trust that the social worker understands. Despite the overtures made by the social worker, her statement is insufficient to persuade Mrs. Walker of her interest in helping. Generally, at this stage of contact, reactance is high, especially in response to feeling judged, controlled, and a loss of freedom (i.e., her status as a parent). Mrs. Walker in fact amplified her feelings about being judged when she expressed anger that neither the social worker nor the judge knew anything about her. Moreover, the order from the judge to find a new apartment, for example, set forth a requirement that she feels is unjust, if not impossible, as she states, “where am I gonna go that’s gonna be better?” Her question is valid. As a lowincome, minority single parent her economic status places her at the mercy of a housing market in which decent affordable housing is difficult to locate. Like most low-income minority individuals, her limited options tend to be concentrated in inner-city neighborhoods, in which the quality of the rental housing stock is questionable. As noted by Anderson and Collins (2001), inner-city neighborhoods tend to be politically isolated conclaves of poverty and subjected to crime and chronic neglect by those in power.

Oppression and Involuntary Status

The Effects of Involuntariness and Oppression Reactance Client reactance may manifest as a reluctance to accept the reason required for seeking help. As a dynamic, reactance can also be linked to stigma, external control, and compliance because a sanctioned authority has identified the problem and the solution, thereby limiting self-determination and curtailing freedom. Emotions such as anger, fear, or anxiety evoke a psychosocial response to the perception of a threat. Clients’ emotional responses in mandated situations are fueled by perceptions of being controlled and subjected to punishment rather than care, each of which are salient factors in their interaction with helping systems. Hence, clients feel threatened and mistrustful of the capacity of social ser vices to treat them fairly. Reactance is a robust emotion that can be understood in the context of the psychosocial self, the origins of which are immersed in the historical and environmental experience with the social environment (Van Voorhis 1998; Walsh 2003). The encounter with a professional for a reason other than one that is identified by the client may be threatening, so the response is reactance, which is emotion focused. Faced with the emotions, the tendency may be to ignore or misinterpret reactance and instead consider it as evidence by which to judge the client’s readiness to change. In many encounters, reactance becomes a circuitous dynamic in the manner in which a professional responds to a client’s reactive emotions relative to his or her involuntary status. In brief, the involuntary client meets the involuntary professional. When faced with client reactance, professionals may feel threatened and consequently vulnerable. Recall for example, when Jermaine’s parents asked, “why can’t you all teach our kids?” The team leader’s perception of the question caused him to react and become uncooperative. The parents’ questions and their statement linking the locked doors to a prison represented a message within a message. The overall message expressed the parent’s world view influenced by the historical legacy of African American males incarcerated in U.S. prisons and the failures of an educational system to prepare them successfully for life. When presented with the parent’s questions and observations, the team leader suggested that Jermaine might “be better served in an alternative school.” What the team leader heard was threatening to him and seemed like an indictment of the team’s professional status and a critique of the team’s judgment. In turn, the team leader, feeling vulnerable, concluded that the parents were uncooperative, hostile, and that they misunderstood the team’s best effort to help their son. Further, the tenor of the interaction underscored the social distance and differing world views of the parents and the team members. Whereas the team leader acted from his position of authority, privilege, and power, the parents behaved as members of a marginalized, alienated group in society. The result was an

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A Foundation for Work with Involuntary Clients impasse in which neither side was satisfied with the outcome. Hence no problem solving occurred because the team leader failed to understand the power dynamics between the parents and the team as well as the experience of the parents as members of a minority group. Crises and Toxic Stress A crisis is generally thought of as an episodic event or situation in which relief will reestablish a previous level of equilibrium (James 2008; James and Gilliland 2013). Even voluntary clients tend to seek help when an event or situation has exceeded their capacity to manage. Clients, especially members of oppressed groups’ lives are routinely permeated with ongoing high levels of psychological, social, and economic stressors that have strained personal and community resources. Regardless of how routine an encounter may be for the social worker, for the involuntary client the contact may evoke a crisis state. Members of oppressed groups, especially those who are poor, live with constant and varying levels of crisis caused by everyday adverse conditions and circumstances in which stressors strain and exhaust their strengths and coping capacities, the results of which often lead to toxic stress. Bucior defines “toxic stress as early exposure to chronic, unmitigated stress that affects behavior, learning, and health for a lifetime” (2015:2). Dr. David Pate interviewed over five hundred black men in Milwaukee, Wisconsin. Participants described a litany of despair that included racism, unemployment, and minimum wage jobs that do not allow sufficient resources for food, medicine, clothing, or shelter for their families. According to the men interviewed, chronic stress included living in unsafe neighborhoods and being exposed to violence, personal and generational incarceration, a lack of education, constant surveillance, and crushing child support debt with the looming possibility of incarceration or loss of a driver’s license for failure to pay. Toxic stress has physical, mental, neurological, and social effects. It is a significant factor that leads to suicide ideation, depression, teen pregnancy, drug and alcohol abuse, domestic violence, and physical ailments (Bucior 2015). Similarly, the case of Mrs. Walker illustrated her experience with a series of events that when combined were traumatic and over which she had little control. For example, she was marginalized as a person and a parent in her encounter with the doctor and the hospital social worker, whose decisions questioned her ability to guarantee her son’s well-being. Her privacy was violated by the child protection worker and the police and her subsequent crisis-level emotional response, specifically a sense of shame, as the incident occurred in the presence of her neighbors. These accumulated events resulted in the ultimate trauma of her son’s removal from her care. The contact as an

Oppression and Involuntary Status additional stressor can be recognized in her recounting of the things that she has done to keep going in spite of her circumstances. Stressors, when measured against Mrs.  Walker’s strengths, have exceeded her coping capacity, and she is distressed by the fact that her efforts to deal with her situation were unrecognized. The strengths perspective is applicable in this case, but it is important for the perspective to take into account the constant struggles poor and oppressed people like Mrs. Walker encounter in their daily lives (Saleeby 1996; Margolin 1997). A lack of recognition in fact distorts Mrs. Walker’s strengths in dealing with constant stressors and the experience of oppression, focusing instead on her assumed deficits as defined by the hospital social worker and the doctor. She is especially angry that the child protection worker, in presenting her case to the judge, “didn’t tell him nothing about me.” Anger-Rage Anger, if unrecognized as legitimate, can lead to rage, which can be a common emotion among involuntary clients as well as oppressed people and communities. In fact, riots are often an outward expression of anger and rage over feeling dismissed, silenced, minimized, and ignored. According to Resnikoff, rioting is often what happens when marginalized groups have no other outlet for expressing grievances (2015:2). The ongoing police lynching of unarmed black men that continues to be sanctioned without any significant steps to hold police accountable has made it clear that handling matters through the “proper channels” does not make a difference (Resnikoff 2015). In these instances, oppressed people may feel consciously and unconsciously that they lack alternatives and publicly acting out their frustration is a means to call attention to circumstances and to be heard. But, when systems and professionals encounter angry involuntary clients, they may ignore or fail to understand the structural and environmental factors that affect members of oppressed groups. In these circumstance, it would be unusual for clients to feel anything other than anger and rage. Cognitively, people’s life experiences and events cannot be separated from the historical and social contexts that influence their beliefs (Clifford and Burke 2005). Despite professionals’ best efforts to make life better in their contact with clients, doing so can be stymied because what is required is a government that is willing to recognize inequality and facilitate a social justice agenda. The nature of mandates or court orders does not encourage trust, nor does it allow for emotions like anger. Further, the mandate does not consider the circumstances in which a behavior or act has occurred and instead the focus is on the outcome. A mandate does contribute to client’s feelings, real or imagined, of their vulnerability to an invisible and unfamiliar power and authority. Moreover, for the involuntary client, trust is difficult to establish in

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A Foundation for Work with Involuntary Clients an asymmetrical relationship in which oppression and involuntary status intersect, and which may resemble the structural arrangements in society that exist between the dominant and the dominated. Hence, it is useful for professionals to recognize and empathize with these dynamics and work through these troubled waters in order establish a working alliance that increases the likelihood of solving a problem as observed in the following case. The Ruiz Family and Educational Neglect The Ruiz family is Mexican American and consists of a father and mother and four children. They recently moved to a small rural Midwestern community where both parents are employed at the poultry processing plant. Some weeks the parents work on the same shift, while at other times their assigned shifts vary. Work schedules are posted at the end of the week, which makes it difficult for the family to plan ahead. They lack the seniority that would allow them to have predictable and desirable shifts. The family’s involuntary entry into the child welfare system and conflict with the educational system occurred because the two older children were responsible for caring for their two younger siblings when both parents were scheduled for the day shift. Each child had missed more than thirty days of school at various times throughout the fall term. A teacher reported that the children appeared to have “lacked an understanding of the issue” and were “vague about whether their parents were sufficiently concerned about their absences to meet with the teacher.” In addition, the teacher considered the reticence of the children to discuss their home situation and their parents as strange. The school (as legally mandated) reported the absences to child protection ser vices, which intervened on the basis of educational neglect. What were the initial assumptions in this case? Under education and child welfare policies the parents were negligent. In seeking to protect and ensure the rights of children, the policies have an explicit assumption and bias. Specifically, child welfare policies assume that some parents are unwilling or incapable of parenting, thus casting the state in the role of the ultimate parent. Educational policies assume that there are certain parents who do not value education. In both instances, a corrective intervention is required and the focus is on parental behavior. Neither policies nor mandates differentiate with respect to individual circumstances. Rather, when public policy or societal rules are violated the inferior outsiders must be sanctioned. Policies do not examine the reasoning behind acts that an individual commits nor

Oppression and Involuntary Status the circumstances in which those acts occur. In consequence, the application of rules and related sanctions becomes oppressive (Day 1981). The Ruiz’s decision that the older children miss school had violated a rule created by societal institutions for the education and protection of children. In their failure to abide by the rules, the parents’ decision was deemed to be an act of neglect that required an intervention, which is often perceived by clients as unreasonable and punitive. Procedural Justice Involuntary clients are rarely involved in the decisions that result in mandates that affect their lives. As such, like Mr. Ruiz, they are more likely to perceive the outcomes of policies as unjust. People seek to have direct and indirect control over their own lives and therefore react with strong emotions to appraisals of their behavior, actions, and decision making as deviant. Unlike distributive justice, which addresses fairness in the allocation of resources, procedural justice involves the client’s perspective and participation and they assess the fairness of an intervention relative to the situation (Greenberg and Tyler 1987; Folger 1987; Tyler 1989; Beitin and Allen 2005). Procedural justice is compatible with the just practice framework articulated by Finn and Jacobson (2003), in particular the ethic of participation. As does procedural justice, the just practice framework considers the big picture, examining the overall context of a client’s life. By incorporating procedural justice into their work with involuntary clients from oppressed groups, specifically by engaging and inviting the client’s story, the social worker can gain access to a client’s perspectives and experience (Rooney 2009; Trotter 2013). Procedural justice and just practice questions facilitate engaging the Ruiz family and Mrs. Walker, as illustrated by the following revisiting of the case examples.

Integration of Attributes and Just Practice Problem Solving In working with involuntary clients, consideration should be given to the behavioral and environmental attributes that can influence the four main tasks of helping professionals: engagement, assessment, goal setting, and problem solving (Rooney 2009; Trotter 2013). Behavioral attributes include clients’ beliefs, cognitions, and emotions associated with reactance and distrust and world view, each of which is a lens through which clients interpret and respond to situations. Environmental attributes include the social environment in which clients live, oppression forces or marginalization, external locus of control, and a lack of power, real or imagined.

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A Foundation for Work with Involuntary Clients Engagement Vulnerable people are often overwhelmed by their life circumstances, thus the meaning that they attach to contact with a social worker may heighten their existing stress level to traumatic stress. The engagement process is facilitated by sensitivity on the part of the social worker, reflective listening, and empathetic responses to the client’s emotional state. The social worker in Mrs. Walker’s case acknowledged and validated her feelings (e.g., “I understand you’re feeling scared and angry; I also imagine that it was traumatic for your child to be removed from your care.”). The social worker’s use of openended questions (e.g., “It would help me to understand your situation if you told me what happened.”), invited Mrs. Walker’s participation and gained information about the meaning of the contact. An important element of engagement is an understanding of involuntary clients’ behaviors, beliefs, and perceptions. As observed in both case examples, clients’ beliefs are often expressed through language and behavior that play a prominent role in the engagement process. Because the socially constructed experiences of clients inform their cognitions and beliefs, exploring beliefs provides insight into their self-image and perception of their place in society. To demonstrate the interplay between behavioral and environmental attributes, we return to the Ruiz family. During the meeting with the Ruiz family, the social worker encountered reactance, expressed in the family’s hostility, shame, anger, fear, and confusion. De Jong and Berg (2001) and Rooney (2009) suggest a first step in engaging clients that is consistent with procedural justice; that is, to allow mandated clients to tell their story and describe their understanding of the mandate or referral. By doing so, practice, as articulated by Trotter (2013) and Rooney (2009), is consistent with Finn and Jacobson’s (2003) “just practice” framework in which participation, engagement, building trust, and power are facets of working with involuntary clients. In this framework, an essential factor for creating an atmosphere in which the client is invited to talk responds to the question, “How do people give meaning to the experience and conditions that influence their lives?” The question essentially extends power to the client as an equal participant in both the process and the outcome. The question further elaborates procedural justice in that it inserts the voice and experience of the client, who has not been involved in the policy debate or its formulation. A second question directs the social worker to query, “How do I comprehend, interpret, and appreciate the contextual nature of human experiences and interactions?” (hence diminishing the opportunity for judgment and bias, and also moving the contact beyond the inherent assumptions of a policy and the language of the mandate or referral.

Oppression and Involuntary Status For example, when asked about his understanding of the intervention by child protective ser vices, Mr. Ruiz explained that a friend had told him that it was because “we kept the children at home to babysit.” As a migrant worker, he felt he had few protections, which added to his confusion about the school’s intrusion into the family’s life and the authority of child protective ser vices. In exploring context, as discussed by Finn and Jacobson (2003), in particular the circumstances and conditions that influence and surround par ticu lar events and situations, the social worker gained an understanding of the family’s difficulties. As the meeting progressed, for example, Mrs. Ruiz spoke about the couple’s work schedule conflict and the need for childcare. She also emphasized, “We want education for the children so they can be better off.” Having heretofore worked as migrants, they had welcomed the opportunity for permanent employment and the stability it provided for the children. Moving to the community also had disadvantages. They were strangers. Having the older children provide childcare was the only alternative that they believed to be available to them given their status in the community. Throughout the interview, Mr. Ruiz expressed anger toward child protective ser vices. “Yes,” he understood the explanation provided by the friend. But, he said “we are honest, hardworking and we don’t cause trouble for nobody.” At one point, he became so frustrated that he demanded that the social worker leave the home. In staying the course, the social worker understood that Mr. Ruiz distrusted the motive for the contact and perceived the intervention as punitive. He also questioned, why now? For example, he asked, “Where were child protective ser vices when my children needed medicine, clothing, and food? No one has tried to help us, so we do the best we can.” He demanded, “Where were child protective ser vices when my children were working in the fields, working long hours, and living in bad conditions?” In fact, he held the aspiration that is common among all people, that of having control over their personal lives. Further, he felt punished because he and Mrs. Ruiz believed that they had made the best decision considering their circumstances. His anger was somewhat diminished when the social worker explained her role, the intent of the policies that had led to the intervention, and the potential choices available to them. The social worker empathized with the family’s situation including the experience of being a stranger in the community, and acknowledged Mr. Ruiz’s comment about being “hard working people, who did not want to cause trouble.” She then moved to reframe the issue to a need of childcare, rather than a case of neglect. Reframing the issue led to both parents agreeing to work with the social worker. What makes this case different? Had this been a less visible, nonminority family with ties to the community, would the situation have been handled differently? At first glance, it appears to be a fairly straightforward case of educational neglect resulting from a decision made by the parents. How was the

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A Foundation for Work with Involuntary Clients decision by the social worker to reframe the case as a lack of childcare rather than that of neglect made? What are the dynamics of marginalization, oppression, and vulnerability that suggest a link to involuntary client status? Mr. Ruiz explained that there were few people in the community “who look like us,” and therefore finding childcare had been difficult. Although there were other Mexican American families in the community, they worked at the poultry plant and as new employees they all had similar schedules. Many of these families had experience with child protective ser vices for reasons that few understood. In addition, while the other people in the community had not been openly hostile, they had not been particularly friendly either. In fact, during the previous two weeks, the local newspaper had published the results of interviews with local residents about the presence of the “Mexican families in the town.” Interviewees referred to the families as “the newcomers,” “those people,” and that it would take some time for “folks around here to get used to seeing them on a regular basis.” Another resident asserted, “But we shouldn’t have to get use to them.” While few people had noticed or objected to these families as transitory migrant workers, the idea that they would “settle in the community was another matter.” Some residents voiced the familiar charges, such as “they are taking our jobs,” and “their children are a burden to our school system.” There were also complaints about Cinco de Mayo celebrations that included displaying the flag of Mexico at the plant. When interviewed, the plant manager stated, “they are good, reliable workers, despite their problems.” The vague notion of “their problems,” as articulated by the plant manager speaks to the family’s vulnerability. In characterizing the families as problems, the community and the manager were absolved of any responsibility for their well-being. An interpretation of their problems was rationalized as characteristics of the individual families, absent their position in and interaction with the community. The very fact that community residents were asked to comment on the “newcomers” was symbolic of the vulnerable marginalized status of the oppressed. The responses of the community illustrated both the process and structure of oppression, in which the superior-inferior hierarchy is reinforced, effectively assigning the newcomers to membership at a lower rank of the community. How might the newspaper story been different if the Mexican American families had invited to talk about who they were and their experience in the community? Let’s assume benign intent on the part of the newspaper. Perhaps the article intended to introduce the families to the community. It is possible that the residents were simply responding to the questions asked. Nevertheless, by focusing on the Mexican American families and eliciting community opinions about their being in the community effectively elevated the power of the non-Mexican American residents and reinforced a hierarchy of ranking. Inherent in the community responses was the fact that the residents held the power to decide whether or not Mexican American families were accepted as

Oppression and Involuntary Status members of the community. Some residents, indifferent to or unaware of the subtleties of oppression would no doubt say that this is much ado about nothing. Realistically, the statement that “it will take some getting used to” perhaps is a normative expectation for all new residents. Yet it is unlikely that the focus would have been on families whose demographics were familiar to the majority residents. This case further illustrates that oppressive circumstances can be instrumental in facilitating involuntary client status. The Ruiz family responded to a public policy about the education and care of children even though no court order had been imposed. The power of the silent mandate is manifested in the authority of the teacher’s interpretation of the children’s response. The children had not been a problem at school, they did not appear to be in distress, nor was there a report that they their grades were a concern. The intervention occurred because they had missed school. Initially, the reason for their absences was unclear. The social worker learned, however, that school attendance was based on the family’s need for and lack of resources for childcare, specifically the irregularity of the parent’s work shifts. The school, in accordance with its responsibility, responded to the situation and the Ruiz’s involuntary contact with the child welfare system. Without the context in which school attendance was located, along with the family’s vulnerable status in the community, the situation could have been judged as simply a matter of failure of parental responsibility and hence neglect. It was the social worker’s diligence in framing her inquiry to include the circumstances of the family’s status that enabled her to seek agreement from the family about resolving their childcare needs rather than pursuing the sanctions associated with educational neglect. As illustrated in the Ruiz case example, clients’ behavioral attributes are not isolated from their environment. The interplay between behavioral and environmental attributes may also be observed in Mrs.  Walker’s case. Mrs. Walker is more explicit in her belief that racism played a role in her son’s removal from her home. She asserted that black people are always being told what to do, monitored and critiqued “like we don’t care about our kids.” Further, her son’s removal is an extension of the racism experienced by others like her. Her comments underscored the fact that she distrusts the system and its representatives to deal with her fairly. The helping professional who was working with the family conveyed that she understood Mrs. Walker’s beliefs. In acknowledging her belief about racism the social worker posed a critical question, “Would it be helpful for me to explain why you were required to see me?” While the social worker could have probed further, she risked the possibility of further alienating Mrs. Walker as well as allowing her behavior and her beliefs to become a barrier to engagement. Instead, the social worker’s acknowledgment of the client’s belief about race validated Mrs. Walker’s belief without losing focus. Her question also started the process of building trust by explaining the reason for the contact. In so doing, she removed the uncertainty

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A Foundation for Work with Involuntary Clients of Mrs. Walker’s essential question of regaining custody of her child. In essence, the message that the social worker conveyed was that she would help return the child home. Clients’ narratives about life events and experiences provide insight into the impact of oppression on daily living (White and Epston 1990; Holland and Kilpatrick 1993; Saleeby 1996; Schmitz, Stakeman, and Sisneros 2001; Choudhuri 2005). Clients’ stories provide professionals with vital information about the alienating experience of oppression (Van Voorhis 1998; Guadalupe and Lum 2005). Allowing clients to share their stories is a means to engage them and invites their participation as well as gives them some power. Note that the social worker asked Mrs. Walker to explain what happened at the hospital. Irrespective of the reason for the contact that has been described in the record, the social worker elicits Mrs. Walker’s frame of reference. This simple act created a shared story from which they could begin to work and allowed the client to direct the interaction. This is another important task of engagement and it begins the assessment process. Assessment Mandates, both silent and legal, are corrective in their intent to address a range of client behaviors. James and Gilliland (2008) emphasize an assessment triage in which the emotional, cognitive, and behavioral state of the client are critical to the process. In addition, there is a range of environmental and structural circumstances that can influence client behavior. Consequently, all of these factors should be included in the helping professionals to assess a problem. A pertinent question for the social worker to explore is, “Is there a relationship between the client’s situation and oppressive forces?” For example, in the contact with the Ruiz family, it would have been easy for the social worker to conclude parental blame, thereby omitting exploration of the family’s status as Mexican Americans and strangers in what appears to be a toxic, hostile, community. Adaptation to unfamiliar environments involves reciprocity in human relationships. Reciprocity between the community and the Ruiz family was notably absent. Interactions between the family and the community were not cordial or welcoming. In consequence, the community’s view of the family as outsiders constrained their capacity to develop relationships in the community and the workplace as equals. In addition, their marginal status as outsiders limited their power and access to resources. The social worker involved with the Ruiz family therefore included informative assessment questions related to the family’s life transition and the degree of alienation they were experiencing. For example, as migrant workers they were marginalized and considered outsiders in the community, without particular ties to the community. Despite their marginalization, the strength of the Ruiz family was the fact that they were functioning, against formidable

Oppression and Involuntary Status odds, until their decision about childcare led to their involvement with child protective ser vices as involuntary clients. Persons, like Mrs. Walker and the Ruiz couple experience environmental, structural, and personal stressors and are more likely to come to the attention of authorities and institutions. They also are likely to be persons of color and the contact with a social worker is more apt to be involuntary. Environmental, structural, and personal stressors are closely associated with the inequalities of oppressive forces. Oppressive forces described as “interpersonal– intrapersonal–environmental systems” that either intentionally or unintentionally reinforce dominance or subordination (Guadalupe and Lum 2005:85). The experience with domination and subordination is also evident in social policies that lack procedural justice, and in effect promote a hierarchy of oppression (Wambach and Van Soest 1997; Van Voorhis 1998; Lum 2004; Beitin and Allen 2005). The circumstances of oppression can be made relevant by the social worker by assessing its impact on the capacity and functioning of individual clients and actively soliciting and using this information in the problem-solving process. Doing so can circumvent the multiple-edged sword that racial and ethnic minority clients experience in their encounters with professionals and social welfare organizations. Their encounters may involve problem-solving strategies that minimize oppression and perpetuate the dominant normative narrative (Pharr 1988; Guadalupe and Lum 2005). The dominant narrative represents an alienating force and includes decisions about their problems, acts, or behaviors, assigns stigma, and makes assumptions about deviance. Recall that Mr. Ruiz’s statement, “we are honest, hardworking and we don’t cause trouble for nobody,” was an attempt to counter the notion that the family was deviant. Clients’ feelings about constrained self-determination and limited power in their everyday lives is real. They perceive that the authority and power of others to define and interpret their behaviors or circumstances as flawed and unjust. Goal Setting In goal setting, social workers need to examine the extent to which oppressive forces may in fact infringe upon a client’s capacity to successfully achieve a goal. Environmental attributes can be formidable barriers to clients’ ability to achieve goals. Assuming, for example, that all parties involved shared the goals of the Ruiz children attending school regularly and returning Mrs. Walker’s child to her, what were the potential barriers? In the case of Mrs. Walker, finding suitable and affordable housing as required by the court was a challenge. For the Ruiz family, given their status in the community, what is the likelihood that the family would find an alternative childcare arrangement? Addressing these questions relative to goal achievement required additional effort on the part of the social workers involved.

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A Foundation for Work with Involuntary Clients Problem Solving Problem solving begins with the recognition of who is the client in light of his or her experience in the social environment. Effective problem solving is initiated by examining the goals of the intervention. Is the goal, for example, to resolve the identified concern, or to apply prescribed sanctions and rules to the situation? Moreover, which strategy involves the least harm? Problem solving rather than sanctions attends to the needs of the client by seeking to understand the reasons for their behavioral and environmental attributes. In essence, problem solving is combined with care and social justice (Orme 2002). It would be equally important to examine whether their status and beliefs pose a barrier to problem solving. Clients, because of their experiences, may in fact be immobilized, believing that little can change. Helping clients to resolve problematic situations may require professionals to advocate for them, mediate conflicts, and educate others regarding the client’s situation and progress or lack thereof. Understanding the reality of Mrs. Walker’s situation, the social worker could advise the court of her constrained housing choices and the fact that limited options would delay or possibly prohibit her compliance with the court order. If corrective action beyond what the client had already done was indicated, the social worker could provide resources that would facilitate the return of her child. This action would require the negotiated cooperation of child protection ser vices and the judge. The social worker also could work with her to file complaints with the city about the code violations in her apartment building. For the Ruiz family, the social worker could meet with the plant manager and the school in an effort to restructure the environment into one that is more nurturing and conducive to the needs of the children. With regard to childcare, she could begin to help the family develop a network of support within the community. When individuals are isolated and alienated and feel under siege, they may not recognize the various resources available to them. In addition, communities of faith could be explored as a source of support as well as for their potential as childcare providers.

What Can Professionals Do to Better Serve Oppressed Involuntary Groups? Self-Work-Reflective Practice A dilemma for clients is that social workers, when confronted with the oppressive content in clients’ stories, are often uncomfortable, relying instead on interpretations of deviance and pathology (Gil, 1998: Saleeby 1996). Saleeby (1996) and Freire (1970) liken this response to the interactions between the

Oppression and Involuntary Status oppressor and the oppressed, in that focus interventions are aimed toward assisting marginalized people to restructure their beliefs or lifestyles and conform to the dominant narrative. The suggestion here is not intended to excuse or minimize behavior or acts that result in involuntary status but rather examine the context in which the incidents occurred. Facilitating client participation is a way to gain access to this information. Evaluative steps that can be taken by the social worker to reconcile the tensions between clients’ experiences and accepted protocols include selfreflection, which is crucial. Self-reflection is guided by a willingness to explore biases, emotions, and reactions that can become enlarged in the encounter with the involuntary client. A question to be included in a reflection is: “How can I use my professional power and authority to resolve the client’s situation?” In addition, “Am I confusing my legal obligation to protect from harm, thereby diminishing the problem-solving objective of the profession?” Consultation with Supervisors Consultations with supervisors are integral to enhancing professional competence in work with oppressed groups. Through review of case records, supervisors can be helpful in this regard. For example, a supervisor questioned the foster care placement decision of a staff person for a disabled child, which included respite care and other resources that aided in her ability to care for the child. However, the same level of resources had not been offered to the biological mother, who was a member of a minority group, which would have allowed her to keep her child. Dismantling Oppression Through Political Advocacy Oppression is hierarchical, pervasive, systematic, and inherently political. Public policy is political. To assume other wise suggests that the system works equally for all people, which is tacit acceptance of the established order (Galper 1975; Gil 1978; Mullaly 1997; Vodde and Gallant 2002). Influenced by the Puritan ethic of good or bad, policies are not neutral, nor do they in most instances seek the input of or collaborate with those affected or seek to understand their circumstances. For the segments of the population that are positioned at the lower ranks, public policy, as reflected in the dominant narrative, in many respects is akin to social control (Gil 1978; Mullaly 1997). Whyte (1956) referred to the controlling dominant narrative in organizations as the social ethic. The social ethic in essence established a set of values that became morally legitimate in the form of pressures of society against the individual (or groups), the origins of which are grounded in the notion of superior-inferior status. As social workers, we have tended to embrace the notion of political neutrality in our relationships with our clients, even those who are voluntary.

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A Foundation for Work with Involuntary Clients Professional standards reinforce this notion by emphasizing a nonjudgmental attitude, human dignity, and worth and self-determination. Political neutrality is not possible with members of oppressed groups or with involuntary clients. For both groups, the helping process is co-managed by legal mandates, the preferences of the dominant viewpoint, and a more restrictive distribution of resources and public policy than occurs for the elite. Note for example the stringent work requirements for welfare recipients that do not apply for employers with political leverage. Some employers were awarded federal funds to hire welfare recipients even though they did not make a commitment to provide long-term employment. In fact, in many instances when the federal supports were exhausted, the employers discontinued the employment of these individuals. Social workers are confronted with a dual responsibility: to the client and to the authority of the legal mandate and dominant societal preferences, the latter of which may often represent the agenda of moral entrepreneurs (Weinberg 2006). More often than not the scope of relationships and professional responsibilities with involuntary clients and members of oppressed groups are codified in the rules, policies, and procedures of public policy and laws. When confronted with the responsibility of the regulation, rehabilitation, and discipline, social workers in the context of caring are caught between balancing tensions as agents of good and a preoccupation with their accountability to a legal mandate and to society (Reamer 1994, 2005; Reid 2002; Orme 2002; Weinberg 2006). In fulfilling their dual responsibility, social workers can become entangled in the process and structure that is oppressive, especially when a legal rather than a problem-solving and relational remedy is emphasized. In the former, the common life circumstances of oppressed people are ignored or dismissed. As professionals who have intimate knowledge of people and their situations, we are in position to participate in and advance the social justice agenda of the profession in practice. Reid traces advances in social work to “practice movements evolved from dissatisfaction with existing order” (2002:7). The existing order for working with involuntary clients who are racial and ethnic minorities should acknowledge that in many instances they are one and the same. Care should be taken by social workers to ensure that their practice does not replicate the experience of oppression. Social work practice with involuntary clients from oppressed racial and ethnic groups is justice work. This work calls for expanding the person-in-theenvironment focus to include human behavior in oppressive circumstances. This focus is consistent with the practice ethics and values that guide our moral, fiduciary, legal, and ethical obligation. Adjunct to this obligation is determining whether the mandates or policies are fair and that the requirements are within the client’s resources. In practice, obeying ethical standards and the right for effective treatment is consistent with the social justice frame-

Oppression and Involuntary Status work of fairness and equality. For example, the potential sanctions, if implemented, would have resolved the family’s need for childcare. The social justice emphasis of the profession also guides us to consider whether the outcomes of processes may be legal but unjust, and therefore harmful (Reamer 2005). The hospital social worker, the doctor, and the teacher acted upon what they perceived to be situations of neglect and hence the legal responsibility to ensure child well-being. The actions of all parties, however, set in motion a series of events that in consequence further exacerbated the fragile life circumstances of the two families. In both case situations, the ethical obligation of effective problem solving resided with the social workers to whom the cases had been referred.

Conclusion Many social work professionals are engaged in practice with individuals who by and large are members of oppressed groups. Although their status as outsiders may differ in degree, on the whole they are outsiders by virtue of being different, by virtue of their behavior or lifestyle, or by their failure to fit into the dominant societal schema. Racial and ethnic minorities served by social workers are further disenfranchised by the framing of social issues. This perception is enabled by propaganda, political debates, and media coverage that negatively profile them as others and disadvantaged, which further contributes to their social, psychological, and economic marginalization. While we as individual social workers may be unable to dismantle oppression, we can acknowledge and seek to neutralize its impact in our practice with clients. In much the same way that we seek to be culturally competent, our practice should include being oppression-competent, specifically, increasing and integrating our understanding of the context of the lives of those from oppressed groups.

Discussion Questions 1. Think about your own practice with racial and ethnic minorities. What do you know about the problems that they experience as a result of oppression? 2. Carniol (1992) suggests “unmasking” oppressive forces is an essential part of the assessment process. Discuss how you would assess both behavioral and environmental attributes with racial and ethnic minority involuntary clients. 3. Models of practice have tended to focus on personal problems or behaviors, instead of the social justice issues that may be present in a

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A Foundation for Work with Involuntary Clients client’s situation. Given these two competing interests, how would you propose to reconcile the differences? 4. In the Ruiz case, the social worker focused on childcare needs rather than educational neglect. What are the potential pitfalls of this shift in focus? Also, would you have handled the case in a different manner? Why or why not? 5. How would you respond to a client who raised issues about race and inequality? References Alexander, M. 2012. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: The New Press. Alexander, R., Jr. 2003. Understanding Legal Concepts That Influence Social Welfare Policy and Practice. Pacific Grove: Brooks- Cole. Alexander, R. 2010. Human Behavior in the Social Environment: A Macro, National and International Perspective. Newbury Park, CA: Sage. Al-Krenawi, A., and J. R. Graham. 2001. “The Cultural Mediator: Bridging the Gap between Non-Western Community and Professional Social Work Practice. British Journal of Social Work 31 (5): 665–685. Anderson, M. L., and P. H. Collins, eds. 2001. Race, Class, and Gender: An Anthology. 4th ed. Belmont, CA: Wadsworth-Thomson Learning. Arrendondo, P. 1999. “Multicultural Counseling Competencies as Tools to Address Oppression and Racism.” Journal of Counseling and Development 77: 102–108. Artiles, A. J., and S. C. Trent. 1999. “The Overrepresentation of Minority Students in Special Education: A Continuing Debate.” The Journal of Special Education 27: 134–142. Baum, D. 2016. “Legalize It All. How to Win the War on Drugs.” Harper’s Magazine. April. https://harpers.org /archive/2016/04 /legalize-it-all/. Beitin, B. K., and K. R. Allen. 2005. “The Multilevel Approach to Integrating Social Justice and Family Therapy.” Journal of Systemic Therapies 24 (1): 19–34. Berman, M., and W. Lowery. 2015. “Analysis of Police Data. The 12 Key Highlights from the Department of Justice’s Scathing Ferguson Report.” Washington Post, March 4, 2015. www .washingtonpost.com/news/post-nation/wp/2015. Berzoff, J. 2011. “Why We Need a Biopsychosocial Perspective with Vulnerable, Oppressed, and At-Risk Clients.” Smith College Studies in Social Work 8 (12): 132–166. Blitz, L.V., M. Pender-Greene, S. Bernabei, and V. P. Shah. 2014. “Think Creatively and Act Decisively: Creating Antiracist Alliance for Social Work.” Social Work 59 (4): 1–4. Breton, M. 2006. “Path Dependence and the Place of Social Action in Social Work. Social Work with Groups 29: 25–44. Bucior, C. 2015. Little Comfort, Little Humanity; University of Wisconsin Milwaukee Expert Explains Toxic Stress. UWM Report. http://uwm.edu /news/little-comfort-little-humanity -uwm-expert-explains-toxic-stress/. Calder, M., ed. 2008. The Carrot or the Stick: Towards Effective Practice with Involuntary Clients in Safeguarding Children Work. Dorset, UK: Russell House Publishing. Carniol, B. C. 1992. “Structural Social Work: Maurice Moreau’s Challenge to Social Work Practice.” Journal of Progressive Human Services 3 (1): 1–20.

Oppression and Involuntary Status Choudhuri, D. 2005. “Oppression of the Spirit.” In Explorations in Privilege, Oppression and Diversity, eds. S. K. Anderson and V. A. Middleton, 127–135. Pacific Grove, CA: Brooks-Cole. Cingolani, J. 1984. “Social Conflict Perspective on Work with Involuntary Clients.” Social Work 29: 442–446. Clifford, D., and B. Burke. 2005. “Developing Anti-oppression Ethics in the New Curriculum.” Social Work Education 87 (2): 677–692. Cohen, A. 2015. “How White Users Made Heroin a Public Health Problem.” The Atlantic. August. https://www.The Atlantic.com/politics archive/2015/08/crack-heroin-and race 404015/ Critical Resistance. 2003. Bureau of Justice Statistics Prison and Jail Fact Sheet, Oakland, CA. Day, P. R. 1981. Social Work, Social Control. London: Tavistock. Dei, G. J. S. 1996. Anti-racism Education. Halifax: Fernwood. De Jong, P., and I. K. Berg. 2001. “Co-constructing Cooperation with Mandated Clients.” Social Work 46: 361–374. Demby, G. 2013. “The Truth Behind the Lies of the Original ‘Welfare Queen.’ ” National Public Radio. Code Switch. www.npr.org /sections/codeswitch/2013/12/20/255589168. Derezotes, D., J. Poertner, and M. F. Testa. 2005. Race Matters in Child Welfare. Washington, DC: Child Welfare League of America Press. Feagin, J. R. 2006. Systemic Racism: A Theory of Oppression. New York: Rutledge. “Ferguson’s Conspiracy against Black Citizens.” 2015. The Atlantic. March. https://www .theatlantic .com /national /archive /2015/03/ferguson-as -a- criminal- conspiracy-against-its -black-residents-michael-brown-department-of-justice-report/386887/. Finn, J. L., and M. Jacobson. 2003. “Just Practice: Steps Toward a New Social Work Paradigm.” Journal of Social Work Education 39 (2): 57–78. Foladare, I. S. 1969. “A Clarification of ‘Ascribed Status’ and ‘Achieved Status.’ ” The Sociological Quarterly, 10 (1): 53–61. Folger, R. 1987. “Distributive and Procedural Justice in the Workplace.” Social Justice Research 1 (2): 143–159. Fong, R., A. Dettlaff, J. James, and C. Rodriguez, eds. 2015. Addressing Racial Disproportionality and Disparities in Human Services. New York: Columbia University Press. Freire, P.  1970. “A Critical Understanding of Social Work.” Journal of Progressive Human Services 22: 3–5. Freire, P. 1998. Pedagogy of the Oppressed. New York: Continuum. Frye, M. 2004. “Oppression.” In Race, Class and Gender in the United States, ed. P. S. Rothenberg, 146–149. New York: Worth. Galper, J. 1975. The Politics of Social Services. Englewood Cliffs, NJ: Prentice-Hall. Gil, D. G. 1978. “Clinical Practice and Politics of Human Liberation.” Catalyst 2: 60–69. Gil, D. G. 1998. Confronting Injustice and Oppression: Concepts and Strategies for Social Workers. New York: Columbia University Press. Gitterman, A., ed. 1995. “Introduction: Social Work Practice with Vulnerable Populations.” In Handbook of Social Work Practice with Vulnerable Populations. New York: Columbia University Press. Greenberg, J., and T. R. Tyler. 1987. “Why Procedural Justice in Organizations?” Social Justice Research 1 (2): 127–143. Guadalupe, K. L., and D. Lum. 2005. Multidimensional Contextual Practice: Diversity and Transcendence. Pacific Grove, CA: Brooks- Cole. Hanna, F. J., W. B. Talley, and M. H. Guindon. 2000. “The Power of Perception: Toward a Model of Cultural Oppression and Liberation.” Journal of Counseling and Development (Fall) 78: 430–441.

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A Foundation for Work with Involuntary Clients Harcourt, B. E. 2001. Illusion of Order: The False Promise of Broken Window Policing. Cambridge, MA: Harvard University Press. Harvey. J., K. A. Case, R. H. Gorsline, eds. 2004. Disrupting White Supremacy from Within. Cleveland, OH: Pilgrim Press. Hasenfeld, Y., and E. E. Garrow. 2012. “Non-profit Ser vice Organizations, Social Rights and Advocacy in a Neoliberal Welfare State.” Social Service Review 86: 295–322. Holland, T. P., and A. C. Kilpatrick. 1993. “Using Narrative Techniques to Enhance Multicultural Practice.” Journal of Social Work Education 29: 302–308. hooks, b. 1984. Feminist Theory from Margin to Center. Edited by M. Marable. Boston: South End Press. Hsia, A. M., and D. Hamparion. 1997. “Disproportionality in Minority Confinement.” Juvenile Justice Bulletin. Washington, DC: U.S. Department of Justice. Hutchison, E. 1987. “Use of Authority in Direct Social Work Practice with Mandated Clients.” Social Service Review 61 (December): 581–598. James, R. K. 2008. Crisis Intervention Strategies. Pacific Grove, CA: Brooks- Cole. James, R. K., and B. F. Gilliland. 2013. Crisis Intervention Strategies. 7th ed. Pacific Grove, CA: Brooks- Cole. Jenson, J. 2000. “Thinking about Marginalization: What, Who, and Why—A Backgrounder.” Ottawa, ON: Canadian Social Policy Networks, 1–14. http://cprn3.library.carleton.ca /documents/15746_en.pdf. Johnson, A. G. 2006. Privilege, Power, and Difference. 2nd ed. Boston, MA: McGraw-Hill. Keyes, K. M., M. Cerda, J. E. Brady, J. R. Havens, and S. Gales. 2014. “Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States.” American Journal of Public Health 104 (2): 52–59. Levin, J. 2013. “The Welfare Queen” Slate.com, December 19, 2013. www.slate.com/articles/news and politics/2013/12lind.tayloe.welfare queen. Retrieved August 6, 2016 Lichtenwalter, S., and P. Baker. 2010. “Teaching Note: Teaching about Oppression through Jenga: A Game-Based Learning Example for Social Work Educators. Journal of Social Work Education 46 (2): 305–313. Linton, R. 1936. The Study of Man: An Introduction. New York: Appleton-Century- Crofts. Lopez, G. E., P. Gurin, and B. A. Nagda. 1998. “Education and Understanding Structural Causes for Group Inequities.” Political Psychology 19 (2): 305–329. Lum, D. 2004. Social Work Practice with People of Color: A Process- Stage Approach. 5th ed. Pacific Grove, CA: Brooks- Cole. Lynch. J. 2016. “EPA Stayed Silent on Flint’s Tainted Water.” Detroit News. January 12. http:// www.detroitnews .com /story /news /politics /2016 /01 /12 /epa - stayed - silent-f lints -tainted -water/78719620/. Margolin, L. 1997. Under the Cover of Kindness: The Invention of Social Work. Charlottesville: University Press of Virginia. Michaels, C. 2010. Historical Trauma and Microaggressions: A Framework for Culturally-Based Practice. Minneapolis, MN: Children, Youth & Family Consortium Children’s Mental Health Program. www.cmh.umn.edu /. Monnat, S. 2016. “Study: Communities Most Affected by Opioid Epidemic also Voted for Donald Trump.” National Public Radio. http://kasu.org /post/study-communities-most -affected-opoid-epedimic. Morton, T. 1999. “The Increasing Colorization of America’s Child Welfare System: The Overrepresentation of African America.” Policy and Practice 57 (4): 23–36. Mullaly, R. 1997. Structural Social Work: Ideology, Theory and Practice. 2nd  ed. Oxford: Oxford University Press.

Oppression and Involuntary Status Nagda, B. A., M. L. Spearmon, L. C. Holley, S. Harding, M. L. Balassone, D. Moïse-Swanson, and S. de Mello. 1999. “Intergroup Dialogues: An Innovative Approach to Teaching about Diversity and Justice in Social Work Programs.” Journal of Social Work Education, 35 (3): 433–449. National Association of Social Workers (NASW). 1999. Code of Ethics. http://www.socialworkers .org /pubs/code/code.asp. Ogawa, B. K. 1999. Color of Justice. Culturally Sensitive Treatment of Minority Crime Victims. 2nd ed. Boston: Allyn and Bacon. Orme, J. 2002. “Social Work: Gender, Care and Justice.” British Journal of Social Work 32: 799–814. Pharr, S. 1988. Homophobia: A Weapon of Sexism. Inverness, CA: Chardon. Pinkney, C. 2012. The Effects of Internalized Oppressions on the Black Community. http:// writingandrhetoric.cah.ucf.edu /stylus/files/kws2/KWS2 _ Pinkney.pdf. Powell, E. C. 2006. The Political Use of ‘Family Values’ Rhetoric. Atlanta: Georgia State University. http//scholarworks.edu /communities-thesis/17. Pyke, K. D. 2010. “What Is Internalized Racial Oppression and Why Don’t We Study It? Acknowledging Racism’s Hidden Injuries.” Sociological Perspectives 53 (4): 551–552. Reamer, F. G. 1994. Social Work Malpractice and Liability: Strategies for Prevention. New York: Columbia University Press. Reamer, F. G. 2005. “Ethical and Legal Standards in Social Work: Consistency and Conflict. Families in Society 86 (2): 163–169. Reid, W. J. 2002. “Knowledge for Direct Social Work Practice: An Analysis of Trends.” Social Service Review (March): 6–33. Reisch, M. 2002. “Defining Social Justice in a Socially Unjust World.” Families in Society 83: 324–354. Resnikoff, N. 2015. “Why Riots Happen in Places Like Baltimore”. Al Jazeera America. April 28. http://america.aljazeera.com /articles/2015/4 /28/why-riots-happen-in-places-like-baltimore .html Roberts, D. 2002. “Racial Disproportionality in the U.S. Child Welfare System: Documentation, Research on Causes and Promising Practices.” Working paper no. 4. Baltimore, MD: Annie E. Casey Foundation. Rooney, R. H. 1992. Strategies for Work with Involuntary Clients. New York: Columbia University Press Rooney, R. H. 2009. Strategies for Work with Involuntary Clients. 2nd ed. New York: Columbia University Press. Rooney, R.H., and A. A. Bibus. 2000. “Clinical Practice with Involuntary Clients in Community Settings.” In Social Work Practice: Treating Common Client Problems, eds. H. E. Briggs and K. Corcoran, 393–406. Chicago: Lyceum Books. Saleeby, D. S. 1996. “The Strengths Perspective in Social Work Practice: Cautions and Extensions.” Social Work 41 (3): 296–305. Sandee, J. 2016. “When Blood Pressure Is Political.” New York Times. August 7, 38. Schmitz, C. L., C. Stakeman, and J. Sisneros. 2001. “Educating Professionals for Practice in a Multicultural Society: Understanding Oppression and Valuing Diversity.” Families in Society, The Journal of Contemporary Human Services 82 (6): 612–622. Segal, E. 2010. Social Welfare Policy and Social Programs: A Values Perspective. Belmont, CA: Brooks- Cole. Stamper. N. 2016. To Serve and Protect. New York,: Nation Books. Stewart, P.  2004. “Afrocentric Approaches to Working with African American Families.” Families in Society, The Journal of Contemporary Human Services 85 (2): 221–228.

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A Foundation for Work with Involuntary Clients Townsend, B. 2000. “The Disproportionate Discipline of African American Learners and Related School Suspension and Experience.” Exceptional Children 66: 381–391. Trotter, C. 2013. Working with Involuntary Clients: A Guide to Practice. 3rd ed. New York: Rutledge Tyler, T. R. 1989. “The Psychology of Procedural Justice: A Test of the Group Value Model.” Journal of Personality and Social Psychology 57 (5): 830–838. U. S. Department of Education. 2014. School, Restraint and Seclusion Highlights, Data Snapshots. Issue Brief Number 1 (March). Washington DC: Office for Civil Rights. https//:www .ocrdata.ed.gov.U. S. Department of Justice. 2016. “Investigation of the Baltimore City Police Department.” Office of Public Affairs Press Release. August 10. Washington DC: Civil Rights Division. https://www.justice.gov/opa /file/883366/download. Van Soest, D., and B. Garcia, eds. 2003. Diversity Education for Social Justice. Alexandria, VA: Council on Social Work Education. Van Voorhis, R. M. 1998. “Culturally Relevant Practice: A Framework for Teaching the Psychosocial Dynamics of Oppression.” Journal of Social Work Education 34 (1): 121–133. Vodde, R., and J. P. Gallant. 2002. “Bridging the Gap between Micro and Macro Practice: Large-Scale Change and a Unified Model of Narrative-Deconstructive Practice.” Journal of Social Work Education 38 (3): 439–458. Walsh, J. 2003. “The Psychological Person: Cognitions, Emotions and Self.” In Dimensions of Human Behavior. Person and Environment, 2nd ed., ed. Elizabeth D. Hutchinson. Thousand Oaks, CA: Sage. Wambach, K. G., and D. Van Soest. 1997. “Understanding Oppression: Linking Knowledge to Practice. What Social Work Students Must Know and Care About Oppression.” In Encyclopedia of Social Work. Supplement to 19th ed. Washington, DC: National Association of Social Workers. Weinberg, M. 2006. “Pregnant with Possibility: The paradoxes of ‘Help’ as Anti- Oppression and Discipline with a Young Single Mother.” Families in Society 67 (2): 161–169. White, M., and D. C. Epston. 1990. Narrative Means to Therapeutic Ends. New York: W. W. Norton. Whyte, W. H. 1956. The Organization Man. New York: Simon and Schuster. Williams, O. J. 1994. “Group Work with African American Men who Batter: Toward a More Ethically Sensitive Approach.” Journal of Comparative Family Studies 25: 91–104. Wilson, A., and P. Beresford. 2000. “Anti-oppressive Practice: Emancipation or Appropriation?” British Journal of Social Work 30: 553–573. Yang, M. C. 2008. “Exploring Cultural Tensions in Cross- Cultural Social Work Practice.” Social Work 53 (4): 317–327. Young, I. M. 2004. “Five Faces of Oppression.” In Oppression, Privilege, and Resistance, eds. L. Heldke and P. O’Connor. Boston: McGraw-Hill.

Chapter 6

Trauma-Informed Care with Legally Mandated Involuntary Clients

Joan M. Blakey

Trauma and its repercussions have received increased attention in recent years. A great deal of effort has been made to modify ser vices and systems to ensure that certain segments of the population that have experienced trauma, such as children, veterans, and other individuals who voluntarily seek ser vices, can maximize the benefits these ser vices and systems provide (Hummer, Dollard, Robst, and Armstrong 2010; Ko et al. 2008). Yet for other segments of the population, such as legally mandated involuntary clients (e.g., parents who are involved with the child protection system; individuals in the criminal justice system), little has been done to explore the intersection of trauma among these types of clients and modify ser vices to make them more trauma informed (Blakey and Bowers 2014; Covington et al. 2008; Killeen et al. 2008; Morrissey et al. 2005; Najavits et al. 2008; Sacks et al. 2013). Once individuals enter the child protection or criminal justice system, they often are seen and treated as perpetrators and criminals, despite their histories of victimization (Miller and Najavits 2012). Consequently, many practitioners who work with legally mandated involuntary clients believe that because they may have broken a social norm (e.g., child maltreatment) or the law (e.g., prostitution and drug-related crime) they are less deserving of traumainformed ser vices and should be grateful for whatever ser vices or treatment they receive. The problem with this belief is that many practitioners and systems continue to treat trauma-informed care as a privilege. Yet if we as a society truly want to reduce incidences of child abuse and neglect, decrease

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A Foundation for Work with Involuntary Clients recidivism, and create a healthier society, we must make trauma-informed care a “right” for everyone, not just a privileged few. This chapter examines the ways that trauma-informed practice is different than traditional practice with legally mandated involuntary clients, explores the prevalence of trauma among certain involuntary populations, discusses trauma-informed principles, and identifies strategies practitioners can use when working with legally mandated involuntary clients.

Degrees of Involuntariness Legally mandated involuntary clients have been defined as individuals who feel forced, coerced, or pressured, formally or informally, to engage in a helping relationship or participate in ser vices because the risk of losing someone or something is too high or there is a lack of attractive alternatives (Rooney 2009). There are two types of involuntary clients—legally mandated and nonlegally mandated (the latter group is socially pressured to seek ser vices). This chapter focuses on legally mandated involuntary clients who are court ordered to participate in ser vices provided by public social ser vice agencies, human ser vice departments, child protective ser vices, and mental health and criminal justice systems. Among legally mandated involuntary clients, there are degrees of involuntariness. Individuals in substance abuse treatment settings are generally the least involuntary, followed by individuals who are involved with child protection, and finally, individuals involved with criminal justice settings. The degree of involuntariness is important for several reasons. First, the degree of involuntariness often is related to the level of consequences experienced (e.g., being kicked out of treatment versus losing custody of your children versus being incarcerated). Second, the degree of involuntariness can affect the level of input and choice individuals have in their treatment and ser vices received. Third, the degree of involuntariness often influences the rights individuals have as well as the extent to which those rights are respected by others. Finally, the degree of involuntariness often affects the extent to which practitioners are willing to move from a traditional or services-as-usual approach to trauma-informed care.

Services-as-Usual Approach with Legally Mandated Involuntary Clients When social ser vice professionals, law enforcement, or other practitioners interact with legally mandated individuals who are believed to have broken a

Trauma-Informed Care with Legally Mandated Involuntary Clients social norm such as maltreating their children or the law, the individual’s behavior is believed to be “the problem.” Therefore, correcting the behavior and/or punishing any wrongdoing becomes the focus of the intervention. Often, the only information that practitioners have is related to the identified problem. They tend to have limited information regarding the background of the individual, particularly as it relates to trauma histories. They often have no formal way of gathering additional information that might be related to the problem (Killeen et al. 2008; Morrissey et al. 2005; Najavits et al. 2008). The necessary forms and procedures are completed and treatment plans are created, often with very little input from the client. If clients are fortunate, they receive an evaluation or psychological assessment. However, this information often is used to support and substantiate the action taken against the individual rather than social ser vice professionals, law enforcement, or correctional officers utilizing the information to change their approach. The intervention is almost entirely focused on changing the individual’s problematic behavior (Blakey and Bowers 2014; Harris and Fallot 2001). If legally mandated involuntary clients’ trauma history comes to the attention of social ser vice professionals, law enforcement, or correction officers, it is often viewed as an isolated event that is in the past and thus believed to have no bearing on the “current problem” (Harris and Fallot 2001). If clients raise trauma as an important factor, they are believed to be avoiding the problem or not taking responsibility for their actions (ibid.). Individuals are instructed to deal with the “real” problem and only then will helping professionals or law enforcement focus on other things such as past trauma, provided the system has the capacity to address concurrent issues (Blakey and Bowers 2014; Harris and Fallot 2001). Service-as-usual approaches often exacerbate trauma for several reasons. First, many of the practices in this approach can be traumatic and add to existing trauma histories that many legally mandated involuntary clients bring into social ser vice and correctional settings. Ryan, Bashant, and Brooks (2006) refer to this as system generated trauma. For example, The public institutions and ser vice systems that are intended to provide ser vices and supports to individuals . . . use coercive practices, such as seclusion and restraints, in the behavioral health system; the abrupt removal of a child from an abusing family in the child welfare system; the use of invasive procedures in the medical system; the harsh disciplinary practices in educational/school systems; or intimidating practices in the criminal justice system can be re-traumatizing for individuals who already enter these systems with significant histories of trauma. (Substance Abuse and Mental Health Administration [SAMHSA] 2014b:2)

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A Foundation for Work with Involuntary Clients Second, many such ser vices that legally mandated involuntary clients participate in use shame-based practices as a central part of the intervention. Shame is an emotion that is meant to make people feel bad enough to correct a problematic behavior. Shame-based practices tend to do the opposite. They focus on the person as bad rather than the behavior. Shame-based practice begins with the ways in which these individuals often are characterized, such as unfit mothers, perpetrators, offenders, criminals, child abusers, and prostitutes. These labels describe what the person is rather than what the person has done. In addition to the shame individuals already feel, shame is reinforced through every interaction they have with helping professionals. Shame-based practices are a form of penance (constant awareness of their defects) from which legally mandated involuntary clients can never escape. Shame is dangerous if left unchecked because it reinforces that individuals’ faults are permanent defects, thereby thwarting any incentive to change. Finally, the service-as-usual approach often fails to consider and incorporate new evidence-supported practices because practitioners embrace the philosophy of “if it ain’t broke, don’t fix it.” For example, an integrated approach (i.e., treating the substance abuse and trauma simultaneously), is considered best practice in substance abuse treatment. A study conducted by Blakey and Bowers (2014) found that a primary reason substance abuse counselors failed to integrate trauma-informed principles in their practice was because they believed trauma-informed practice coddles individuals thereby holding them less accountable for their actions. Many of them believed that the use of confrontational techniques more effectively broke through clients’ denial. However, the more practitioners used these confrontational techniques, the more the clients shut down or dissociated in an attempt to protect themselves from the abuse (Elliot et al. 2005). Despite evidence that confrontational ways of treatment worsen individuals’ experiences of trauma, practitioners remained wedded to these practices (Blakey and Bowers 2014). If legally mandated involuntary clients are not benefiting from the services despite their willingness to participate, it is believed that they are the problem rather than the ser vices or ser vice providers. Research shows that the absence of a trauma-informed approach is “the equivalent of denying the existence and significance of trauma in clients’ lives” (Elliot et al. 2005:462). Service-as-usual approaches do not work with legally mandated involuntary clients who have histories of trauma (Harris and Fallot 2001). There is a need for social and human ser vice systems to incorporate trauma-informed care principles into practice with the goal of creating trauma-informed systems of care.

Trauma-Informed Care with Legally Mandated Involuntary Clients

Trauma-Informed Care with Legally Mandated Involuntary Clients Trauma-informed care emerged as an alternate paradigm to the services-asusual approach in which individuals seeking mental health and social ser vices were provided with specialized ser vices that considered their histories of trauma and how it would affect their ability to benefit from ser vices. Service-as-usual paradigms asked individuals who sought ser vices “What is wrong with you?” Trauma-informed ser vices asks individuals “What has happened to you?” (Salasin 2011). Trauma-informed care “thoroughly incorporates, in all aspects of ser vice delivery, an understanding of the prevalence and impact of trauma and the complex paths to healing and recovery” (Fallot and Harris 2009:2). Traumainformed care should result in a profound shift in which clients are viewed differently, practitioners respond compassionately, and the day-to-day ser vices are delivered in ways that are sensitive to clients’ histories and experiences (Jennings 2004). Trauma-informed care is a paradigm shift in which legally mandated involuntary clients who have histories of trauma are best served by practitioners, organizations, and systems that: 1. 2. 3. 4.

understand what trauma is, realize the widespread prevalence of trauma, recognize the ways trauma impacts clients’ lives, and integrates knowledge about trauma by modifying ser vices, policies, procedures, and practices. (Brown, Harris, and Fallot 2013; SAMHSA 2014a)

Understand What Trauma Is Increasingly, our understanding of trauma has become more mainstream, which has raised our overall awareness of trauma. Unfortunately, trauma is increasingly being used to describe a wide array of events (Haslam 2016). It is not unusual to hear individuals refer to any unpleasant experiences (e.g., bad hair day, tough test, or other challenges) as traumatic (Haslam 2016). Using trauma in this way diminishes the experiences of individuals who have survived war, domestic violence, rape, witnessing someone murdered, natural disasters such as Hurricane Katrina, as well as abuse and neglect. According to the Substance Abuse and Mental Health Ser vices Administration (SAMHSA), trauma is an event, series of events, or set of circumstances that result in harm and/or the threat of harm or death that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being (SAMHSA 2014b). Traumatic events are extraordinary because they overwhelm

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A Foundation for Work with Involuntary Clients human beings’ ability to cope with life and cause them to feel intense hopelessness, helplessness, and terror (Herman 1997). Terr (1991) proposed that there were two types of trauma. Type I trauma includes individuals who experience a single trauma event such as being raped, witnessing a murder, or involvement in a tragic car accident or natural disaster. Type II trauma results from exposure to extreme, repeated events such as multiple rapes, repeated childhood physical and sexual abuse, and ongoing neglect due to a parent who has mental health or substance abuse issues. Those who experience type II trauma generally have some lasting memories of the experience and have developed coping mechanisms such as denial, repression, dissociation, and aggression. Solomon and Heide (1999) created an additional category of trauma (type III, complex trauma). Their clinical experiences and the previous work of Herman (1997) and others required a term that more accurately reflected individuals who experience prolonged, repeated, ongoing abuse such as being kidnapped or held hostage for extended periods of time, prisoners of war or concentration camps, religious cult survivors, and individuals who were subjected to prolonged and pervasive types of abuse and neglect such as domestic violence, childhood physical and sexual abuse, and organized sexual exploitation (Herman 1997). There also were concerns that many individuals were being misdiagnosed as having other mental health disorders with strong negative connotations such as borderline, antisocial, and multiple personality disorders as well as major depression and schizophrenia when the real causes of symptoms—high exposure to multiple forms of prolonged trauma—was not addressed (Herman 1997; Markoff et al. 2005; Sacks et al. 2008). In many cases, inaccurate diagnoses led practitioners to see these individuals in stigmatizing ways. For example, child abusers were seen as neglectful, heartless, manipulative, and undeserving, were thrown away or hated by society instead of viewed as individuals with significant histories of trauma (Herman 1997). The majority of legally mandated involuntary clients are in the type III category (Blakey and Hatcher 2013). The main difference between the three types is that type III (complex trauma) often results in more severe psychological harm; higher levels of distress; more difficulty regulating affective impulses such as anger; more pervasive symptomology related to somatization, depression, suicidality, self-mutilation, drug addiction and alcoholism; more prolonged dissociative states; increased negative self-perception; and strained or difficulty forming and maintaining relationships with others (Courtois and Ford 2009; Herman 1997; Hien et al. 2009). Consequently, many individuals who have experienced complex trauma tend to have more impairments, severity, chronicity, and hard-to-treat effects and therefore are less responsive to treatment than individuals who experience a single traumatic episode (Cohen and Hien 2006; Cottler, Nishith, and Compton 2001; Herman 1997; Sacks et al. 2008).

Trauma-Informed Care with Legally Mandated Involuntary Clients Factors That Exacerbate Trauma Additionally, Vogt, King, and King (2007) found that individuals who live in certain communities, are members of certain minority groups, or live in certain societies often experience cumulative adversities that worsen the impact of complex trauma. These experiences include, but are not limited to: • Economically impoverished individuals • Historical and intergenerational trauma among people of color such as mass killing of Native Americans and slavery (Walters, Simoni, and Evans-Campbell 2002) • Experiences of gender and sexual violence, e.g., many transgender individuals experience violence and discrimination (Lombardi 2001) • Being incarcerated • Homelessness • Victims of genocide, ethnic cleansing, torture, or displacement • Developmentally, intellectually, or psychiatrically challenged individuals • Veterans, civilian workers, or soldiers (men and women) who experience military sexual trauma, harassment or are assaulted in the line of duty or in the ranks (U.S. Department of Veterans Affairs 2010) • Emergency responders who are repeatedly exposed to grotesque death and suffering (Courtois and Ford 2009)

Realize the Widespread Prevalence of Trauma Among Involuntary Client Populations Trauma survivors make up the majority of clients in human ser vice systems (Browne and Finkelhor 1986; Finkelhor 1986; Kessler et al. 1995; Najavits, Weiss, and Shaw 1997; Neumann 1994; Polusny and Follette 1995). Legally mandated involuntary clients with experiences of trauma are involved with multiple service sectors. For many legally mandated involuntary clients, trauma begins in childhood and is compounded by adult experiences of trauma. Over 70 percent of involuntary clients with histories of trauma experienced five to twelve different traumatic events over the course their lives (Blakey and Hatcher 2013; Kubiak 2005). In fact, it can be argued that many legally mandated involuntary clients’ involvement with human ser vice systems results from these traumatic experiences.

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A Foundation for Work with Involuntary Clients Child Welfare A significant number of parents (30–100 percent) who become involved with the child welfare system have experienced at least one traumatic event (Blakey and Hatcher 2013; Chemtob et al. 2011; Haight et al.2005). In fact, 73 to 85  percent of parents reported multiple experiences of trauma with 19 to 42  percent of parents reporting five or more traumatic events (Blakey and Hatcher 2013; Chemtob et al. 2011). The most common types of trauma reported were intimate partner violence (81  percent); nonsexual assault by a family member (60  percent), rape (38  percent), childhood sexual abuse (34–54  percent), unspecified traumatic events (34  percent), physical abuse (31  percent), car accident (28  percent), nonsexual assault by a stranger (22 percent), and sexual assault by a family member (21 percent) (Blakey and Hatcher 2013; Chemtob et al. 2011). Case Example Barbara is a thirty-eight-year-old African American woman and the mother of eleven children who range in age from two months to twenty years old. Barbara was adopted when she was six weeks old through the public child welfare system. She grew up with one brother and a lot of foster kids who came in and out of the home over the years. Barbara was sexually abused by one of her foster brothers when she was five until he left the home when she was six. Barbara never told anyone until she was in her early thirties. Barbara did not know she was adopted until she was ten or eleven. On this particular occasion, she was spanked for misbehaving. Out of her mother’s anger, she told Barbara “that is why you don’t have none of my blood in you. You just like your crack head momma.” Barbara said “from that day on I took it as I don’t have to listen to her. I started hanging out with the bad crowd ended up on drugs at twelve years old. I started hanging out. I’d run away on the weekends to hang out and go to clubs. I did every thing I could to rebel against my parents.” Barbara started by using syrup with codeine and gradually moved to heroin. In the tenth grade, she decided to drop out of school and run away for good. Barbara’s friend Jane introduced Barbara to her pimp. They started prostituting and getting high. While on the street, Barbara was kidnapped and raped repeatedly. One time, she was raped and left for dead in an abandoned drug house. A couple months later, Barbara found out that she was pregnant. She was sixteen at the time. Even though the baby was a product of rape, she decided to keep the baby. Her adoptive mother took her son and raised him as her child. Barbara continued to prostitute. She described how her pimp would beat her and the other women to keep them submissive and compliant. When she could no longer get the kind of money she once did from prostituting, she started forging checks, stealing from stores, and robbing

Trauma-Informed Care with Legally Mandated Involuntary Clients people, basically doing anything she could to get money for drugs. Four of her eleven children were born substance exposed. All of her children except for her eldest son and the twins were adopted. She often cries because she can’t remember what her other children look like. She said, “If I saw my children on the street, I would not even recognize them.” The most recent pregnancy resulted in twins and she fought for custody. She became involved with child protection because she gave birth to substance-exposed infants. As part of her case plan, she was required to participate in and complete substance abuse treatment as well as a host of other ser vices. I met Barbara through her involvement with the child protection system.

Substance Abuse Treatment Individuals with histories of addiction also have significant histories of trauma. Studies report that as many as 85 percent of women with histories of substance abuse have experienced some form of trauma (Markoff et al. 2005; Sacks, McKendrick, and Banks 2008; Savage et al. 2007). Many individuals entering substance abuse treatment report multiple experiences of trauma with some individuals identifying as many as ten different incidents of trauma in their lifetime (Farley et al. 2004; Kubiak 2005; Savage et al. 2007). Individuals commonly reported physical abuse (10–82 percent); sexual abuse (23–82 percent); rape (18–80  percent); and intimate partner violence (30–75  percent) (Cohen and Hien 2006; Elliott et al. 2005; Huntington, Moses, and Veysey 2005; Jones 2004; Markoff et al. 2005; Najavits et al. 2004; Sacks et al. 2008; West 2002). The variation in the percentages reported can be attributed to the different ways in which studies define trauma, sample size, and other study design issues (McCauley et al. 1997).

Case Example Vickie is a twenty-six-year-old African American woman from the South. When Vickie was five years old, she witnessed the death of her mother and brother, who were murdered. After their deaths, she went to live with her father who sexually abused her from until she was twelve years old. When Vickie’s paternal grandmother found out that she was being sexually abused by her son, she brought Vickie to live with her. Although the abuse no longer occurred, the father remained in her life until her grandmother’s death when Vickie was sixteen. Following her grandmother’s death, and without alternatives, Vickie became homeless and began prostituting to support herself. When she was eighteen she had her first son. She became involved with child protection because her son was born substance exposed. Vickie lost custody of her son for failing to complete any of the conditions of her case plan including

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A Foundation for Work with Involuntary Clients remaining abstinent. Vickie continued to engage in prostitution to support herself and her drug habit. While on the streets, she was raped multiple times. In an altercation with another woman, the woman cut her throat and part of her face. After healing from these injuries, Vickie was able to get her life together for a brief period of time. Within two months, she met Mike and they decided to move to another city to be with Mike’s family with the goal of getting their lives together. Shortly after her twenty-fifth birthday, Vickie found out that she was pregnant. She managed to stay clean throughout most of her pregnancy, but relapsed in her eighth month. As a result, she went into labor and gave birth to her daughter who was born substance exposed. Vickie was able to retain custody of her daughter as long as she agreed to participate in a substance abuse treatment program and never leave the facility with the baby. Vickie’s child protection worker deemed that Vickie was a flight risk and was fearful that if she was allowed to leave with the baby she would disappear because she lacked significant ties to the community. I met Vickie at the substance abuse treatment center in a large city.

Criminal Justice There is a high prevalence of trauma among incarcerated women and men (Blaauw et al. 2002; Carlson and Shafer 2010; Clements-Nolle, Wolden, and Bargmann-Losche 2009; Jordan et al. 1996; Richie 1996; Sered and NortonHawk 2008). The most common experience of trauma among incarcerated women is neglect-abandonment, sexual and physical abuse, domestic violence, and sexual assault by nonintimate partners (Clements-Nolle, Wolden, and Bargmann-Losch 2009; Richie 1996; Sered and Norton-Hawk 2008). Whereas men in the criminal justice system commonly experienced sexual abuse, physical maltreatment, emotional maltreatment, abandonment, and suicide attempts (Blaauw et al. 2002). Childhood physical abuse among both men and women was experienced by 11 to 73 percent (Carlson and Shafer 2010; Harlow 1999; Pollock, Mullings, and Crouch 2006); sexual abuse by 11 to 80  percent (Carlson and Shafer 2010; Harlow 1999; McDaniels-Wilson and Belknap 2008); domestic violence by 25 to 96 percent; and adult sexual assault by 25 to 89 percent (Carlson and Shafer 2010; McDaniels-Wilson and Belknap 2008; Pollock, Mullings, and Crouch 2006). Additionally, Carlson and Shafer (2010) reported that death of children and sex trafficking were common among incarcerated women.

Case Example Sasha is a twenty-two-year-old white women who was incarcerated because of a parole violation. Sasha grew up poor. Her mother and father, both of

Trauma-Informed Care with Legally Mandated Involuntary Clients whom were addicted to drugs and alcohol, not present in the lives of their children. Her older sister April raised Sasha and her siblings. April was ten years older than Sasha and had been prostituting since she was twelve to provide for Sasha and her siblings. April was Johnny’s “bottom bitch.” In this position, April helped recruit women and keep them in line in exchange for more of the benefits (e.g., nicer treatment, freedom to come and go, more profits). One day April let Sasha come with her to work. April’s “boyfriend” liked Sasha. He started being nice to her and buying her expensive presents. Sasha said, “He treated me like a queen.” Sasha became his newest girlfriend. Sasha said, “April got jealous at the attention that I was getting and convinced Johnny that he could get a lot of money for me.” Gradually, Sasha started dating more and more men. Sasha indicated that she has slept with as many as fifteen men per night. Sasha indicated that she got “pregnant on purpose” so she could get a break. However, she was forced to sleep with men up until her seventh month when she really started to show. After having the baby, she was hospitalized for three days. The day she was released from the hospital, she was forced to sleep with men. She said, “I had to sleep with men stitches and all.” This is when Sasha realized that Johnny did not love her. Every thing (diaper, formula, clothes) that Johnny provided for his daughter, she had to pay off by sleeping with men. He would never let her leave with the baby. If she left, she had to leave the baby with him. He told her that if she told anyone about him, she would never see her daughter again. One day, she escaped while Johnny was asleep. She took her baby to a friend and a former john who took an interest in her. In order to make money, she started prostituting. She was arrested for drug possession and prostitution. Since this was a violation of her parole, she was put in jail to serve the remainder of her time. These are three examples of legally mandated involuntary clients who have complex histories of trauma. These women, like so many others, experienced abuse and neglect as children, which contributed to their adult experiences of abuse. Although these women may have acted in ways that put their children or community at risk, they are victims. Asking the question “What happened to you?” allows for a more compassionate and empathetic response. Using these three examples, the next section will discuss the ways in which trauma impacts legally mandated involuntary clients’ lives.

Recognizes the Ways Trauma Impacts Clients’ Lives Individuals who have histories of trauma experience myriad effects. Trauma affects every person differently. What may be traumatic for one person may not be traumatic for another. This explains how two people who experience the same incident can be impacted differently. A traumatic experience for one

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A Foundation for Work with Involuntary Clients person might be an unfortunate event for someone else. Additionally, trauma manifests itself differently in survivors. It is not completely understood why some traumatized individuals have more physical effects while other individuals have more psychological events. Nonetheless, there are common effects of trauma and most traumatized individuals will experience one or more of them. The Most Common Effects of Trauma The effects of trauma can be psychological, emotional, physical, relational, and spiritual. These effects become problematic when they begin to interfere with the ability to perform daily tasks and routines as well as cope with what has happened to traumatized individuals. These effects can be expressed externally or internally. External expressions of trauma are directed primarily at other people or expressed outwardly. While internal expressions of trauma are directed primarily inward and effect individuals’ self-perception and what they do to themselves. Table 6.1 identifies the most common effects of the three types of trauma. Legally mandated involuntary clients who do not have experiences of trauma can experience feelings of anger, hostility, resentment, and a host of others (Rooney 2009). These effects often are magnified for legally mandated involuntary clients with histories of trauma. Whether trauma is expressed externally or internally is significant because external expressions of trauma tend to lead to harsher, more serious consequences. For example, Blakey and Hatcher (2013) found that 92  percent of traumatized women who were involved with child welfare and expressed trauma externally lost custody of their children. The most common external expressions of trauma are anger or hostility, a lack of trust, poor decision making, dishonesty, and manipulation. External expressions of trauma such as rage, anger, and hostility can make mental health practitioners, law enforcement, and social workers feel threatened or uncomfortable. From the practitioner’s perspective, it is challenging to be the target of someone else’s anger, particularly when the professional did not do anything to cause such a response. Moreover, the lying, manipulation, lack of trust, and poor decision making often cause the professionals to question whether legally mandated involuntary clients were invested in and ready to change the problematic behaviors that had led to their involvement with the social ser vice and criminal justice systems. These external expressions of trauma made it difficult for the professionals to help the women, particularly when their efforts were constantly met with anger, lack of trust, dishonesty, and manipulation. Consequently, many of the social ser vice professionals did the bare minimum (e.g., saw clients once per week or month, completed the treatment or case plans). They did not go above and beyond for clients and tended not to give them the benefit of the doubt. Some actively stopped trying to help their clients (Blakey and Hatcher 2013).

Table 6.1

Effects of Trauma

Effects

Type I

Type II

Type III

INTERNAL Full detailed memory

X

V

X

PTSD symptoms

X

X

X

Denial

V

X

Repression

V

X

Emotional numbing

V

X

Poor self-esteem/self-concept

X

X

High anxiety

V

X

V

X

V

X

X

X

Foreshortened sense of the future

V

X

Affective dysregulation

V

X

Self-injury

V

X

Eating disturbances

V

X

Substance abuse

V

V

Narcissism

V

X

Identity confusion

V

X

Dissociative symptoms

V

X

Self-sabotage

V

X

EXTERNAL Interpersonal distrust

X

X

Superficial relationships Dependency Anger/hostility Rage Irritability/agitation

V V X V X

X V X X X

Poor decision making

V

X

Lying/dishonesty

V

X

Manipulation

X

X

Chronic depression

V

Suicidality Feelings of shame

V

V

Source: Adapted from Solomon and Heide (1999). Note: V = varies; X = typically

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A Foundation for Work with Involuntary Clients Vickie felt that she was constantly under a microscope and that everyone was waiting for her to mess up so they could take her baby. Vickie primarily had externalizing behaviors. Vickie was angry most of the time and hostile toward treatment staff, her child protection caseworker and her caseworkers’ supervisor. If she did not respect you, she would not even acknowledge your presence. There were many times I saw Vickie simply walk away from someone who was talking to her. She was unable to accept feedback and felt that treatment was a waste of time. She had a hard time participating in groups because every thing that everyone said was “dumb or uneducated” or “pathetic.” According to Vickie, she was nothing like the other women in the treatment program. She could not understand why she had to participate in treatment because she could stop whenever she wanted to. She just did not want to stop. Vickie had some redeeming qualities. If she liked you, she would listen. Oftentimes, it did not change what she did, but she would at least hear you out. She was very spiritual. Her faith in God was miraculous in a lot of ways. Her faith in God strengthened my resolve and faith. She was a good mother. She loved her daughter so much. She was attentive and nurturing. She had a good sense of humor. She was from the South and had funny sayings and ways of putting things. However, most people did not get to see this side of Vickie. In the end, her hostility, anger, and unwillingness to listen to feedback contributed to her losing custody of her daughter. Once Vickie’s daughter was taken (i.e., her primary motivation for getting her life together), she left treatment. Two months later, Vickie was killed by a drug dealer for stealing drugs. He saw her on the street and shot her. He then turned his car around, ran over her body, and kept driving. Internalizing behaviors can include depression, negative view of self, shame, need for constant validation, limited dreams, and self-sabotage. Practitioners are better equipped to address and deal with internal expressions of trauma. In fact, almost all of the training that practitioners receive teaches them how to deal with internal expressions of trauma. Consequently, professionals are much more comfortable dealing with internalizing behaviors (Blakey and Hatcher 2013). Legally mandated involuntary clients who express trauma internally tend to be a lot less threatening, are easier to work with, and have a strong desire to make lasting changes in their lives. There were times when the professionals became frustrated by these women because they required a lot of their time and needed constant validation. They often did not trust themselves to make a move without seeking someone else’s advice and therefore checked in with the professionals at every turn. Nonetheless, these individuals often were more open to help. They incorporated the feedback they received from professionals and were able to make noticeable changes when their depression or lack of self-esteem did not interfere with their goals. As a result, the professionals went above and beyond to help the women. They often became cheerleaders and were a source of motivation for the women.

Trauma-Informed Care with Legally Mandated Involuntary Clients Barbara primarily expressed trauma internally. She had a negative view of herself. She did not believe in herself or her abilities. She was either depressed and crying or in need of constant reassurance and validation. She did not trust herself or her ability to make good decisions. Barbara relapsed while in treatment. She left for two days and went on a drug binge. This happened after a court hearing in which she felt that the whole court session was about the father or her children and needing to find him. She felt that the judge and her child protection worker did not acknowledge the progress she had made. She took this lack of acknowledgment to mean that the did not care about her. She left the court hearing and went on a two-day drug binge. When she returned to the drug treatment program, her counselor processed all of this with her. Barbara then became withdrawn and depressed. She felt that she had sabotaged any chance to regain custody of her children. Her counselor worked hard to get her to see how she was getting in her own way and that she could still turn things around. Her counselor often remarked on how exhausting it was to work with Barbara because she needed so much time and encouragement. In the end, Barbara was able to regain custody of her twins. Her child protection caseworker and substance abuse treatment counselor were invested in Barbara and did whatever they could to help her to be successful. Some clients like Sasha express trauma externally and internally. Her response depends on the circumstances. Depending on the stressor, she may be withdrawn, sullen, and keep to herself. Some days she would cry all day long. Other days, if someone said something negative to her, she would explode. The guards would have to break up fights between her and the other inmates. Sasha said, “maybe I do have bipolar because some days I am depressed and other days I just go off.” In many ways, legally mandated involuntary clients who expressed trauma externally and internally are unpredictable, as it is difficult to know how they will respond or what will set them off. Because of their unpredictability, they most often are treated similarly to clients who express trauma externally. The effects of trauma experienced by legally mandated involuntary clients are often misunderstood by professionals. In the absence of a deeper understanding of trauma, many of the expressions of trauma among these clients are interpreted by professionals as negative and pathological. Viewing trauma in this way disadvantages clients and often leads to negative outcomes such as losing custody of their children, being kicked out of treatment, or being incarcerated or taken to solitary confinement, which only exacerbates the trauma. It is impor tant for practitioners to know the possible ways that trauma manifests itself. When practitioners observe or experience perplexing behaviors, it is important for them to ask themselves, “Could this behavior be linked to an experience of trauma?” It also is important to understand that the externalizing behaviors should not be taken personally. Hostile behavior in these cases should n t be judged according to what you would or would not

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A Foundation for Work with Involuntary Clients do. While their behavior may be perplexing, it makes rationale sense to them. There is a reason for the behavior or response. It is important for practitioners to set their feelings aside and try to understand why clients may be responding in a par ticu lar way and find creative, nonjudgmental ways of helping them to understand why they made that choice, the consequences of that choice, and how to make choices that are better aligned with their intended goals.

Integrate Knowledge about Trauma by Modifying Ser vices, Policies, Procedures, and Practices Since practitioners, organizations, and systems of care often are unable to distinguish between legally mandated involuntary clients who have histories of trauma and those who do not have these histories, best practice recommends treating all clients as if they might be trauma survivors (Elliot et al. 2005). Modifying ser vices, policies, procedures, and practices certainly will benefit all legally mandated involuntary clients who are required or mandated to seek assistance. However, “they are absolutely essential for trauma survivors who may not be able to participate or benefit from ser vices without them” (Elliot et al. 2005:464). Nonetheless, there is a dearth of concrete examples available in the literature that operationalize trauma-informed principles when working with legally mandated involuntary clients (Elliot et al. 2005).

Possess True Willingness and Desire to Work with and Help People Who Are Seen as Less Deserving of Help This is the first principle because without it, the other principles do not matter. If nothing else, trauma survivors are astute readers and observers of people and behavior. They have had to read people and situations quickly in order to keep themselves safe. If you do not have a willingness and desire to help them, if you feel negatively toward them or feel that they are undeserving of help, it will come out in your actions and the relationship will be over before it starts. However, if you are truly invested in helping legally mandated involuntary clients with histories of trauma, you must look at your views of “these people” as well as reflect on the ways in which your views may be influencing the process. One of the primary ways that legally mandated involuntary clients judge your desire to help them is by the words you use to describe them: Criminal, prostitute, offender, child molester, perpetrator, murderer, child abuser. These words convey judgment and will cause individuals to feel like you have already made up your mind about them. In the jail where I was conducting

Trauma-Informed Care with Legally Mandated Involuntary Clients research, a counselor created a group for ‘prostitutes.” We were talking in passing one day and she was telling me that she started the group because many of the women had a history of prostitution, yet no one came to her group. It never dawned on her that the reason was because she was calling it a group for prostitutes. Language matters and it often lets people know what you think about them. These words label individuals as bad rather than focusing on their behaviors (i.e., women who have histories of prostitution). Again, it is important that practitioners explore their feelings, beliefs, and judgments about the legally mandated involuntary clients they are working with and if they have negative views of these clients find ways to work through these feelings and beliefs so they are able to effectively engage their clients.

Commit to Practice in a Different Way Trauma-informed practice requires a commitment to practice in different, more affirming ways (e.g., challenge service-as-usual practices). This commitment must happen at the individual and systemic levels in order to be truly effective and long lasting. Other wise, the practitioner or system will be limited in terms of the kinds of ser vices that can be provided to legally mandated involuntary clients with histories of trauma. On the individual level, practitioners must commit to learning all they can about trauma and the ways in which it manifests itself in clients’ lives. They must be willing to explore beliefs they have about certain types of clients. They also must be willing to look at any personal experiences of trauma or vicarious traumatization that could influence their interactions with legally mandated involuntary clients. Finally, practitioners must let supervisors and administrators know of systemic practices that affect their ability to work with clients in trauma-informed ways. On the systemic level, there is a need for organizational readiness, assessment, and cultural change to support trauma-informed care (Bloom, Owen, and Covington 2003; Harris and Fallot 2001; Rivard et al. 2005). Agency supervisors and administrators must ask whether the agency’s policies, practices, and procedures are congruent with trauma-informed care. It is their responsibility to make an administrative commitment to hire and train staff who are willing to work in trauma-informed ways, work with a network of ser vice providers or contractors to make sure that these agencies are carrying out the work in an appropriate manner, develop ways to periodically evaluate and assess the work to ensure a sensitivity to trauma, and review all practices and policies to ensure they are trauma informed (Harris and Fallot 2001). Examples of policies and practices that should be reviewed include: • Comply with legally mandated involuntary clients’ preferred location or conditions under which they want to meet with practitioners.

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A Foundation for Work with Involuntary Clients • Debrief after a seclusion, restraint, or other potentially traumatic incident as it is important for practitioners to explore whether their response was appropriate as well as explore other, more trauma-sensitive responses. • Allow legally mandated involuntary clients to identify preferences regarding safe and unsafe situations. There are a variety of reasons why legally mandated involuntary clients feel safe or unsafe. Legally mandated involuntary clients’ feelings of safety should be respected. • Allow legally mandated involuntary clients to specify characteristics of the worker (e.g., gender or race of the person) and request a different staff person when possible. • Give legally mandated involuntary clients the right to refuse to answer a question, refuse treatment, or request an alternative treatment. • Cross-train all staff and create “open forums” in which staff members and practitioners provide feedback, problem solve, and develop policies and procedures as an integral part of a culture of openness, learning, and teamwork. (Elliott et al. 2005) Ask If Behavior Might Be Linked to Experiences of Trauma This is one of the most important questions that practitioners who work with legally mandated involuntary clients should ask themselves when observing behaviors that seem incongruent with clients’ stated desires or are perplexing. Asking this question requires an understanding of trauma and the multitude of ways in which it can show up. If you knew someone had a physical disability, you would work with them differently and would take the disability into account. Experiences of trauma can create mental and emotional challenges and therefore require an empathetic, trauma-informed response. Understand the Common Coping Strategies and Adaptations Used by Trauma Survivors and Effective Treatment Approaches and Tools Many legally mandated involuntary clients’ behaviors were developed originally as ways to cope with and adapt to traumatic events (Harris 1998). Traumainformed practice recognizes that symptoms originate as adaptations to traumatic events (Allen 1995; Saakvitne et al. 2000). It is important for practitioners to acknowledge that despite the problems caused by certain coping mechanisms, such as rage, legally mandated involuntary clients are resilient. Moreover, reframing the effects of trauma as adaptations rather than defects can reduce legally mandated involuntary clients’ guilt and shame, increase their self-esteem, and serve as a guide for developing new skills and

Trauma-Informed Care with Legally Mandated Involuntary Clients resources that allow them to create new, healthier ways of coping with current situations. Give Clients as Many Choices as Possible There are many situations in which legally mandated clients have no options. It is important that, wherever possible, clients are allowed to make choices. For example, clients who become involved with child protection often must attend therapy, but practitioners can give the client a choice about the type of therapy (cognitive behavioral, psychodynamic, eye movement desensitization, or reprocessing), the order of therapy (individual first and then family), and which therapists and what agency they would like to use. Ideally, the primary goal of any interaction and ser vice provision for legally mandated involuntary clients should be to create opportunities so they can take charge of their lives. Providing them with the ability to have conscious choice and control over important life decisions is beneficial (Elliot et al. 2005). When clients’ choices and control over certain aspects of the helping process are limited, it recreates feelings of powerlessness. Practitioners will not be in clients’ lives forever. Giving them choices and control over certain aspects of the interaction helps legally mandated involuntary clients reclaim their right to direct their own lives in pursuit of their personal goals and dreams. If practitioners disagree with their clients’ choices, it is important for them to try to understand why legally mandated involuntary clients are making them. Often, professionals evaluate legally mandated involuntary clients’ decisions through the lens of people who have an array of choices. Many professionals do not understand the decisions or choices that many traumatized individuals make. This is largely because they put themselves in the same situation and believe that the “correct” choice is simple. For example, I have heard child protection workers tell women who are in abusive relationships that if they leave an abusive relationship, they can have their children back. The choice seems so simple. What those workers often fail to understand is that if she leaves the relationship she will likely have to go to a shelter. She has limited skills so finding a job that will support her and her children is unlikely. She does not have any family she can count on. If the woman is lucky, she will find a domestic violence shelter where she can stay longer than the usual one to three months to gain the skills she needs to sustain herself and her children. If you were told to leave your family and move into a shelter, would you do it? Probably not. Yet we expect clients to do it all the time. Many professionals have never had to choose between two “bad choices,” but it is a common scenario for most legally mandated involuntary clients, and particularly those who have histories of trauma.

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A Foundation for Work with Involuntary Clients How do legally mandated involuntary clients choose when none of their choices are ideal? My research has found that people who have limited or bad choices often choose the one that causes them the least amount of pain or meets an immediate need. The problem is that when individuals make choices based on pain or an immediate need, it may lessen the pain and suffering in the short term, but often causes more damage long term (Blakey 2015). Nonetheless, many trauma survivors must deal with what is happening for them in the moment. They will worry about the next moment next time. Living moment to moment is what tends to cause clients problems because they fail to see how what they do in this moment affects subsequent moments. They are in a constant state of reacting and trying to find ways to ease the pain. If practitioners try to understand the following, they can help legally mandated involuntary clients make more beneficial choices. 1) Legally mandated involuntary clients’ available choices at any given moment are constrained by life circumstances. 2) Legally mandated involuntary clients make choices that seem reasonable to them. Practitioners only see the end result and do not know this background that led to the decision. 3) People who have been traumatized make choices differently than people who have not been traumatized. They often choose whatever is going to cause them the least amount of pain or meet an immediate need. They don’t have the luxury of thinking about tomorrow because they are just trying to survive today. 4) No one makes the best choice every time, especially when the best choice is not always obvious. (Blakey 2015) Empowerment Should Be the End Result of Any Interaction with Legally Mandated Involuntary Clients According to Elliott et al., “the ultimate goal of the empowerment model is to expand a clients’ resources and support network such that the client becomes less and less reliant on professional ser vices” (2005:466). By remembering that the goal of every interaction is empowerment, practitioners can facilitate helping relationships in which legally mandated involuntary clients are able to learn and hone skills to exercise their voice and advocate for themselves to get their needs met (Elliot et al. 2005).

Trauma-Informed Care with Legally Mandated Involuntary Clients The Relationship and Interactions Between Practitioners and Legally Mandated Involuntary Clients Are Based on a Collaborative Rather Than Expert Model This involves practitioners believing that legally mandated involuntary clients are the experts regarding their lives, which means legally mandated involuntary clients are given maximum choice and control over the helping process. The collaborative relationship between practitioners and these clients is a partnership rather than a traditional hierarchy. All parties are working toward the same goal. This approach also acknowledges that practitioners are in no way superior to any client and that trust is not automatically afforded to them. Rather, practitioners must earn their clients’ trust so they can work together to address problems. Interpersonal Trauma Is Healed Through Relationships with Others and Trauma-Informed Practitioners Have an Opportunity to Facilitate Healing This principle recognizes that therapeutic relationships can facilitate healing among legally mandated involuntary clients with histories of trauma. Many legally mandated involuntary clients’ experiences of trauma involved a perpetrator who had power over them and used that power to hurt them. While there is an inherent power imbalance between legally mandated involuntary clients and practitioners, there are ways that practitioners can minimize the inherent hierarchy. One way to minimize the hierarchy is to create a therapeutic relationship that is RICH (Respectful, Informative, Connected, and creates Hope; Saakvitne et al. 2000). This type of relationship can facilitate safety and trust, which are the essential building blocks of healing trauma (Herman 1997). RICH relationships recognize that trauma is best healed through relationships that are collaborative, empowering, consistent, predictable, nonviolent, nonshaming, and nonblaming (Miller and Stiver 1997; Saakvitne et al. 2000). Safety Is an Essential Part of Service Delivery Safety is defined as a feeling in which individuals are able to be themselves without fear of repercussions and a space in which they will not be physically or emotionally harmed. There are two main types of safety: emotional and physical. Emotional safety includes addressing and validating clients’ lived experiences, including trauma histories, minimizing revictimization, shame, and any other things that make it hard for individuals to feel safe. Physical safety includes a place that is welcoming to individuals who have histories of trauma. The space should be sufficient for comfort and privacy and be free

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A Foundation for Work with Involuntary Clients from violent, sexual, or other offensive material. Physical safety also includes procedures and policies that monitor and hold practitioners accountable for intrusive or harassing behavior or language. Practitioners Follow Their Clients’ Lead Some practitioners are so afraid of retraumatizing participants that they do not bring up or allow participants to bring up past trauma for fear of overwhelming them. Others believe that talking about past histories of trauma serves as a distraction that some legally mandated involuntary clients will use to avoid focusing on recovery. Still other practitioners may push legally mandated involuntary clients to talk about past histories of trauma before they are ready to share details regarding past traumatic events. Legally mandated involuntary clients need to have their experiences heard and validated. They also need practitioners to not push them to uncover memories, face situations, or deal with things they may not be ready to face. A trauma-informed approach should follow the client’s lead in terms of readiness to share and work through past trauma.

Why Is Trauma-Informed Care Important? There is an understanding that without a trauma-informed approach, clients will not and cannot get better because the ser vices are focused on the symptoms (i.e., their behavior) rather than the cause (i.e., traumatic histories). Addressing trauma is increasingly becoming a necessary component of effective ser vice delivery and interventions (SAMHSA 2014b). Research shows that a commitment to provide resources that effectively address trauma that precipitates individuals’ involvement with these systems lessens trauma symptoms, increases trust between individuals and the institutions serving them, and reduces the likelihood of further traumatization (Brown, Harris, and Fallot 2013). Moreover, trauma-informed care improves client engagement and retention and improves outcomes, which makes ser vices more effective (SAMHSA 2014b). Finally, trauma-informed ser vices minimize staff fatigue and burnout and reduces vicarious traumatization (Harris and Fallot 2001). Becoming a trauma-informed practitioner and developing a trauma-informed organization requires commitment by all involved, from the practitioner to those at the top of the power hierarchy. According to Brown and Worth, “Behavior change is not just about changing client’s behavior, but our own— the ser vices, the systems, the institutions and organizations” (2000:393).

Trauma-Informed Care with Legally Mandated Involuntary Clients References Allen, J. G. 1995. Coping with Trauma: A Guide to Self-understanding. Arlington, VA: American Psychiatric Association. Blaauw, E., E. Arensman, V. Kraaij, F. W. Winkel, and R. Bout. 2002. “Traumatic Life Events and Suicide Risk Among Jail Inmates: The Influence of Types of Events, Time Period and Significant Others. Journal of Traumatic Stress 15 (1): 9–16. Blakey, J. 2015, May 26). The Power of Choice. Video. May 26. https://www.youtube.com/watch ?v =_ IgSkD9x6YE. Blakey, J. M., and P. H. Bowers. 2014. “Barriers to Integrated Treatment of Substance Abuse and Trauma Among Women.” Journal of Social Work Practice in the Addictions 14 (3): 250–272. Blakey, J. M., and S. S. Hatcher. 2013. “Trauma and Substance Abuse among Child Welfare Involved African American Mothers: A Case Study.” Journal of Public Child Welfare 7 (2), 194–216. Bloom, B., B. Owen, and S. Covington. 2003. Gender-Responsive Strategies: Research, Practice and Guiding Principles for Women Offenders. Accession No. 018017. Washington, DC: U.S. Department of Justice, National Institute of Corrections. Brown, V. B., M. Harris, and R. Fallot. 2013. “Moving Toward Trauma-Informed Practice in Addiction Treatment: A Collaborative Model of Agency Assessment.” Journal of Psychoactive Drugs 45 (5): 386–393. Brown, V. B., and D. Worth. 2000. Recruiting, Training and Maintaining Consumer Staff: Strategies Used and Lessons Learned. Culver City, CA: Prototypes. Browne, A., and D. Finkelhor. 1986. “Impact of Child Sexual Abuse: A Review of the Research. Psychological Bulletin 99 (1): 66–77. Carlson, B., and M. Shafer. 2010. “Traumatic Histories and Stressful Life Events of Incarcerated Parents: Childhood and Adult Trauma Histories.” Prison Journal 90: 475–493. Chemtob, C. M., S. Griffing, E. Tullberg, E. Roberts, and P. Ellis. 2011. “Screening for Trauma Exposure, Posttraumatic Stress Disorder and Depression Symptoms among Mothers Receiving Child Welfare Preventive Ser vices.” Child Welfare 90 (6): 109–127. Clements-Nolle, K., M. Wolden, and J. Bargmann-Losche. 2009. “Childhood Trauma and Risk for Past and Future Suicide Attempts among Women in Prison.” Women’s Health Issues 19 (3): 185–192. Cohen, L. R., and D. A. Hien. 2006. “Treatment Outcomes for Women with Substance Abuse and PTSD Who Have Experienced Complex Trauma.” Psychiatric Services 57 (1): 100–106. Cottler, L. B., P. Nishith, and W. M. Compton. 2001. “Gender Differences in Risk Factors for Trauma Exposure and Post-traumatic Stress Disorder among Inner City Drug Abusers In and Out of Treatment.” Comprehensive Psychiatry 42 (2): 111–117. Courtois, C. A., and J. D. Ford, eds. 2009. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York: Guilford Press. Covington, S. S., C. Burke, S. Keaton, and C. Norcott. 2008. “Evaluation of a Trauma-Informed and Gender Responsive Intervention for Women in Drug Treatment.” Journal of Psychoactive Drugs (SARC suppl.) 5: 387–398. Elliott, D. E., P. Bjelajac, R. D. Fallot, L. S. Markoff, and B. G. Reed. 2005. “Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Ser vices for Women.” Journal of Community Psychology 33 (4): 461–477. doi:10,1002/jcop.20063. Fallot, R., and M. Harris. 2009. “Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol.” Community Connections 2 (2): 1–18. Farley, M., J. M. Golding, G. Young, M. Mulligan, and J. R. Minkoff. 2004. “Trauma History and Relapse Probability among Patients Seeking Substance Abuse Treatment.” Journal of Substance Abuse Treatment 27: 161–167. doi:10.1016/j.jsat.2004.06.006.

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A Foundation for Work with Involuntary Clients Finkelhor, D. 1986. “A Sourcebook on Child Sexual Abuse and Neglect.” Beverly Hills, CA: Sage. Haight, W. L., S. Mangelsdorf, J. Black, M. Szewczyk, S. Schoppe, G. Giorgio, K. Madrigal, and L. Tata. 2005. “Enhancing Parent-Child Interaction during Foster Care Visits: Experimental Assessment of an Intervention.” Child Welfare 84 (4): 459–481. Harlow, C. W. 1999. “Prior Abuse Reported by Inmates and Probationers.” Alcohol 75 (29): 24. Harris, M. 1998. “Trauma Recovery and Empowerment.” New York: The Free Press. Harris, M., and R. D. Fallot. 2001. “Envisioning a Trauma-Informed Ser vice System: A Vital Paradigm Shift.” New Directions for Mental Health Services (89): 3–22. Harris, M. E., and R. D. Fallot. 2001. Using Trauma Theory to Design Service Systems. Hoboken, NJ: Jossey-Bass. Haslam, N. 2016. “How We Became a Country Where Bad Hair Days and Campaign Signs Cause Trauma.” Washington Post. August 12. https://www.washingtonpost.com/posteverything/wp /2016/08/12/when-bad-hair-days-and-campaign-signs-cause-trauma-the-concept-has-gone -too-far/?utm _term=.f572b05a8600. Hein, D., L. C. Litt, L. Cohen, G. M. Miele, and A. Campbell. 2009. Trauma Services for Women in Substance Abuse: An Integrated Approach. Washington, DC: American Psychological Association, 143–161. Herman, J. 1997. Trauma and Recovery: The Aftermath of Violence— From Domestic Abuse to Political Terror. Rev. ed.. New York: Basic Books. Hummer, V. L., N. Dollard, J. Robst, and M. I. Armstrong. 2010. “Innovations in Implementation of Trauma-Informed Care Practices in Youth Residential Treatment: A Curriculum for Orga nizational Change.” Child Welfare 89 (2): 79–95. Huntington, N., D. J. Moses, and B. M. Veysey. 2005. “Developing and Implementing a Comprehensive Approach to Serving Women with Co-occurring Disorders and Histories of Trauma.” Journal of Community Psychology 33 (4): 395–410. Jennings, A. 2004. Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services. Alexandria, VA: National Association of State Mental Health Program Directors, National Technical Assistance Center for State Mental Health Planning. Jones, L. 2004. “The Prevalence and Characteristics of Substance Abusers in a Child Protective Ser vice Sample.” Journal of Social Work Practice in the Addictions 4 (2): 33–50. Jordan, B. K., W. E. Schlenger, J. A. Fairbank, and J. M. Caddell. 1996. “Prevalence of Psychiatric Disorders among Incarcerated Women: II. Convicted Felons Entering Prison.” Archives of General Psychiatry 53 (6): 513–519. Kessler, R. C., A. Sonnega, E. Bromet, M. Hughes, and C. B. Nelson. 1995. “Posttraumatic Stress Disorder in the National Comorbidity Survey.” Archives of General Psychiatry 52: 1048–1060. Killeen, T., D. Hien, A. Campbell, C. Brown, C. Hansen, H. Jiang, and E. Nunes. 2008. “Adverse Events in an Integrated Trauma-Focused Intervention for Women in Community Substance Abuse Treatment.” Journal of Substance Abuse Treatment 35: 304–311. doi: 10.1016/j. jsat.2007.12.001. Ko, S. J., J. D. Ford, N. Kassam-Adams, S. J. Berkowitz, C. Wilson, M. Wong, M. J. Brymer, and C. M. Layne. 2008. “Creating Trauma-Informed Systems: Child Welfare, Education, First Responders, Health Care, Juvenile Justice.” Professional Psychology: Research and Practice 39 (4): 396–404. Kubiak, S. P. 2005. “Trauma and Cumulative Adversity in Women of a Disadvantaged Social Location.” American Journal of Orthopsychiatry 75 (4): 451–465. Lombardi, E. L. 2001. “Enhancing Transgender Health Care.” American Journal of Public Health 91: 869–872.

Trauma-Informed Care with Legally Mandated Involuntary Clients Markoff, L. S., R. D. Fallot, B. G. Reed, D. E. Elliot., and P. Bjelajac. 2005. “Implementing Trauma-Informed Alcohol and Other Drug and Mental Health Ser vices for Women: Lessons Learned in a Multi-site Demonstration Project.” American Journal of Orthopsychiatry 75 (4): 525–539. McCauley, J., D. Kern, K. Kolodner, L. Dill, A. F. Schroeder, H. K. DeChant, et al. 1997. “Clinical Characteristics of Women with a History of Childhood Abuse: Unhealed Wounds.” Journal of the American Medical Association 277 (17): 1362–1368. McDaniels-Wilson, C., and J. Belknap. 2008. “The Extensive Sexual Violation and Sexual Abuse Histories of Incarcerated Women.” Violence Against Women 14 (10): 1090–1127. Miller, J. B., and I. P. Stiver. 1997. The Healing Connection: How Women Form Relationships in Therapy and Life. Boston: Beacon Press. Miller, N. A., and L. M. Najavits. 2012. “Creating Trauma-Informed Correctional Care: A Balance of Goals and Environment.” European Journal of Psychotraumatology 3: 1–8. Morrissey, J. P., E. W. Jackson, A. R. Ellis, H. Amaro, V. B. Brown, and L. M. Najavits. 2005. “Twelve-Month Outcomes of Trauma-Informed Interventions for Women with Cooccurring Disorders.” Psychiatric Services 56 (10): 1213–1222. Najavits, L. M., D. Ryngala, S. E. Back, E. Bolton, K. T. Mueser, and K. T. Brady. 2008. “Treatment for PTSD and Comorbid Disorders: A Review of the Literature.” In Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, eds. E. B. Foa, T. M. Keane, M. J. Friedman, and J. Cohen, 2nd ed. New York: Guilford Press. Najavits, L. M., J. Sonn, M. Walsh, and R. D. Weiss. 2004. “Domestic Violence in Women with PTSD and Substance Abuse.” Addictive Behaviors 29: 707–715. Najavits, L. M., R. D. Weiss, and S. R. Shaw. 1997. “The Link Between Substance Abuse and Post-Traumatic Stress Disorder in Women: A Research Review.” American Journal on Addictions 6: 273–283. Neumann, D. A. 1994. “The Long-Term Sequelae of Childhood Sexual Abuse.” In Violent Victimization, ed. J. Briere. San Francisco: Jossey-Bass. Pollock, J. M., J. L. Mullings, and B. M. Crouch. 2006. “Violent Women: Findings from the Texas Women Inmates Study.” Journal of Interpersonal Violence 21 (4): 485–502. Polusny, M. A., and V. M. Follette. 1995. “Long-Term Correlates of Child Sexual Abuse: Theory and Review of the Empirical Literature.” Applied and Preventive Psychology 4 (3): 143–166. Richie, B. 1996. Compelled to Crime: The Gender Entrapment of Battered Black Women. New York: Routledge. Rivard, J. C., S. L. Bloom, D. McCorkle, and R. Abramovitz. 2005. “Preliminary Results of a Study Examining the Implementation and Effects of a Trauma Recovery Framework for Youths in Residential Treatment.” Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations 26 (1): 83–96. Rooney, R. H. 2009. “Introduction to Involuntary Practice.” In Strategies for Work with Involuntary Clients, 3–18. New York: Columbia University Press. Ryan, B., C. Bashant, and D. Brooks. 2006. “Protecting and Supporting Children in the Child Welfare System and the Juvenile Court.” Juvenile and Family Court Journal 57 (1): 61–69. Saakvitne, K. W., S. J. Gamble, L. A. Pearlman, and B. T. Lev. 2000. Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Lutherville, MD: Sidran. Sacks, S., M. Chaple, J. Sirikantraporn, J. Y. Sacks, J. Knickman, and J. Martinez. 2013. “Improving the Capability to Provide Integrated Mental Health and Substance Abuse Ser vices

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Part II

Practice Strategies for Work with Involuntary Clients

Part 1 provided a conceptual basis and principles for legal, ethical, and effective work with involuntary clients. Part 2 transforms these principles into concrete guidelines for practice through frequent use of transcripts of interactions between involuntary clients and practitioners. Chapter 7 focuses on assessing initial contacts and chapter 8 contains guidelines for work in the initial phase. Chapter 9 presents an adaptation of the task-centered approach to work with involuntary clients in the middle and final phases. Chapter 10 expands this to working with families and chapter 11 focuses on groups.

Chapter 7

Assessing Initial Contacts in Involuntary Transactions

Rebecca Mirick

Review of the legal, ethical, and effective framework for working with involuntary clients provides a basis for planning. However, use of these principles often takes place in difficult face-to-face encounters in which the practitioner ends up feeling attacked, irritated, or defensive. Principles of intervention may be far from the practitioner’s mind as he or she focuses on the immediate task of conducting an initial assessment while simulta neously managing these challenging reactions. This chapter introduces deviance, resistance, reactance, and strategic self-presentation as four perspectives or alternative lenses to aid in “seeing” this interaction. The four perspectives are assessed according to how well they fit a transactional view, their empirical and theoretical bases, how parsimoniously they explain observable facts, and how well they contribute to proactive practitioner responses. Three case studies are provided as an aid to explore these concepts.

Assessment with Involuntary Clients Assessments are working explanations of persons, problems, and situations, and their dynamic interaction. They are developed to aid the client and practitioner in formulating a plan of action (Epstein and Brown 2002). Since assessments should aid the client and practitioner in formulating a plan of action, they must focus on key issues and their use rather than gathering facts for their own good. Guides for assessment often emphasize the synthesis of

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Practice Strategies for Work with Involuntary Clients objective and subjective facts from a variety of sources such as background sheets, verbal reports, direct observation of nonverbal behavior and interaction, collateral information, use of psychological testing, and the personal experience of the practitioner (Hepworth et al. 2016). Such guides further recommend focus on the person, his or her coping capacity, strengths, role transitions, needs and resources, aspirations and opportunities, problem sequences of antecedents, behaviors, consequences, and an analysis of impinging systems, which can be peer or work environments that contribute to difficulties (ibid.). While guides have been developed for the assessment process with voluntary clients, assessment with involuntary clients is distinctly different. Skeem et al. (2007) describe the “dual role” that practitioners play with involuntary clients, to “care for and have control over” clients (p.397). In fact, involuntary assessment differs in at least four major ways from voluntary assessment. First, in legally mandated transactions, the practitioner is required to assess the client’s situation according to legal mandates and agency guidelines, whether or not the involuntary client sees this assessment as useful. Results of that assessment may include actions against the client’s wishes. Second, there are often conflicting expectations about who has a problem and who wants help; a nonvoluntary client experiences formal and/or informal pressure since assessments are often done at the request of a third party to inform a plan for a nonvoluntary client. Such assessments frequently begin with difficulty, with conflicting goals on both sides and intense feelings from the client (Forrester, Westlake, and Glynn 2012; Mirick 2012). Influenced by these conflicting expectations, involuntary assessment often takes place in the “heat of battle” with high client and practitioner tension. This emotional intensity can create further problems because practitioners are often urged to note their subjective responses to client behavior as part of the assessment. Responses of involuntary clients at a point of conflicting expectations, perceived limitations on freedom from coercion or constraint, and high emotion may not be representative of their behavior in other settings and might best be seen as a sample of client behavior under pressure (Epstein and Brown 2002). Assessment tools exist within a framework of gathering information to promote decision making. They vary in the extent to which would-be clients are afforded the opportunity to tell their own stories, participate in the assessment, and seek solutions (Iversen, Gergen, and Fairbanks 2005). In many situations, behaviors are assessed for potential to take responsibility for actions while assessing denial and minimization as defensive maneuvers (Frost 2004; Kroner and Mills 2004; Henning, Jones, and Holdford 2005). Elaborate assessments may be of little value if they do not engage the nonvoluntary client to remain in counseling. Similarly, required assessments with mandated clients may have little lasting value if plans are made for them without their commitment to implement the recommendations. Assessment formats that seek to both present danger and protective factors and engage family

Assessing Initial Contacts in Involuntary Transactions members’ accounts of what has occurred and their participation in the development of solutions are important in work with involuntary clients (Akamatsu 1998; Parton and O’Byrne 2000; Lohrbach and Sawyer 2004; Lohrbach et al. 2005). The challenge for assessment with involuntary clients is to assess danger and risk while engaging potential clients in developing solutions (Mirick 2012; Oliver and Charles 2016; Skeem et al. 2007). This chapter presents four perspectives to aid in assessment with involuntary clients. We begin with a case vignette as the basis for examining the first perspective: social deviance.

As a teen, Molly experienced considerable family conflict and she called a social ser vice agency requesting placement outside of the home.* It is unusual for a child or adolescent to be the initiator of such a report. The child welfare agency made an assessment of abuse and neglect and determined that the strife between adolescent and family did not constitute abuse or neglect that endangered her well-being and a case was not opened. Soon thereafter, Molly ran away from home. She was then placed outside of the home in a variety of placements ranging from shelters to group homes. * A videotape in which Dr. Ronald Rooney interviews Molly Morgan (disguised name) about her history as a client of several involuntary systems is available on https://alexanderstreet.com/, See “Work with Involuntary Clients: The Consumer’s Perspective.” A full listing of videos is available in the appendix.

Deviance as an Assessment Perspective Conrad and Schneider define deviance as “those categories of condemnation and negative judgment which are constructed and applied successfully to some members of a social community by others . . . a quality attributed to such persons and behaviors by others” (1992:5). Whether behaviors are labeled as “deviant” differs from culture to culture, but all cultures use agents of social control to encourage non-deviant behavior and discourage or change deviant behavior (Conrad and Schneider 1992). Agencies, organizations, and groups such as schools, the criminal justice system, medical professionals, and child protection agencies act as agents of social control. Many people who are engaged in behaviors that society has labeled deviant, such as child maltreatment, driving under the influence of alcohol, domestic violence, or other criminal behaviors, become involuntary clients of practitioners at these agencies or organizations. Other life-threatening behaviors, such as eating disorders and suicidal ideation and behavior, are also considered deviant behaviors

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Practice Strategies for Work with Involuntary Clients in many cultures. Individuals with these behaviors often become involuntary clients at social ser vice agencies. This view of deviance is one of several definitions of the concept. One perspective on deviance has been described as an individual pathology definition because of its focus on abnormal behavior that should be corrected by social control agents and therapists (Kirk 1972). The causes of deviance in this view are typically sought in the personal history of the deviant with relatively little attention to the social causes or the practitioner’s role in detecting and labeling deviant status (Nooe 1980). The individual pathology view may be prevalent in social control and helping agencies assigned to work with individuals labeled deviant. An individual focus is compatible with the therapy training of counselors and the individual focus of ser vice delivery efforts by many agencies. Following this view, it might be useful to have explored Molly’s developmental history as well as the escalating family tensions in her household that precipitated her running away. While the individual pathology view is compatible with the ser vices offered by many practitioners and agencies, it also has major blind spots. According to Kirk, persons holding an individual pathology view of deviance are likely to approach clients “as if they suffer from a defective self, which leads them to come voluntarily to the agency; as if the contact with the agency and the contact with the [practitioner] is always benign and as if the relationship exists in a social vacuum” (Kirk 1972:23). As Molly put it in a videotaped interview many years after the running away incident, “I was seen as the problem.” The social ser vice system focused on the running away event and her as the problem. The individual pathology view may lead to errors in ignoring nonvoluntary pressures, including very real dangers to the freedom of the persons labeled deviant, and, finally, may overemphasize individual causes of deviance while underemphasizing social or interactional causes. There are several alternative perspectives on deviance that can supplement the strengths and correct for some of the blind spots in the individual pathology view. The structural model of deviance suggests that while goals of wealth, power, and status may be common across a society, access to opportunities and resources needed to reach those goals is often impeded for lower socioeconomic segments of the society (Merton 1980). People labeled as deviant may be seen in this view as frustrated in their attempts to use legitimate means to reach social goals and therefore are driven rather than attracted to illegitimate means. The structural model sensitizes us to the role of access to resources and opportunities as a factor in creating circumstances that lead to deviance. Following this view, we might hypothesize that more involuntary and deviant clients are created in times of economic hardship and lack of resources, should access to societal goals by legitimate means be blocked. Following a structural view, it would be considered significant that as a teenaged female runaway, Molly had less access to resources and support than her family did. Fewer

Assessing Initial Contacts in Involuntary Transactions societal resources are expended on protecting adolescents than on younger children. Adolescents are presumed to be more able to protect themselves physically than their younger, more vulnerable counterparts. The structural approach suggests society-wide prevention efforts to distribute resources and opportunities such that the conditions leading to deviance are reduced. The structural view has its own blind spots because of inattention to individual choice and action. Not all individuals in similarly deprived conditions use deviant means. Nor does the structural view explain the deviant or illegal behavior of individuals with high access to societal rewards (Thio 1978). The social labeling perspective is particularly relevant for analysis of the involuntary transaction. In this perspective, no behavior is considered inherently deviant. Society is seen as creating deviance by setting rules that define it. These definitions have considerable cultural variation in the behavior defined as abnormal with, for example, differences in definitions of “good” parenting and appropriate child behavior from cultural to culture. Consequently, from the social labeling perspective, a deviant is one to whom the label has been successfully applied and deviant behavior is behavior that others label as such (Becker 1963). The response of society may interact with the response of the person labeled deviant to create and maintain a deviant role. The social labeling perspective shares a blind spot with the structural view. It ignores the choice to participate in the act labeled deviant. It is not necessary to take the position that social reaction causes a person to take on a deviant role to recognize that the practitioner and the agency can play an interactive role in contributing to a deviant identity. Roger Nooe (1980) suggests that the individual pathology and structural and social labeling views can be combined to reduce the blind spots of each and produce proactive practice guidelines that focus on actions in the practitioner’s control. The discussion that follows draws heavily on Nooe’s analysis to present that integration and practice guidelines. A key concept in the social labeling perspective is primary deviance, which is defined as acting to violate social norms without being observed by others and hence not labeled as deviant by them. The particular cause of the original deviant act is not specified and can be influenced by organic, psychological, and environmental causes (Nooe 1980). Persons committing the violation may be aware that their behavior is somewhat different from others, may or may not see the behavior as a problem, and may decide to seek help. At the stage of primary deviance, persons generally do not take on a deviant role or label themselves as deviant (see the following text box). For an example of primary deviance, we return to Molly. When she ran away from home as an adolescent, she saw herself as escaping from an untenable family situation after making appropriate efforts by asking for placement to remedy the situation. At a later point, she had a child, became seriously

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Practice Strategies for Work with Involuntary Clients depressed and received a psychiatric hospitalization. Over the next several years, Molly experienced several lengthy hospitalizations.

Integrative model of deviance Individual Pathology Model • Focus on abnormal behavior of individuals to be corrected by therapy and rehabilitation • Tends to ignore structural, social reaction, and labeling effects Structural Model • Focus on restricted access to resources needed to achieve goals • Tends to ignore choice and rule breaking by more powerful persons Social Labeling Model • Focus on social response contingencies in creating deviant role through labeling • Tends to ignore role of choice and blames the social labelers

Social labeling theory next focuses on social reaction to the primary deviant behavior, suggesting that rules for identifying deviant behavior are inconsistently applied with many intervening factors influencing labeling. For example, when, where, and by whom the deviant behavior was identified becomes important. Age, race, sex, social distance, power, and social status are among the factors that influence who will be identified as deviant and who will not. Evidence for the mitigating factor of these variables includes the fact that low-income minority clients are frequently overrepresented in child protection caseloads and within the juvenile justice system (Boyd 2014; Council on Crime and Justice 2006). The social labeling perspective suggests that persons labeled deviant often respond to protect their identity, to avoid isolation and stigma. Included among the responses to deviant labeling are rationalizing, minimizing, or denying harm, overgeneralizing, dissembling, blaming others, discrediting the alleged victim, arbitrary interpretations, selective abstractions, and magnification (Sagarin 1975). These defensive response patterns have been identified as occurring with those labeled as deviant, ranging from adolescents engaged in antisocial behaviors to those prosecuted for insider stock trading. For example, mothers who have been accused of child maltreatment by child protection agencies may focus their energy on disagreement with the label, by trying to convince the worker the label is incorrect (Gibson 2014). The defensive, alienated responses are often interpreted as further evidence of pathology and

Assessing Initial Contacts in Involuntary Transactions deviance rather than normalized as a typical response to the labeling process or involuntary treatment ser vices (Gibson 2014; Mirick 2012). Defensive reactions by the person labeled deviant can then interact with the social response to create a vicious cycle that can reinforce the primary deviance and become secondary deviance: when a person labeled deviant responds to that labeling by acting to take on a deviant role. Research on persons with disabilities has shown that persons can respond to the stigma of the label and perceived discrimination with illicit drug use considered by them as a small compensation for suffering that stigma (Li and Moore 2001). In 1993, I had the opportunity to interview Molly about her lengthy career as a client of several involuntary systems. She spoke about labeling in relation to a hospitalization ten years earlier. molly: My prognosis in 1983 was guarded and that’s about as low as you can get. That’s where you get put on the maintenance program . . . and that essentially means three square meals, a roof over your head. rooney: And at the time how did that feel to you? molly: I think it felt pretty hopeless. They were telling me for the rest of my life someone is going to put a roof over my head and I’m not going anywhere and I believe I saw a therapist at that time, but I don’t know why. If no one believed I was going anywhere, why see a therapist? But they just believed . . . that’s the most anyone could expect out of me. I would live where someone would put me or feed me or whatever. rooney: And you didn’t have much hope for your own future then? molly: No, I didn’t. A doctor told me that that was the prognosis and told me what it meant and I kind of lost all kind of hope that I was going to do anything, so I didn’t really try. I just laid around in bed and did what’s expected of a hopeless person I guess . . . nothing. It appears that Molly was describing a process similar to secondary deviance whereby she was reacting to the diagnostic label and what she understood it to mean. The transition to secondary deviance is not inevitable. It may be influenced by the role of human ser vice practitioners and agencies who act to normalize and defuse labeling or to reinforce a stabilized deviant role. Practitioners can reinforce secondary deviance by discrediting the client’s own explanations for the incidents and excluding them from treatment planning. As a result, the client might confess and take on a sick role while protesting that such a label may be seen as further evidence of resistance and sickness. How can practitioners and agencies assess individuals while reducing their contribution to labeling and secondary deviance? Agencies can act through alternative programs developed for diverting many first-time juvenile offenders from formal court processing. Practitioners can be sensitive to the specific contingencies surrounding events leading to identification of deviant activity.

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Practice Strategies for Work with Involuntary Clients Finally, the practitioner can act preventively to alleviate conditions that led to the primary deviance. In this case, it is possible that more assertive exploration of family difficulties when Molly asked to be placed out of the home, including exploration of kinship alternatives for alleviating family stress, might have been helpful. While the social labeling perspective is useful in exploring the impact of labeling and the reaction to it on behavior, it is no longer credible to assume that labeling alone is sufficient to produce behavior labeled as mental illness (Gove 1970). That is, social labeling is not a sufficient explanation for what results in hospitalization, but it may delay progress if the client is not empowered to participate in recovery. Persons are often aware of deviant labeling and appear to strive to avoid such labels (Link 1987) and the stigma that accompanies them. For example, for many people it is less stigmatizing to describe one’s behavior as having had a “ner vous breakdown” rather than suffering from a mental illness (Gove 2004). Indeed, voluntarism can often be considered as a more positive status than being legally involuntary. In the next section of the transcript, Molly emphasizes her voluntarism and appears to wish to separate herself from the stigma of having a court order into psychiatric treatment. rooney: Can you tell us something about your experiences in being hospitalized? molly: I have never been court ordered, there has never been any court action for me to be hospitalized but I have been in locked units. That’s where every thing your tableware, clothing and every thing is locked up. The staff and doctors control your every move. You lose every move. rooney: Tell us . . . you were not court ordered into that situation, so how did you come to be in it? molly: Most of the time I was in a locked unit to be self protected. . . . so I could be protected from myself because that’s why I ended up there. rooney: Had you signed a release to enter the hospital? molly: I think I signed standard admission papers, consent to treatment papers. You don’t sign specifically what they’re going to do to you. You just sign a blank or a standard consent to treatment. rooney: You’re telling us that part of your placement was voluntary in that you thought you needed help and probably needed to be in a safe environment. molly: Right, right. I talked with my doctor, or in some cases, my doctor suggested it or my therapist suggested it, but it was voluntary and I walked in the door.

Assessing Initial Contacts in Involuntary Transactions

Resistance Martin, nineteen, applied to become a resident of a supportive living community for homeless men and women. He had just been released from a hospital, where he had been treated for pneumonia, and had been living on the streets before his hospital admission. Since Martin had been a resident twice before and had been expelled for fighting with other residents, his application was discussed heatedly at a staff meeting. Staff hesitated about readmitting him, describing Martin as hostile and resistant, a person who might abuse resources that others could use more productively. Staff finally recommended to the intake interviewer that Martin be admitted if he agreed to the following conditions: (1) no overnights away from the community for two months, (2) attendance at a GED class on time every day, (3) full participation in the program structure of the center, and (4) obtaining a mental health and chemical dependency assessment. When the conditions were presented, Martin sat staring into space without speaking for several minutes, and then said: “I agree to all of it . . . but I don’t like the no overnights. . . . But I have no choice if I want to move back here, do I?” The interviewer agreed with Martin’s assessment but urged him to think about his decision for a day. Martin declined to wait, saying he would agree to the conditions. As Martin’s alternative was to live on the streets, he could be said to have made a coerced choice influenced by formal agency pressure to abide by the community rules. In the weeks that followed, Martin followed the rules to the letter . . . but not the spirit. While he took no overnights, Martin stayed awake all night many nights and persuaded other residents to keep him company! After sleepless nights, he slept through GED classes that he attended every day and on time. Martin would also become ill or forget to arrange to get bus passes for his assessment appointments. Meanwhile, he continued to press for permission for overnights, saying he was “obeying the rules.”

Many would consider Martin as not only engaging in deviant behavior but also demonstrating resistance. Evidence for this assessment might be Martin’s varied, ingenious efforts to undercut the rules. In fact, while deviant labeling and involuntary status overlap, resistance and involuntary status have historically been considered synonymous (Nelsen 1975). This is understandable since the behav iors and attitudes often grouped under the resistant label are familiar in the responses of involuntary clients: provocation, hostility,

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Practice Strategies for Work with Involuntary Clients intellectualization, projection, verbosity, seduction, withdrawal, passive compliance, martyrdom, flight from the scene, refusal to answer, lateness for appointments, noncompliance, and changing the subject (Forrester et al. 2012; Gibson 2014; Gitterman 1983). What do these varied behaviors and attitudes have in common? They may be considered resistance if “resistance” is defined as client behavior that the practitioner considers inappropriate and not in line with the plans the practitioner has for the client (Turkat and Meyer 1982). This definition can be considered from the perspective of deviant labeling. I define “resistance” as a label assigned by practitioners to clients who have not acted to the practitioner’s satisfaction. It is not typically applied by practitioners to their own behavior or their agency policies. Use of the term constitutes pejorative labeling; hence, it may have consequences for subsequent secondary deviance through reinforcing a resistant role. Current usage of resistance differs greatly from the original meaning of the term in psychoanalytic theory. Resistance originally referred to the analytic patient’s unconscious use of defenses when subjects threatening to the ego were uncovered (Fenichel 1945). Hence, in this original definition, resistance was considered normal and expectable, unlike the current view, which emphasizes abnormal behavior. Second, resistance was considered to be unconscious, hence not under the client’s control, while current use includes conscious opposition to plans. Third, the original use implied that the practitioner’s responsibility for control or reduction, while current uses emphasize client responsibility and blame. Finally, the original use assumed application to voluntary analytic patients who, at least consciously, agreed to the goals and methods of treatment while current use routinely applies to involuntary clients (Nelsen 1975). Consequently, since involuntary clients neither seek treatment nor agree to the means by which it is conducted, their opposition is a conscious refusal to participate, and hence resistance in the original sense should not be used to describe their behavior since they have not agreed to goals (Ewalt 1982). What are the consequences of the current usage of the term? On the one hand, describing a client as resistant provides a shorthand way to describe difficult, uncomfortable behavior in a way that often enlists support from colleagues. On the other hand, resistant labeling as one form of expressing practitioner discomfort becomes part of the client assessment and may form a stigmatizing label that will have repercussions far beyond the instance in which it is first applied. This form of client labeling locates the cause of disturbance within the client rather than examining the transaction with the agency or the worker (Ewalt 1982). Having labeled the client as resistant, practitioners often feel discouraged and may project this helplessness onto the client. Instead of leading to positive steps, this use of the term absolves practitioners and their settings from responsibility for reducing the tension in the

Assessing Initial Contacts in Involuntary Transactions transaction and contributes to a self-fulfilling prophecy of failure. By locating the tension in the client, the practitioner never needs to examine his or her own behavior, or components of the treatment mandate, in order to better understand whether the resistance is in response to the practitioner’s own behaviors or the mandate. There are several alternatives to the use of resistance as a form of deviant labeling. First, the term could be dropped from parlance as an undefined, pejorative term. The possibility of banning word usage among practitioners is limited, however, and such elimination might lead to “term substitution” to find another way to express practitioner exasperation for lack of compliance. Second, the term could be reserved for use in its original sense by psychoanalysts describing a phenomenon that occurs in their particular form of influence. The advantage of such a move would be to reduce the pejorative connotations and not misapply the term to circumstances beyond the original meaning. This solution carries some of the problems of the first, however, as it is difficult to monitor inappropriate usage. Third, the term could be specified and studied more objectively and operationally defined with focus on specific behaviors and influences rather than blame (Mahalik 1994). Fourth, the term could be reframed and used in a transactional, normalizing context. Carel Germain suggests that there may be hope for resistance as a concept if it is applied to the whole transaction rather than to the internal processes of the client alone. She suggests that resistance should be considered a natural reaction to unwanted change that occurs to clients, practitioners, and their agencies (Germain 1982). Following this perspective, sources of unwanted change would be explored including the very real possibility that the involuntary client response stems at least in part from pressures brought by the practitioner or agency. Practitioners would be alerted to recognize their discomfort with involuntary client opposition without labeling it as the client’s internal problem. Practitioners might then not only consider client hesitation as normal but might also acknowledge their own hesitance to see a potentially hostile client as exhibiting normal resistance. Miller and Rollnick (2012), in their Motivational Interviewing approach, have conceptualized resistance in this way and have gone even further. They suggest that when client resistance emerges, it is the responsibility of the practitioner, not the client, to understand and address it. In fact, it is likely a sign that the practitioner has misstepped and is not the fault of the client. This expanded usage of the term could also be applied to agencies and other parties to the transaction. There are many ways in which agency policies can create unnecessary hurdles for clients and elicit resistance, such as having office hours that are inconvenient for clients, punitive policies on tardiness or missed appointments, or unnecessary hurdles to jump through in order to initiate treatment ser vices.

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Practice Strategies for Work with Involuntary Clients Reframing resistance is unlikely to occur on a widespread basis unless there is a shift in focus from explaining behavior as primarily internally motivated to examining its transactional aspects. Should a reframing approach not be adopted, we return to a social labeling definition of resistance as applied to client responses when practitioners are dissatisfied with less than full compliance. Application of that label has consequences, however, for reinforcing a secondary deviant role as “resistant client.” Most theories of helping acknowledge that some form of opposition often occurs in treatment, whether as an enduring client oppositional characteristic or as a transactional phenomenon that occurs during sessions, perhaps as a response to practitioner directiveness or confrontation (Beutler et al. 2001, 2011; Forrester et al. 2012). However it is described, there is general agreement that its presence does not bode well for productive outcomes. Client hesitation to try out suggestions and explore new beliefs would be better reframed as an expected ambivalence about making change. That is, practitioners should expect that clients will likely be caught between a desire to change and fearfulness or belief that change is unwanted or not possible to obtain. This ambivalence should be normalized, not pathologized (Arkowitz 1996; Miller and Rollnick 2012). In the interview with Molly after discussing her long period of hospitalization, we discussed events in her life after leaving the hospital. rooney: Something changed? What has occurred since then? molly: It was about six years being hopeless and being on maintenance and doing essentially nothing. I was in a residential program and they had just started the community support and part of the program was that I was in a home that had outside programming and they told me after six years I had to do something ten hours . . . I didn’t think I could do it. I entered what is now called a kind of a community support day program kind of a thing. rooney: So you were scared that you couldn’t do it? molly: I was terrified! I was terrified to do it. I was scared I would somehow lose the house I was living in, if you can call it that, it was a group home. I was terrified I would lose that house because it was a condition that I do something if I would live there. In a way I was terrified that I could do it, too. rooney: Because? What would that tell you, that you could do it? molly: Um, it would just . . . It scared me because it would create so much confusion. After so many years of being told I would go nowhere by people that were supposed to know what they were doing, or saying, it would just create too much confusion. If I could do something ten hours a week, that would mean all these people all these six years were wrong. rooney: That they made a mistake. molly: They had made a mistake.

Assessing Initial Contacts in Involuntary Transactions Molly describes a state of ambivalence, caught between desires to change and fear of changes. Rather than describe such as state as resistance, the stages of change concept of contemplation describes this ambivalence more positively. That is, contemplation (Di Clemente and Velasquez 2002) captures the idea of a mental state in which a person is considering change but is not ready to make a commitment to action. With this definition, contemplation can be seen as an opportunity for a targeted intervention and increasing client motivation to change. Other behaviors often grouped under the term “resistance” may in fact be quite different from one another. For example, having no desire to change, as is often the case with the involuntary client, can be different from not knowing how to change or not believing change is possible. Motivation and self-efficacy, while both required for change, are very different concepts. Similarly, a negative reaction to pressure from others or a referral source may be more focused on that pressure than it is on the actual behavior. Finally, there may be a negative response to the form of treatment or the helper but not about the focus of the change effort. Each of these can be experienced as contrary to desired outcomes by a practitioner but functionally indicate quite different phenomena (Arkowitz 1996). Finally, the psychological literature has dealt almost exclusively with resistance as a negative set of behaviors that a practitioner strives to overcome. A strikingly different perspective is one that describes some behavior labeled “resistant” to be indicative of coping and surviving an oppressive environment (Robinson and Davis-Kennington 2002). For example, having a negative attitude about the potential for change, being inclined to grasp onto quick relief to escape chronic problems, and expressing an external locus of control in the sense of a belief that events control you more than you control events can all be seen as ways by which people cope with a hostile, unsupportive environment. That is, this view validates that it is not just “all in the head” of the involuntary, resistant client, but rather possibly in part a natural response to an unsupportive environment.

Reactance Theory The experienced practitioner knows that by whatever name it is called, opposition from involuntary clients frequently occurs and that opposition is uncomfortable for the practitioner. While one might admire the ingenuity of Martin’s efforts to bend the rules, one might also be frustrated and angry. Concepts are needed that describe responses to involuntary situations under the pressure of coerced and constrained choices. These concepts need to acknowledge practitioner discomfort while moving beyond blaming the client to suggest positive resolutions to expectable tension. Reactance theory provides

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Practice Strategies for Work with Involuntary Clients an empirically based description of the behavior of persons in pressured situations. I often introduce reactance theory in classes and workshops with the following exercise. Think about a situation in which you have been forced to do something against your will. Now, write down your thoughts, feelings, and actions in that situation as you remember them. What do practitioners and students report? The most frequent thoughts about the coerced situations are: “Why me?” “I don’t deserve this.” “How can I get out of this?” “What are my rights?” “Can I appeal to a higher authority?” “This isn’t fair.” The feelings most frequently reported are: “I felt powerless . . . angry . . . frustrated . . . vengeful . . . confused . . . self-doubting.” The most frequent actions reported are: “I did what was required but I sabotaged the requirement.” “I complied verbally, but didn’t follow through.” “I did just enough to get by.” “I delayed, procrastinated.” “I went along passively, without sharing my true feelings.” “I complained bitterly.” “I talked to others and tried to get them to rebel.” “I went along and tried to make the best of it.” “I did what I wanted within their boundaries.” “I took out my anger on someone outside the situation.” “I refused to do it and took the consequences.” After this exercise, practitioners and students are often struck with how much negative thinking, feeling, and half-hearted compliance, and how little “positive experience with authority” is reported. They also note how similar their responses are to involuntary clients. Reactance Theory suggests these responses are typical. In fact, these sorts of responses to pressured situations may be more normal, predictable, and nonpathological than is often thought; most people respond to pressure or coercion with some type of resistance. Reactance theory assumes that we each have behaviors that we are free to exercise (Brehm et al. 1966). Should some of these free behaviors be threatened or eliminated, the theory suggests that a person will experience reactance. Reactance is often expressed as one or more of five different direct or indirect response patterns designed to regain those freedoms (Brehm 1976). 1. Direct efforts are those in which the person attempts to recapture the freedom directly, in spite of the consequences. We see this effort to restore freedom directly in Martin’s brief attempt to negotiate overnight privileges. 2. As many freedoms cannot be restored directly, efforts may focus on restoring them indirectly. For example, a person may try to restore freedom by implication through violation of another of the same class of behavior: “finding a loophole” or breaking a norm without technically violating the rules. Martin appeared to be a master at the “loophole” strategy. While he followed rules about overnights to the letter, he undercut the spirit and purpose of the rules by staying up all night and sleeping in class. This loophole pattern was also frequently reflected in practitioner responses such as: “I did what was required but I sabotaged the requirement.” When practitioners use this strat-

Assessing Initial Contacts in Involuntary Transactions egy, they may consider it clever. When clients use it, practitioners may label it passive-aggressive. 3. Another form of indirect restoration occurs when reactance is reduced by observing another person attempting to restore freedom or attempting to incite others to perform forbidden behaviors. Martin may have reduced his reactance by convincing fellow residents to bend the unwritten rules about getting adequate rest; their reactance may have been reduced by watching Martin’s antics. 4. If a person is blocked from expressing their reactance either directly or indirectly such that they have to “sit” on their reactance, their desire for the forbidden behavior increases (Brehm 1976). Readers who have given up an addictive habit such as smoking can attest to a rise in the attraction of the prohibited behavior. Martin’s preoccupation with overnights may be explained by this pattern. The preoccupation ended when he was given permission to take them: yet he rarely used the privilege after it was earned! 5. Reactance may also be expressed in the form of hostility or aggression toward the source of the threat, even when it is unlikely to restore freedom. The practitioner response that “I complained bitterly” might fit this pattern. Reactance research suggests that adolescents may be more likely to use this than their elders. The five reactance patterns are familiar and sound like many of the behaviors grouped under the pejorative definition of resistance. Reactance theory, however, is similar to the reframed definition of resistance in describing responses to unwanted change in a normalizing fashion. It goes beyond the reframed view of resistance to provide a base of theory and empirical study that helps predict when reactance will occur and how it might be reduced. Whether reactance is likely to occur and to what extent can be predicted by five factors. First, a person must have expected that they had the freedom to begin with and felt competent to exercise that freedom. Reactance occurs in relation to threats to free behavior. In the videotaped interview with Molly Morgan, she describes her response to the institutionalized living environment. rooney: So among the things you found there, went along with, what I call the package deal of being in the safe environment, was that you were in a locked ward. What were other things you found? molly: Well my freedom was taken away from me . . . even what to do with my time. At one hospital with adults, we had nap time. Everyone had to go in these small little rooms for a certain amount of time. rooney: How did that make you feel? molly: It made me feel angry. What if I don’t want to nap, or I don’t feel tired? There wasn’t a choice. You just had to do it as part of being a patient.

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Practice Strategies for Work with Involuntary Clients Molly is describing the freedom to decide whether she wanted to take a nap or not as an expected freedom as an adult. Over time, Molly’s reactance to events such as required nap time diminished. A second factor is that repeated efforts to restore freedom that do not succeed may lead to learned helplessness. That is, a person may learn not to try in response to uncontrollable outcomes (Wortman and Brehm 1975). Earlier in the discussion about secondary deviance, Molly said: I think it felt pretty hopeless. They were telling me for the rest of my life someone is going to put a roof over my head and I’m not going anywhere and I believe I saw a therapist at that time, but I don’t know why. If no one believed I was going anywhere, why see a therapist? But they just believed that until my doctor or whatever . . . that’s the most anyone could expect out of me. I would live where someone would put me or feed me or whatever. . . . A doctor told me that that was the prognosis and told me what it meant and I kind of lost all kind of hope that I was going to do anything, so I didn’t really try. I just laid around in bed and did what’s expected of a hopeless person I guess . . . nothing. The first response to a loss of control is an attempt to reassert control. If those efforts are not successful over a period of time, efforts to reassert control are curtailed (Wortman and Brehm 1975). Such learned helplessness appears to be stimulated in a variety of environments in which such efforts to assert oneself are unlikely to succeed. For example, Goldsmith, Veum, and Darity (1996) found that unemployment, particularly longer periods of unemployment, were linked to feelings of helplessness and lower levels of self-efficacy. Third, reactance occurs in relation to the importance or unique value of threatened behaviors to fulfill needs. If valued freedoms can be maintained with means still available, then the threatened freedom may not have unique value. It is not unusual for child welfare workers to be working with a female single parent who is attached to a male who is considered to represent a risk for her or her children. Efforts to persuade her to shed or loosen ties to the male often act to raise reactance and reinforce how important he is to her. It he finds her attractive, provides adult company, and assists with children, these factors may eclipse his deficits in her eyes. Should he represent a risk to her and her children, it is important to acknowledge the attributes he represents for her as well as those risks. She might be helped to consider how else she could get her own and her children’s needs met should she choose to distance herself from him. Fourth, reactance will be high if a person loses even a few freedoms if the person has few freedoms left. Reactance occurs in relation to the proportion of freedoms threatened or eliminated. If the number of choices is small,

Assessing Initial Contacts in Involuntary Transactions removing any of them will cause considerable reactance (Brehm et al. 1966). Martin’s strong response to the withdrawal of freedom to have overnights might be explained by overnights being one of few valued freedoms left to him. Group home staff members have mentioned that withdrawal of telephone privileges is perceived as a very severe penalty by group home residents. This may be explainable in terms of the limited number of free behaviors available. Fifth, reactance is higher if there is an implied threat to other freedoms beyond those that are immediately threatened. For example, overnights may symbolize a continuation of a private social life for Martin, a connection with friends. Any threat to the overnights may stimulate reactance more because of the implied threat to these other freedoms than for the loss itself. These factors then help predict whether reactance might occur and how strong it will be. Can reactance then be predicted primarily through situational variables? What about individual differences? Martin appeared to experience every kind of reactance. Could some persons experience more reactance than others? While reactance theory comes from a social psychology tradition that does not emphasize individual differences, there are indications that some individuals are more likely to experience reactance than others. Reactance has been studied as an individual variable that is stable over time and associated with behaviors that are not promising for the process and outcome of psychotherapy (Dowd, Milne, and Wise 1991). For example, Dowd has developed a Therapeutic Reactance Scale (TRS) that measures reactance as a relatively enduring characteristic across situations. Those who rank high on the scale also score high on dominance, autonomy, aggressiveness, and minimal concern for impressions on others. They were also more likely to be dominant, quick to take offense, and frequently in conflict with authority. Finally, persons scoring high on the TRS were relatively careless of obligations, intolerant of beliefs, inclined to resist rules, and likely to express strong emotions (Dowd et al. 1994). In a study in which therapists rated improvement in functioning and compliance with medication, reactance was negatively associated with global improvement and positively associated with premature termination (Seibel and Dowd 1999). Reactance theory has many practice implications, including strategies designed to reduce it and others to increase it or take advantage of the fact that it is high. Sharon Brehm describes many ways that reactance can be reduced. First, a client can be aided in directly restoring his or her own freedom (Brehm 1976). This can be done by avoiding giving directives to the client, contracting to restore freedom, and clarifying available choices. When the intake worker at the homeless community center suggested that Martin think it over before deciding whether to enter the program, this might have reduced reactance. Second, attributing behavior to the situation rather than the person reduces reactance. If Molly’s guarded prognosis had been interpreted to her as a current

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Practice Strategies for Work with Involuntary Clients situational assessment rather than a permanent judgment of her capacities, hope for possible improvement might have been stimulated. Third, emphasizing the freedoms still retained should avoid reactance. If Molly’s nap time had been presented as a quiet time in which she could choose to sleep, read, or do whatever she wished quietly, she might not have experienced reactance. Fourth, avoiding dependency implications and linkage to other behaviors reduces reactance. Consequently, reactance is reduced when behaviors to be changed are highly specific rather than broad. For example, a directive to an adolescent boy to “find a new peer group” is a global requirement that would be predicted to cause high reactance since it means the loss of much freedom. If this requirement were modified to “stay away from two specific friends” maintaining friendships with others, reactance would likely be reduced. Hence, the implied threat to other freedoms is reduced by separating requirements from what remains free. The staff may have reduced Martin’s reactance by contracting with him to restore his freedom to take overnights and emphasizing the choices he could make within constraints, that is, by emphasizing specific rather than global changes, for example, “attending and participating in class daily” rather than “earning your GED.” Fifth, reactance can also be reduced by minimizing the strength of persuasion efforts. Providing more than one alternative should be considered since one-sided persuasion tends to increase reactance. When Molly experienced deinstitutionalization through a release to live in the community, she reported at first that she was fearful that she would fail in the requirement that she spend ten hours per week in outside programming and jeopardize her community living arrangement. She found, however, that there were many ways that she could fill those ten hours. rooney: What happened then, when you went out, and did those ten hours? molly: I was scared for maybe a week. I got out and went out to a place called Vale Place and I loved it. I could be around people. I could help by writing a newsletter, or typing on the typewriter, and I learned I could do something. So I was really only scared for about a week. And I went from ten hours a week to almost ten hours a day. The preceding example shows how clients may feel empowered through expanding choices. Clients with high levels of reactance are less successful when practitioners use directive approaches (Karno and Longabaugh 2005). Clients may be more willing to try new behaviors if the practitioner does not overemphasize them. Greater pressure may be counterproductive and produce a boomerang effect. For example, when family members, friends, or practitioners pressure an individual to decrease self-harming behaviors (e.g., smoking, consuming alcohol), these pressures can trigger reactance and actually increase use instead of diminishing it. The response to this increase in nega-

Assessing Initial Contacts in Involuntary Transactions tive behaviors is often an increase in pressure, creating more reactance and more negative behavior; an “ironic, problem-solving loop” (Shoham, Trost, and Rohrbaugh 2004:180). Strategies are also available to increase reactance, or to take advantage of the fact that reactance is high. Reactance can be increased by heightening the importance of the free behavior and implying or stating threats to future freedoms (Brehm and Smith 1986). Stating the requirement of ten hours of outside programming as a condition for living in the community facility stimulated reactance in Molly. Practitioners working with involuntary clients in mandated situations may be forced by the responsibilities of their position to assess risks, danger, and law violations in such a way that reactance is likely to be heightened. Indeed “scared straight” educational programs for troubled youth were designed in part to increase reactance by making future losses of freedom due to incarceration evident. When reactance is high, it has been suggested that the use of defiance-based paradoxes may be an effective approach. Such a paradox means that one prescribes the opposite of what is desired (Rohrbaugh et al. 1981). The strategy would suggest that if reactance is high such that suggestions are not likely to be followed, a boomerang effect is to be expected, then a practitioner might take advantage of this by making a prescription he or she does not want or expect to be followed. One such approach is “symptom prescription” in which the practitioner requests that the client consciously and purposely experience the problem behaviors or symptoms (Dowd and Sanders 1994). Clients with high levels of reactance tend to resist practitioner directives, so will tend to make changes faster than directed. Studies with students with problems such as procrastination and insomnia found that those with high reactance responded better to paradoxical instructions than they did to straightforward directive advice in resolving the issue (Shoham-Saloman 1989). For example, directives to make a record of the procrastination or insomnia without trying to change it actually resulted in more successful efforts to change the behavior than straightforward advice for those with high reactance (ibid.). Other studies have been less supportive of the positive effect of defiance-based paradoxes with reactant persons (Dowd et al. 1988). Regardless of the effectiveness, caution needs to be exercised in using paradoxical interventions; ethical issues are present when practitioners manipulate clients into changing or not changing behaviors (Miller and Rollnick 2012). Shoham and Rohrbaugh have studied the interaction of couples in which one partner had a drinking problem and the spouse made persistent efforts to persuade the partner to quit. Well-intentioned efforts to resolve problems sometimes make them worse. Persisting in those efforts despite their failure has been called an ironic process (Shoham and Rohrbaugh 1997; Wegner 1997; Rohrbaugh and Shoham 2001). For example, a spouse may use nagging to influence a partner to reduce harmful drinking. If, however, the nagging itself

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Practice Strategies for Work with Involuntary Clients produces a boomerang effect of increasing attraction to drinking, then it has become an ironic process (Rohrbaugh and Shoham 2001). Reducing the demand for change and emphasizing freedom of choice was more successful in reducing drinking behaviors (Rohrbaugh 1999). Similarly, clients high in reactance are not responsive to high levels of practitioner directiveness and have more success with nondirective interventions (Karno and Longabaugh 2005). Practitioners working with involuntary clients should readily see the dangers of ironic processes in their work. They are called on to enforce laws and alert clients to dangers. The monitoring of the problem and attention to it may act, ironically, to reinforce it (Wegner 1997). Awareness of such a process in work with involuntary clients is paralleled in solution-focused methods where the focus of attention is on goals rather than on problems (de Jong and Berg 2001).

Assessment of the Value of Reactance Theory to Work with Involuntary Clients Reactance theory makes a major contribution to understanding work with involuntary clients from a transactional perspective. It suggests that pressures generating reactance can be personal or in response to direct coercion (like coerced choice), impersonal or constraining barriers that make engaging in a behavior more difficult or impossible (like constrained choice), or even selfimposed. Reactance theory helps unlock the puzzle of how some persons can lose many freedoms yet not seem involuntary, while others may lose what appears to be insignificant freedom and yet experience a great deal of reactance. As Sharon Brehm notes: “Thus what may look to the observer like a mild threat directed at what appears to be an insignificant freedom on other grounds, such as importance or proportion of freedoms threatened, may to the person appear to be a threat of considerable magnitude, especially when other freedoms are implicated” (Brehm 1976:19). Reactance theory appears to be a very promising source of hypotheses for intervention and research with involuntary clients. Debate continues in psychology about the extent to which reactance occurs as a response to threatening situations as opposed to existing as a continuing personality characteristic across situations (Shoham-Salomon 1989). However, its pertinence is clear for situations in which choices are limited. Work with involuntary clients may often bring together both conditions for reactance. Sharon Brehm suggests that “the more people who pose threats to a person’s freedom and the more situations in which such threats occur, the more generalized and diffuse a person’s anger may be” (Brehm 1976:21). That is, many involuntary clients in settings such as corrections and domestic violence treatment may be likely to score high on instruments such as the Therapeutic Reactance Scale, such that reactance across situations

Assessing Initial Contacts in Involuntary Transactions may be predicted (Chovanec 1995). On the other hand, such settings are likely to stimulate reactance in many recipients of ser vice whether or not they are likely to experience reactance in other settings. Consequently, increased attention to reactance theory in relation to involuntary populations, problems, and settings is in order. In fact, failure to attend to the promise of reactance theory in such circumstances may approximate an ironic process whereby methods are repeatedly used with involuntary clients that are intended to reduce the problem but may result instead in heightened reactance and aggravation of the problems.

Strategic Self-Presentation Clients are often urged to be absolutely candid to get the most benefit from treatment. However, individuals in all types of situations, including clients receiving ser vices, work to manage others’ impressions of them (Leary and Kowalski 1990). There is evidence that suggests that clients often attempt to put their situation in the best light by selective reporting so that the therapist or other expert will look favorably on them, especially in the initial meeting (Fruhauf, Figlioli, Bock, and Caspar 2015). Keeping secrets from therapists is common, particularly for clients with less symptomology (Kelly 1998). Therapists may not be entirely candid either for fear that the client might think less well of them (Kelly 2000). “Strategic self-presentation” refers to efforts to manage the impressions others have of us in order to better reach our goals (Friedlander and Schwartz 1985). Self-presentation efforts are most often made when the stakes are high. Consideration of this concept is introduced with a third case study. Irv and Joan were originally voluntary clients in the sense that there was no external pressure for them to get a divorce. As a precondition for granting the divorce, a court ordered them to participate in mediation about visitation and custody for their two children, ages four and five. Should mediation fail, the court would appoint a professional to make a custody recommendation. Both Irv and Joan were hesitant about court-ordered mediation and had even more reservations when they were assigned to a mediator who was a social work student in a field placement. While both wanted the divorce, the court-ordered mediation and assignment to the student mediator came as a less desirable part of a “package deal.” Irv and Joan can be considered to have chosen participation in mediation as a constrained choice from a formal pressure source.

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Practice Strategies for Work with Involuntary Clients Joan, as the primary care provider, was concerned about the children’s safety when they were with Irv since he had unsuccessfully completed alcoholism inpatient treatment twice, did not want to return for more treatment, and did not see drinking as a problem that should affect custody. Meanwhile, Irv insisted on joint legal custody with primary physical custody remaining with Joan. Joan said that she would consider joint custody only if Irv would agree to not drink before or during visits.

The student mediator’s supervisor felt that Irv’s alcoholism would prevent him from keeping his promise not to drink. Hence, she recommended to the student that no mediation be attempted until Irv agreed to complete chemical dependency treatment once again. The student mediator, however, wanted to explore mediation with stipulated conditions about drinking and later wrote: “The more I was told to discontinue working with this couple, the more attractive the other alternatives became.” The student mediator persisted in the negotiation of an agreement in which Irv would lose joint legal custody if he violated the agreement about drinking before or during visits and attorneys for both parents supported this recommendation. The student mediator wrote later that during the sessions “Irv seemed to readily accept what I said, agree with my advice, observations, and interpretations. If he didn’t agree, he avoided the issue or changed the subject. Perhaps this influenced my desire to work with them.” Irv’s behavior may strike us as less than candid. Just as the student mediator and other practitioners might try to create a particular impression such as empathy, competence, and fairness, involuntary clients may present selected parts of themselves in order to achieve particular goals, as in this case in which visitation of children and a possible return to chemical dependency treatment are the goals. Irv might have chosen to tell his wife and student mediator that he had no problems with alcohol, that they should mind their own business, or that he was entitled to visitation. While this response might have been candid, it might also have prevented Irv from reaching his goal of regular visitation. Irv’s quick agreement to the mediator’s recommendation, on the other hand, influenced the mediator’s willingness to work with the couple. The six self-presentation strategies include ingratiation, intimidation, facework, supplication, self-promotion, and exemplification. Irv may have used ingratiation, which refers to attempts to make oneself more attractive in order to influence a person in power to act favorably (Jones 1964). Ingratiation usually takes the form of flattery, public agreement with the opinions of the other despite possibly conflicting private views, overemphasizing one’s own positive

Assessing Initial Contacts in Involuntary Transactions traits, and deemphasizing the negative. Ingratiation efforts are covert, since their discovery might interfere with the goal of a better impression. Efforts to ingratiate are more likely to occur when one is in a dependent position and the stakes are high, when there are no onlookers who might spot the insincerity of the effort, and when the actors feel the circumstances of their dependency are unfair (ibid.). In this case, Irv’s efforts might have been spotted as ingratiating by Joan. She might have chosen not to expose the ingratiation because she shared the goal of receiving mediation. There are also indications that ingratiation may be rewarded if a person in power is simultaneously being threatened by others in a similar lower power position (Jones and Pittman 1982). For instance, other more compliant, ingratiating residents of the homeless community might have indirectly benefited from the contrast to Martin’s challenging behavior. The student mediator noted after the case that “it took me a while to figure out that I was not that good at my job but that he was just good at letting me think I was. Perhaps, without realizing it, his behavior influenced my decision to work with these clients and not follow the conventional policies about substance use disorders in mediation.” Are there some persons who are more susceptible to ingratiation than others? Higher-power persons who believe in cooperation, understanding, and cohesion with the lower-power person and have high self-esteem, may be more susceptible to ingratiation than others without these views and with lower self-esteem. Not all clients or practitioners in involuntary situations ingratiate. Intimidation is often used to influence the target person by creating a fearful impression. Threats may be direct, or messages may be given such as “I can’t tolerate stress” or “I am not responsible for what I do if I get angry.” Intimidation is often used in involuntary situations when the intimidator has resources to which the target does not have access, when the target cannot easily retaliate, and when the intimidator is willing to forgo good will (Jones and Pittman 1982). Consequently, intimidation may be attractive to the practitioner. There are many practice situations, however, in which involuntary clients appear to use intimidation when they do not have resources and the practitioner can retaliate. Such strategies may be overlearned and inappropriately generalized from other situations in which they were successful. A third strategy is supplication, in which clients point out their own negative characteristics, advertise their dependency and inability to cope, and throw themselves at the mercy of the higher-power person in an effort to acquire sympathy and support. Research has shown this to be one of the most commonly used strategies at intake meetings (Fruhauf, Figlioli, Bock, et al. 2015). Supplication is most likely to be used in crises, when the higher-power person controls key rewards and can use that power arbitrarily. Supplication may be costly to the self-esteem of the person using it and may not succeed with persons who do not recognize a responsibility to help the defenseless (Jones and

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Practice Strategies for Work with Involuntary Clients Pittman 1982). In fact, in some cases the use of supplication as an impression management technique is negatively related to the ser vice provider’s rating of the therapeutic alliance (Fruhauf, Figlioli, Oehler, et al. 2015). A fourth strategy common in involuntary situations is facework, in which a lower-power person, anticipating blame from a higher-power person, may deny the charge, justify his or her actions, or selectively confess to particular problems in order to diffuse the impact of anticipated negative feedback. Self-promotion is similar to ingratiation in that it emphases one’s best qualities. However, the focus is on creating an impression of competence rather than likeability. Along with supplication, self-promotion is one of the most commonly used strategies for impression management in an initial meeting (Fruhauf, Figlioli, Bock, et al. 2015). Self-promotion may be more likely in situations in which there are conflicting claims about competence. Finally, exemplification strategies refer to efforts to convey an impression of integrity and moral worthiness. Practitioners may be inclined to self-promote with clients to create an impression of competence and to use exemplification to point out their best qualities (Friedlander and Schwartz 1985). Indeed, most of us have probably utilized self-promotion and exemplification in job interviews when asked, for instance, to describe our weaknesses and responded with an admission that perhaps we work too hard and take the job home with us. This tactic appears to be fairly successful. One study found that the use of self-promotion strategies was positively linked to the provider’s opinion of the therapeutic alliance (Fruhauf, Figlioli, Oehler, et al. 2015). Impression management theorists suggest that these strategies may be used selectively, simulta neously, or not at all. They may not be used when a person is very involved with the task at hand and when the person is particularly motivated to be candid. Strategies are stimulated by desires to increase power. Two or more strategies may be used simulta neously such as ingratiation, self-promotion, and supplication. Use of particular strategies may be influenced by personality variables and may be fairly consistent across situations. Strategic self-presentation is particularly pertinent for older adults in our society. Specifically, many feel that they must present themselves as competent, self-reliant, and fitting social norms or they might risk losing independence (Martin, Leary, and Rejeski 2000). Meanwhile other elders may exaggerate their complaints with apparent hypochondriasis in order to have their complaints taken seriously, with the goal of avoiding the perception of being old and less competent. Self-presentation is often difficult to maintain in pressured situations (Vohs, Baumeister, and Ciarocco 2005). While the strategic self-presentation strategies ring true with the responses of many involuntary clients, there is once again danger of creating new labels for “the ingratiator” and “the intimidator.” Self-presentation strategies can offer normalizing explanations for irritating behavior that has often been

Assessing Initial Contacts in Involuntary Transactions labeled as a personality deficit rather than a situational response. Clarifying the realities of power, including how to regain lost power, may go a long way toward reducing their use.

Conclusion This chapter has explored the assessment of initial interactions between involuntary clients and practitioners, suggesting that involuntary client behavior in first contacts may be a sample of behavior under high stress or response to authority. Consequently, efforts to generalize from those responses to behavior outside the assessment situation are of questionable value. Explanations of initial session behavior that focus on internal causes have been overemphasized, while explanations focusing on transactional perspectives have been underemphasized. Four such transactional perspectives have been presented in an effort to augment and correct for some of the blinders of the individual pathology focus. Social labeling theory has provided insights into the process of identifying persons who will be labeled deviant and the role the practitioner and agency responses may have in rewarding and maintaining that deviance. Describing involuntary clients as resistant is a frequent source of deviant labeling that might be reduced by reframing resistance to refer to normal responses to unwanted pressures to change that may occur to clients, practitioners, and agencies. Reactance theory concepts have been presented as rich sources of hypotheses in predicting when these oppositional responses may occur and specific strategies to reduce reactance have been described. Self-presentation strategies used by practitioners and clients have been explored for insights into behavior involving differences of power. These perspectives have suggested proactive guidelines for increasing sensitivity to a transactional perspective: 1. Practitioners can be aware of their own settings and their own use of power as factors influencing the involuntary transaction. 2. Practitioners can be more aware of client responses in the involuntary transaction as explainable in part by the circumstances of the transaction and not necessarily as pathology or labeled as resistance. Normalizing explanations for client oppositional behavior can be used including responses to deviant labeling, reactance responses, and efforts to manage impressions. 3. Practitioners can reduce deviant labeling by sticking to the facts and the objective consequences of behavior. 4. Practitioners can reduce reactance and efforts to manage impressions by clarifying the requirements of the situation, specifying the limits

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Practice Strategies for Work with Involuntary Clients to that power, specifying changes needed to regain freedom, emphasizing choices, and pointing out remaining free behaviors.

Discussion Questions 1. How is the term “resistance” used in your work setting? What are the implications for practice of its use? 2. What are the implications for deviant labeling and secondary deviance in the use of diagnostic and administrative categories for assessing clients in your setting? 3. What are the implications of expectations that both clients and practitioners might be expected to be less than fully candid with one another but rather to present themselves in the best light? 4. What is the value of viewing reactance as a situational variable? What are the implications of high ratings on reactance scales of many clients in your setting? 5. What are the implications for use of paradoxes or prescribing the symptom with reactant involuntary clients? For example, would you agree with a truant adolescent who feels that attendance is out of his or her control?

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Assessing Initial Contacts in Involuntary Transactions Chovanec, M. G. 1995. “Attrition in the Treatment of Men Who Batter: A Closer Look at Men’s Decision-Making Process About Attending or Dropping Out of Treatment.” Proceedings of the Eighth National Symposium on Doctoral Research and Social Work Practice, Ohio State University, November 3–4. Conrad, P., and J. W. Schneider. 1992. Deviance and Medicalization: From Badness to Sickness. Philadelphia, PA: Temple University Press. Council on Crime and Justice. 2006. “An Analysis of Racial Disproportionality in Juvenile Confinement.” https://static.prisonpolicy.org /scans/ccj/Final _ DMC _ II _ Report.pdf. De Jong, P., and I. K. Berg. 2001. “Co-constructing Cooperation with Mandated Clients.” Social Work 46 (4): 361–374. DiClemente, C., and M. Velasquez. 2002. “Motivational Interviewing and the Stages of Change.” In Motivational Interviewing: Preparing People for Change, eds. W. R. Miller and S. Rollnick, 201–216. New York: Guilford Press. Dowd, E., S. Hughes, L. Brockbank, and D. Halpain. 1988. “Compliance-Based and DefianceBased Intervention Strategies and Psychological Reactance in the Treatment of Free and Unfree Behavior.” Journal of Counseling Psychology 35 (4): 370–376. Dowd, E., C. Milne, and S. Wise. 1991. “The Therapeutic Reactance Scale: A Mea sure of Psychological Reactance.” Journal of Counseling and Development 69 (6): 541–545. Dowd, E. T. F., and D. Sanders. 1994. “Re sistance, Reactance, and the Difficult Client.” Canadian Journal of Counseling 28 (1): 13–24. Dowd, E. T., F. Wallbrown, D. Sanders, and J. M. Yesenosky. 1994. “Psychological Reactance and Its Relationship to Normal Personality Variables.” Cognitive Therapy and Research 18 (6): 601–612. Epstein, L., and L. Brown. 2002. Brief Treatment and a New Look at the Task- Centered Approach. 4th ed. New York: Macmillan. Ewalt, P. 1982. “Understanding Resistance: Seven Social Workers Debate.” Practice Digest 5: 5–24. Fenichel, O. 1945. The Psychoanalytic Theory of Neuroses. New York: W. W. Norton. Forrester, D., D. Westlake, and G. Glynn. 2012. “Parental Resistance and Social Worker Skills: Towards a Theory of Motivational Social Work. Child and Family Social Work 17 (2): 118–129. Friedlander, M., and G. Schwartz. 1985. “ Toward a Theory of Strategic Self-Presentation in Counseling and Psychotherapy.” Journal of Counseling Psychology 32 (4): 483–501. Frost, A. 2004. “Therapeutic Engagement Styles of Child Sexual Offenders in a Group Treatment Program: A Grounded Theory Study.” Sexual Abuse: A Journal of Research and Treatment 16 (3): 191–208. Fruhauf, S., P. Figlioli, J. Bock, and F. Caspar. 2015. “Patients’ Self-Presentational Tactics as Predictors of the Early Therapeutic Alliance.” American Journal of Psychotherapy 69 (4): 379–397. Fruhauf, S., P. Figlioli, D. Oehler, and F. Caspar. 2015. “What to Expect in the Intake Interview? Impression Management Tactics of Psychotherapy Patients.” Journal of Social and Clinical Psychology 34 (1): 28–49. Germain, C. 1982. “Understanding Resistance: Seven Social Workers Debate.” Practice Digest 5: 5–24. Gibson, M. 2014. “Shame and Guilt in Child Protection Social Work: New Interpretations and Opportunities for Practice.” Child and Family Social Work 20 (3): 333–343. Gitterman, A. 1983. “Uses of Resistance: A Transactional View.” Social Work 28 (2): 127–131. Goldsmith, A. H., J. R. Veum, and V. W. Darity. 1996. “The Psychological Impact of Unemployment and Joblessness.” Journal the Socio-Economics 25 (3): 333–358.

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Practice Strategies for Work with Involuntary Clients Gove, W. 1970. “Societal Reaction as an Explanation for Mental Illness: An Evaluation.” American Sociological Review 35 (5): 873–884. Henning, K., A. Jones, and R. Holdford. 2005. “ ‘I did not do it but if I did, I had a good reason’: Minimization, Denial and Attributions of Blame Among Male and Female Domestic Violence Offenders.” Journal of Family Violence 20 (3): 131–138. Hepworth, D. H., R. H. Rooney, G. Rooney, and K. Strom-Gottfield. 2016. Direct Social Work Practice: Theory and Skills. 10th ed. Boston: Cengage. Iversen, R., K. Gergen, and R. Fairbanks. 2005. “Assessment and Social Construction: Conflict or Co- Creation?” British Journal of Social Work 35 (5): 689–708. Jones, E. 1964. Ingratiation: A Social Psychological Analysis. New York: Appleton-Century. Jones, E., and T. Pittman. 1982. “Toward a General Theory of Strategic Self-Presentation. In Psychological Perspectives on the Self, ed. J. Suls, 231–262. Hillsdale, NJ: Erlbaum. Karno, M. P., and R. Longabaugh. 2005. “Less Directiveness by Therapists Improves Drinking Outcomes of Reactant Clients in Alcoholism Treatment.” Journal of Consulting and Clinical Psychology 73 (2): 262–275. Kelly, A. 2000. “Helping Construct Desirable Identities: A Self-Presentational View of Psychotherapy.” Psychological Bulletin 126 (4): 475–494. Kelly, A. E. 1998. “Clients’ Secret Keeping in Outpatient Therapy.” Journal of Counseling Psychology 45 (1): 50–57. Kirk, S. 1972. “Clients as Outsiders: Theoretical Approaches to Deviance.” Social Work 17 (2): 24–32. Kroner, D., and J. Mills. 2004. “The Criminal Attribution Inventory: A Measure of Offender Perceptions.” Journal of Offender Rehabilitation 39 (4): 15–29. Leary, M. R., and R. M. Kowalski. 1990. “Impression Management: A Literature Review and Two Component Model. Psychological Bulletin 107 (1): 34–47. Li, L., and D. Moore. 2001. “Disability and Illicit Drug Use: An Application of Labeling Theory.” Deviant Behavior 22 (1), 1–21. Link, B. 1987. “Understanding Labeling Effects in the Area of Mental Disorders: An Assessment of the Effects of Expectations of Rejection.” American Sociological Review 52 (1): 96–112. Lohrbach, S., and R. Sawyer. 2004. “Creating a Constructive Practice: Family and Professional Partnership in High-Risk Child Protection Case Conferences.” Protecting Children 19: 26–35. Lohrbach, S., R. Sawyer, J. Saugen, C. Astolfi, K. Schmitt, P. Worden, and M. Xaaji. 2005. “Ways of Working in Child Welfare: A Perspective on Practice.” Protecting Children 20 (2/3): 93–100. Mahalik, J. 1994. “Development of the Client Resistance Scale.” Journal of Counseling Psychology 41 (1): 58–68. Martin, K., M. Leary, and W. Rejeski. 2000. “Self-Presentational Concerns in Older Adults: Implications for Health and Well-Being.” Basic and Applied Social Psychology 22 (3): 169–179. Merton, R. 1980. “Social Structure and Anomie.” In Theories of Deviance, eds. S. Traub and C. Little, 2nd ed., 105–138. Itasca, IL: F. E. Peacock. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Preparing People for Change. New York: Guilford. Mirick, R. 2012. “Reactance and the Child Welfare Client: Interpreting Child Welfare Parents’ Re sistance to Ser vices through the Lens of Reactance Theory.” Families in Society: The Journal of Contemporary Social Services 93 (3): 165–172.

Assessing Initial Contacts in Involuntary Transactions Nelsen, J. 1975. “Dealing with Re sistance in Social Work Practice.” Social Casework 56 (1): 587–592. Nooe, R. 1980. “A Model for Integrating Theoretical Approaches to Deviance.” Social Work 25 (5): 366–370. Oliver, C., and G. Charles. 2016. “Enacting Firm, Fair, and Friendly Practice: A Model for Strengths-Based Child Protection Relationships.” British Journal of Social Work 46 (4): 1009–1026. Parton, N., and P. O’Byrne. 2000. Constructive Social Work: Towards a New Practice. London: Macmillan. Robinson, T., and P. Davis-Kennington. 2002. “Holding up Half the Sky: Women and Psychological Resistance.” Journal of Humanistic Counseling, Education and Development 41 (2): 164–177. Rohrbaugh, M. 1999. “Demand-Withdraw Interaction and the Ironic Maintenance of Alcoholism.” Symposium conducted at the meeting of the American Psychological Society, Denver, Colorado, June. Rohrbaugh, M., and V. Shoham. 2001. “Brief Therapy Based on Interrupting Ironic Processes: The Palo Alto Model.” Clinical Psychology: Science and Practice 8 (1): 6–81. Rohrbaugh, M., H. Tennen, S. Press, and L. White. 1981. “Compliance, Defiance and Therapeutic Paradox: Guidelines for Strategic Use of Paradoxical Interventions.” American Journal of Orthopsychiatry 51 (3): 454–467. Sagarin, E. 1975. Deviants and Deviance. New York: Praeger. Seibel, D., and E. Dowd. 1999. “Reactance and Therapeutic Noncompliance.” Cognitive Therapy and Research 23 (4): 373–379. Shoham, V., and M. Rohrbaugh, 1997. “Interrupting Ironic Processes.” Psychological Science 8 (3): 151–153.Shoham, V., S. E. Trost, and M. J. Rohrbaugh. 2004. “From State to Trait and Back Again: Reactance Theory Goes Clinical.” In Motivational Analyses of Social Behavior: Building on Jack Brehm’s Contributions to Psychology, eds. R. A.Wright, J. Greenberg, and S. S. Brehm, 167–183. Hillsdale, NJ: Lawrence Erlbaum Associates. Shoham-Salomon, V. 1989. “You’re Changed If You Do, Changed If You Don’t: Mechanisms Underlying Paradoxical Interventions.” Journal of Consulting and Clinical Psychology 57(5): 590–598. Skeem, J. L., J. E. Louden, D. Polaschek, and J. Camp. 2007. “Assessing Relationship Quality in Mandated Community Treatment: Blending Care with Control.” Psychological Assessment 19 (4): 397. Thio, A. 1978. Deviant Behavior. Boston: Houghton-Mifflin. Turkat, I., and V. Meyer. 1982. “The Behavior Analytic Approach.” In Resistance: Psychodynamic and Behavioral Approaches, ed. P. Wachtel, 157–184. New York: Plenum Press. Vohs, K., R. Baumeister, and N. Ciarocco. 2005. “Self-Regulation and Self-Presentation: Regulatory Resource Depletion Impairs Impression Management and Effortful Self-Presentation Depletes Regulatory Resources.” Journal of Personality and Social Psychology 88 (4): 632–657. Wegner, D. 1997. “When the Antidote Is the Poison: Ironic Mental Control Processes.” Psychological Science 8 (3): 148–150. Wortman, B., and J. Brehm. 1975. “Responses to Uncontrollable Outcomes: An Integration of Reactance Theory and the Learned Helplessness Model.” In Advances in Experimental Social Psychology, ed. L. Berkowitz, vol. 8, 278–336. New York: Academic Press.

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Chapter 8

Initial Phase Work with Individual Involuntary Clients

Rebecca Mirick

Dora, twenty-nine, had a serious and persistent mental illness. While she had always lived with her parents, she now wished to leave home and move to a public housing project. The housing staff required that Dora either complete an independent skills program or live in a group home for three months before they would agree to let her live in their project. At her next meeting with the county social ser vice case manager, the following transpired. practitioner: Last month when we met with public housing, Dora, they suggested that before they could admit you, you would have to live in a group home for three months. dora: No, I don’t want to live in a group home. practitioner: That was definitely an option you didn’t want. The other option was to have somebody from the skills program work with you in your parents’ house on independent living skills as a way of proving to them that you could make it in their apartment program. It’s about time for me to make that referral since that is the plan that you agreed on. I’d like your okay to do that. dora: I know I agreed to work with skills, but after thinking about it these last few weeks, don’t want to work with them. I don’t want people . . . I’m dealing daily with my parents, that’s two people and then to have six or eight other people telling me what to do, telling me how to clean, doing stupid little things that are an insult to my intelligence. I don’t need people telling me how to clean.

Initial Phase Work with Individual Involuntary Clients practitioner: Right, but Dora you know the fact is you made that decision to apply for public housing and to agree to the skill program. And now you’re changing that? dora: Well, I agreed to move into an apartment, I didn’t agree to have all these people telling me what to do, breathing down my neck, making me do all these little daily things that I am capable of doing on my own. practitioner: Yeah, I know. I know, Dora, that you want your own apartment. Right? But I think you are kind of making it harder on yourself to get that. dora: Harder on myself?! (with anger) practitioner: At this point, yes. dora: These people are making it hard on me. They are the ones making all the rules that I have to live by. No one else has to live by these damn rules. Why should I? practitioner: Well, Dora, okay . . . rules are a way of life. I mean if you want something, you have to jump through some hoops to get there. That’s just the way life is. dora: I’m not going to jump through hoops. I don’t need them. I can just stay here in my parents’ house, I don’t need you. They are trying to tell me what to do and now you are doing it. Just get out of my house and leave me alone. Is Dora a client? If so, what kind of client? Potential clients and practitioners begin the initial phase with different goals and perspectives. Expectations of clients can be cast on a grid representing an active-passive continuum on one axis and a positive-negative continuum on the other (see table 8.1). Practitioners desire and prefer to work with clients who are cooperative and compliant or both active and positive (cell 1). They frequently encounter clients who are active-negative or hostile clients who are actively involved with the treatment and practitioner, but not in a positive way, though they may be compliant (cell 2). For example, some involuntary clients see treatment as an invasion of their rights (Jones 1990). Practitioners also encounter clients who are positive-passive and appear acquiescent. That is, these clients may appear to be amenable to the practitioner’s plans but are not actively involved in them (cell 3). Finally, some clients are passive-negative, such that they are not actively involved in treatment and oppose it in a passive way (cell 4). This has been termed a resistant response (Littell, Alexander, and Reynolds 2001). This matrix helps to separate demeanor from activity. Practitioners may be inclined to favor positive demeanor and unfortunately be less sensitive to activity level. That is, involuntary clients who are vocal about being unhappy about a plan yet comply with it are preferable to clients who may superficially support a plan but not act to enact it. Within the field of child welfare, clients referred by others or legally mandated are already in a circumstance in which they are

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Practice Strategies for Work with Involuntary Clients Table 8.1

Continuum of Participation Level of Activity and Cooperation

Demeanor toward interaction Active

Passive

Positive

Cooperative and compliant

Cooperative and noncompliant

Negative

Hostile and compliant

Passive and noncompliant

Source: Adapted from Littell, Alexander, and Reynolds (2001), p. 4.

likely to minimize problems identified by others (O’Hare 1996). Dora is involved with the practitioner but not in a positive way. She would be classified as hostile based on this interaction. In this chapter, we will explore means of working with mandated and nonvoluntary clients and the potentials for motivational congruence. While Dora and the practitioner originally agreed on the goal of moving to public housing, they have become entangled in a struggle about how to meet her goal, with the practitioner feeling the pressure to accede to the demands of the agency and Dora rejecting that pressure. Motivational congruence between client and practitioner on goals and methods of practice was presented in chapter 3 as an important clue for legal, ethical, and effective practice. Often, contact between involuntary clients such as Dora and their practitioners lacks congruence, as practitioners pressure involuntary clients to accept responsibility for their actions, to accede to the wishes of others, to work on the “right problems” for the “right reasons.” On the other hand, involuntary clients often appear equally determined not to acknowledge these “right” problems attributed to them by others (Levenson 2011). They may be described as “in denial” by professionals working with them, which can include denying the problem or having a distorted view of its impact or consequences (ibid.). When clients are mandated to treatment due to behavior that is dangerous to others (e.g., sexually offending, child maltreatment), this denial is particularly concerning to practitioners and they may feel more pressure to change the client’s opinion (Forrester et al. 2008; Holland 2000; Levenson 2011). Conflict between practitioner and client perspectives often leads to efforts to manipulate one another: to “hook” the involuntary client and to avoid being hooked. The practitioner may use his or her authority to push her perspective instead of using active listening and empathy to develop the initial relationship (Forrester et al. 2008). In this way, an adversarial relationship is created instead of a collaborative one. The resulting deadlock often results in

Initial Phase Work with Individual Involuntary Clients limited compliance with mandates, little self-attributed change, escalating frustration, and charges and countercharges. The cycle of charges, accusations, and defenses has been called the confrontation-denial cycle, whereby charges are met with defenses. Those defenses are interpreted by prac titioners as denial, leading to a further round of charges (Kear- Colwell and Pollock 1997). This is similar to ironic processes, whereby the very means to explore the problem may stimulate reactance and worsen the problem (Shoham and Rohrbaugh 1997). As the practitioner pushes the client harder, the client becomes more resistant to engaging in the work and making significant change. Socialization or role preparation for practitioner and client can begin to extricate the practitioner and involuntary client from this deadlock by separating the fixed and nonnegotiable from alternatives in meeting requirements and identifying rights and free choices. Completion of socialization steps can increase voluntary aspects of contact and decrease coerced aspects while working for the lasting change that is likely to occur if change is self-attributed (see chapter  5). Such self-attribution of change can be pursued with both mandated and nonvoluntary clients. Self-attribution with mandated clients occurs in a context in which compliance strategies of coercion and inducement are also employed around nonnegotiable requirements. Even when using strengths-based practices, mandated practitioners are always in a position of authority and must partly play an enforcer role. Their authority is a key part of their work at all times and must be included in any work with clients (Forrester et al. 2008; Oliver and Charles 2016). Sometimes, however, this authority role becomes the primary role, at the expense of important relationship-building skills such as active listening and empathy (Forrester et al. 2008; Smith et al. 2013). Compliance with mandates and motivational congruence can be enhanced if the mandated practitioner also plays negotiator and compromiser roles (ibid.). Persuasion, negotiation, and bargaining skills can be useful tools for practitioners to assist mandated clients in making constrained choices. Nonvoluntary clients like Dora can be helped to make informed decisions to become voluntary clients, or at least semivoluntary, or not to become clients at all. Should the nonvoluntary client choose to accept ser vices and become at least semivoluntary, the enforcer role should be limited to nonnegotiable requirements of the setting. Greater emphasis should be placed on playing the negotiator and compromiser roles as well as sometimes acting as an advocate or coach. Hence, negotiating, bargaining, and persuasion should be used more frequently with nonvoluntary clients than compliance strategies. This chapter presents preparation for initial contact, guidelines on initiating contact, and socialization steps to prepare for four negotiation and contracting strategies.

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Preparation for Initial Contact Practitioners can prepare for initial contact with involuntary clients by completing nine preparatory steps: (1) review available case information; (2) anticipate possible stage of change related to attributed problems; (3) identify nonnegotiable legal requirements (if any); (4) identify nonnegotiable agency and institutional policies (if any); (5) identify rights; (6) identify free choices; (7) identify negotiable options; (8) examine practitioner attitudes that may interfere with ser vice; and (9) make arrangements for initial contact. The extent to which each of these steps is completed depends on time available and caseload size, competing responsibilities, and amount of information available before initial contact. The sequence of these preparation tasks is depicted in figure 8.1. 1. Review available case information. Available case information should be screened to determine what brings this person in at this time. The practitioner should focus more on the specific behaviors and events reported that led to contact than on pejorative labels. For example, a supervisor might find written in Dora’s case record following the above session that Dora was “resistant, hostile, and unresponsive.” Such labels often come as part of a diagnosis focusing on client pathology without consideration of the degree to which they are based on behaviors that may be normal responses to involuntary situations. Without a description of what occurred, the accuracy of such labels cannot be assessed. We know, however, that Dora requested help in getting into an apartment. She did not request the group home living or skills program that came as a “package deal” from the housing agency. Her anger might be seen as normal given her view that she did not need to demonstrate readiness for such living arrangements. Practitioners frequently encounter such client labels in records without an account of the interaction that may have in part produced the label. 2. Anticipate possible stage of change related to attributed problems. Practitioners working with involuntary clients frequently encounter persons such as Dora whose acknowledged concerns differ from those attributed to her. Clients who come to treatment under pressure from others, such as threat of divorce, job loss, or court referral, are likely to minimize problems that have been identified by others (O’Hare 1996). Much of the frustration of work with nonvoluntary clients stems from developing action plans based on the assumption that the client sees a need for change and is prepared to proceed. The stages-of-change perspective can help the practitioner to assess whether a problem is attributed by others or acknowledged (Corcoran 2003). For example, it appears that Dora wishes to live in an apartment. That is an acknowledged problem. She does not want to go through a training skills program in order to qualify for it. That problem is attributed. Should she not be willing to con-

Initial Phase Work with Individual Involuntary Clients Figure 8.1

Preparation for initial contact

Review available information

Identify negotiable items

Anticipate possible stage of change related to attributed problem

Identify practitioner attitudes that may interfere with service

Identify free choices Determine non-negotiable legal mandates (if any)

Identify non-negotiable agency and institutional policies

Make arrangements for initial contact Identify client rights

sider the value of the skills program, she might be said to be in precontemplation on this issue. That is, she does not know about or does not anticipate adverse consequences from failure to participate, she does not anticipate changing her mind or behavior about this in the near future, and she has no faith in the ability of the program to assist her with her concerns. If pressured to change, she might make token changes as a result of coercion but would be likely to resume her current attitudes when pressure is removed (Hanson and Gutheil 2004). It is common to anticipate that clients who are pressured to accept assistance or are court ordered to do so are often in this stage related to the problem attributed to them (Peterocelli 2002). If Dora was willing to consider the problem, but ambivalent about its value, she would be in the contemplation stage. Persons in contemplation are more receptive to feedback as they are not yet convinced of the value of change. Meanwhile, it should be noted that around the concern of getting her own apartment, Dora is probably in the preparation stage as this refers to having made a decision to change but not having sustained action beyond initial steps (Miller and Rollnick 2012). Meanwhile, in the action stage, clients are prepared to make substantive changes over a more extended period and to plan and carry out exactly how to do it (ibid.). Clients who have made substantive changes over a period of time and are striving to maintain those changes and avoid a relapse are said to be in the maintenance stage (ibid.).

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Practice Strategies for Work with Involuntary Clients Stages of change are used here primarily for their heuristic value, as there are difficulties with broad application to problems that are outside the domain of the health-related concerns from which the stages-of-change model and motivational interviewing emerged (Littell and Girvin 2004). That is, many problems attributed to involuntary clients are not primarily or exclusively health related and action plans often require environmental modification, not just changes in client behavior. As the example attests, it is not uncommon for involuntary clients to be in different stages related to different attributed concerns. Knowing this has value for practitioners as they prepare for client response to problems they have not acknowledged. Passive or hostile responses to plans to work on attributed problems about which clients are in precontemplation can be anticipated. In addition, this knowledge draws attention to problems that clients acknowledge and may be prepared to address. 3. Identify nonnegotiable legal requirements (if any). In reviewing case information, the practitioner should separate what must be done legally from what might be desirable but is not required. If legal requirements do not pertain, as in Dora’s case, then the practitioner should proceed directly to step 4. What must be done legally frequently becomes confused with what the practitioner or referral source privately feels should be done. Failure to make this distinction may inadvertently sabotage the socialization and contracting process by using compliance methods on issues that are based neither on law nor on policy and may affect subsequent evaluations of effectiveness. Restricting requirements to a limited number of specific behaviors should also reduce client reactance (Brehm 1976). Consequently, mandated practitioners need to identify the federal, state, and local legal parameters that limit and guide their work with involuntary clients. Practitioners employed in fields such as child protection or probation must thoroughly understand the nonnegotiable requirements that govern their behavior and determine the extent to which client behavior can be legally required to change (Palmer 1983). For example, a mandated client might be court-ordered to participate in a substance use disorders treatment program but the extent of the mandate for the practitioner is to make the referral to the treatment program, not actually provide any of the ser vices. In many child protection agencies, while the caseworker often makes a referral, parents may choose which agency to use to obtain those ser vices. When this option exists for clients, it should be made explicit to them, so they do not misunderstand the mandate to be more restrictive than it is. When nonnegotiable requirements exist, they should be made explicit so that areas for freedom of choice and maintenance of current behaviors can then be identified and clearly understood by the clients. The mandated practitioner needs to find out:

Initial Phase Work with Individual Involuntary Clients • • • •

What legal requirements apply here? What do those requirements indicate that the practitioner must do? What must the mandated client do? What recourse does the mandated client or the practitioner have in modifying the requirement? • What are the consequences of noncompliance with the requirement for the practitioner and client? 4. Identify nonnegotiable agency and institutional policies, if any. Practitioners working in agency settings are also influenced by policies that guide ser vice delivery. For example, job descriptions for case managers may describe how frequently contact with clients must take place and priorities in carrying out their roles. Private agencies often have policies that include “package deals.” For example, the housing agency may require that if Dora “chooses” to apply for their housing, she must satisfy requirements such as an assessment to show she is capable of living there safely. In an outpatient mental health clinic, clients seen by the psychiatrist may also be required to see a mental health clinician. Similar guidelines to those developed for legal requirements then apply for nonnegotiable agency or institutional policies: • • • •

What nonnegotiable agency or institutional policies apply here? What do those policies specify that the practitioner do? What do those policies specify that the involuntary client do? What recourse does the involuntary client or the practitioner have in modifying those policies? • What are the consequences for noncompliance with the policies for the practitioner and client? Preparation for work with involuntary clients in mandated and institutional settings too often does not progress beyond these four steps. To enhance motivational congruence, empower clients, and achieve greater success it is equally important to identify rights, free choices, and negotiable options and share them with the client. 5. Identify rights. Too often identifying rights is interpreted as handing involuntary clients a copy of legal rights without the kind of dialogue and discussion about rights and options needed to pursue genuine informed consent (see chapter 2). Since the choice not to accept an offer of ser vice is available for nonvoluntary clients, this most basic right should be clarified. For example, the practitioner could have prepared for the session with Dora by reminding herself that Dora could choose whether to pursue living in the housing project or not. Then, she could have talked through Dora’s choices with her, clarifying them for the client. The practitioner should prepare to help the

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Practice Strategies for Work with Involuntary Clients nonvoluntary client make an informed decision based on accurate information about the advantages and disadvantages of continuing that contact on a voluntary basis. Presenting two sides to the decision about whether to participate, instead of presenting it as the only option or pressuring the client to comply and emphasizing choices, should reduce reactance (Brehm 1976). Hence, the practitioner could prepare by thinking about advantages and disadvantages for Dora of choosing to work with the housing authority, and explore other available options as well. The practitioner should remember here that mandated clients can also choose to accept legal consequences if they refuse ser vices. As well as thinking through the client’s options, the practitioner should also prepare to inform both mandated and nonvoluntary clients about their rights to confidentiality including any limitations to those rights, as well as available recourse to requirements or alternative ser vices for which they may qualify. Referring agencies have different requirements about mandated treatment. A client who is mandated to attend treatment ser vices through probation may just need to provide evidence that she attended the required number of treatment ser vices. A client mandated by a child protection agency, however, will likely need to demonstrate that she has been working in treatment on the identified issues, not just attending. These requirements have different implications for confidentiality limitations when working with mandated clients. The practitioner should examine the client’s rights in regard to accepting or rejecting the recommended ser vice. Nonvoluntary clients often choose to work on a problem different from the one attributed by the referral source (Epstein and Brown 2002). The practitioner might explore, however, the consequences for the client of making such a choice. 6. Identify free choices. It was suggested in chapter 5 that reactance may be decreased by clarifying behaviors that are not affected by requirements. The practitioner can do this by highlighting the choices the client is able to make. For example, mandated clients can choose how to respond to the situation: whether to comply at all, to comply passively, or to make the best of the situation by working on some of their own concerns as well. Nonvoluntary clients can choose not to accept the service, or to accept it and work on their own concerns. Hence, Dora can choose to remain at home, to accept the housing authority’s terms, to explore negotiation with the authority, or pursue another housing alternative. 7. Identify negotiable options. Reactance should also be reduced if options or constrained choices are available in the implementation of policies and requirements. The practitioner should be aware of any discretion available in the interpretation of mandates and policies. For example, the practitioner might have explored whether there were alternative ways that Dora might be assessed for skills in living in the housing program without completing the

Initial Phase Work with Individual Involuntary Clients skills program or living in a group home. Could she take a competence examination and, if she passed, obtain a waiver out of the program? 8. Examine practitioner attitudes or assumptions that may interfere with ser vice. Practitioners often make quick assumptions about what might occur with a client based on a rapid assessment of available case information and comparisons with past experience of other clients with similar case information. While making assumptions is normal and often unavoidable, prejudging has serious consequences. Although prejudging clients is more likely to occur when clients are nonvoluntary or mandated, practitioners are particularly vulnerable to prejudging when involuntary clients are accused of offenses such as child abuse or battering, which are not only illegal but often personally offensive to practitioners. Practitioners’ own values or personal history with the harm of such behaviors may cause them to prejudge if they do not strive remain aware of their own values about the alleged behavior. Avoiding prejudgment is important in order to make avoid sabotaging a legitimate offer of ser vice. For example, practitioners in child welfare settings are required to provide “family centered” ser vices, and to work to support families as much as possible while maintaining the safety of the child (Pecora et al. 2012). Skepticism about the ultimate success of efforts to support the family may be legitimate based on practitioner experience with similar cases. However, failure to monitor this skepticism would be analogous to an instructor examining student transcripts and assigning a grade before the class begins. It is not in the best interest of either involuntary clients or agencies to “determine the grade” before the contact begins. While some referral information may trigger negative prejudgments from practitioners, positive prejudging can also occur. Practitioners might tend to discount illegal behavior that they think should not be illegal. For example, some practitioners have experimented with marijuana and other illegal drugs and may have come to personal opinions that such drugs are not harmful and should be legalized. That personal opinion might result in discounting the consequences for involuntary clients who might be misled to believe that laws will not be enforced. 9. Make arrangements for initial contact. Involuntary clients, like voluntary clients, often pick up cues about what to expect from contact through the choices made available in arranging the time, locale, and physical arrangements of that contact. In most other practitioner-initiated contacts, however, the practitioner can call ahead or write to schedule an interview at the client’s convenience. Timing choices may not be available in investigations of imminent danger or harm in which the practitioner may be required to make an unannounced contact. In such circumstances, potential protection needs may carry as an unavoidable byproduct a predictable sense of invasion of privacy and high levels of reactance.

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Practice Strategies for Work with Involuntary Clients The locale of that contact and the physical arrangement of the meeting place may also be modifiable. In many cases, the client may choose to meet in the office, in his or her home, or in a neutral location of his or her choice. Should the initial contact with the practitioner take place in an office, the practitioner can be aware of what nonverbal messages office interviews may suggest. For example, moving through a series of locked doors to an office may convey accurately that confinement is an issue here. A sterile environment without pictures and other amenities can convey threat. Seating arrangements can be made to create an expectation of collaboration by sitting to the side of a desk or arranging comfortable chairs or couches. Having toys and games available for children can communicate sensitivity to them and their parents. Some practitioners adorn their walls with attractive pictures or posters with positive motivational statements. In some cases, practitioners may be unable to modify the physical arrangements of initial contact. Setting decor may be a low priority for the agency or institution, personal decorations may be prohibited, and chairs may be uncomfortable or unmovable. Rather than dwell on unchangeable physical arrangements, the practitioner is better advised to be aware of what those arrangements might communicate and to modify what they can.

Initiating Contact Practitioners are often encouraged to initiate contact with voluntary clients by tuning in to what brings those clients in for contact (Shulman 2015). Outside pressures, including those represented by the practitioner, are frequently the reasons that contact is established with the involuntary client. The guidelines that follow differ according to whether the client was self-referred, referred, or mandated (figure 8.2).

Self-Referred Clients Contact with self-referred clients begins with the following steps: (1) explore their reason for seeking help; (2) explore any pressures effecting that selfreferral; (3) explain nonnegotiable policies; (4) explore negotiable options; (5) clarify rights; and (6) clarify free choices. Since many who ostensibly self-refer actually seek help as a result of pressure from others, practitioners should take seriously such self-referred clients’ viewpoint that other things, people, and events brought them in. For example, a male client who comes into counseling because “his wife told him he had to come talk about his alcohol use” may not recognize any problematic behaviors. The counselor should consider that the client’s alcohol use, including perhaps the quantity of alcohol consumed

Initial Phase Work with Individual Involuntary Clients Figure 8.2

Initial phase steps

Self-referred clients

Referred clients

* Explore reason for

* Explore what precipitates

seeking help

* Explore pressures (if any) affecting self-referral

contact

* Review referral source information

Explain non-negotiable setting policies

Mandated clients

* Mandated client can state cause of referral from own viewpoint

Describe non-negotiable legal mandates

Clarify rights

Identify free choices for self and other referred clients, this includes the choice not to seek services

Identify negotiable options

or his behavior when drinking, probably played a part in stimulating the circumstances that led to contact. Indeed, the client’s wife might be signaling the possibility of an alcohol use disorder in this case. But it may also be true that, from the client’s viewpoint, he is just responding to his wife’s pressure by attending counseling. Rather than dismiss such an expression as a refusal to accept personal responsibility for “the problem,” the practitioner should recognize in a non-blaming way that the client is simply expressing the situation as he sees it. Should this initial assessment reveal external pressures that are not legal mandates, the practitioner can attempt to reduce reactance immediately and enhance voluntarism by acknowledging those pressures, helping the client assess the potential consequences of dealing with or ignoring those pressures, and clarifying the client’s rights, including their choice not to participate. The practitioner can proceed to explore the advantages and disadvantages of continuing that contact voluntarily.

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Practice Strategies for Work with Involuntary Clients For example, Keith ostensibly made a voluntary contact for admission into a substance use disorder treatment center to treat his alcohol use disorder. The following exchange comes from his initial contact with Dick, his case manager in the program.1 Dick begins by exploring the reason for coming into treatment from Keith’s viewpoint. He suggests ways that Keith can reframe his decision to increase self-attribution and then explores Keith’s feelings about the pressured contact. dick: Keith, I believe this is your second treatment? What brings you in for treatment at this time? keith: Yep. This is the second treatment. Ah, the family life just started blowing up again. Of course, using alcohol got blamed for every thing, so I got kicked out of the house, and after about a week and a half of living in different places, I decided that I might as well come into treatment to see if I missed something the first time. dick: So it was really your decision to come in? keith: Well, it was my decision to come in, but I was caught between a rock and a hard place, either come to treatment or lose my family. dick: Oh, I see. So it’s pretty much the family says, do this or no family. I see. How do you feel about that? keith: I feel that I’m taking the brunt of every thing again. I feel like if I do this, every thing else is going to be okay, and I don’t think that’s right. Keith has produced a good operational definition of a coerced choice: being between a rock and a hard place! Dick could now move to explicitly acknowledge Keith’s view of the cause of contact and clarify the choice he is making. For example, Dick could say: dick: So, Keith, it sounds as if you feel pressured by your wife and family to come in for more alcoholism treatment and that pressure doesn’t feel good. Are you aware that you could choose to stay? I want to clarify that because it is important for people to make up their own minds about the program. Would it help if we were to explore the reasons why you might decide to stay here and make this work for you or to decide not to stay? Dick should then go on to discuss the rights of patients and the nonnegotiable policies and rules of the center, including policies for initiating discharge. This emphasis on Keith’s autonomy and decision-making ability, as well as a 1 This selection of dialogue is abstracted from a training videotape entitled Socialization at Chemical Dependency Intake, by Dick Leonard. This videotape is available from Ron Rooney at the University of Minnesota. See appendix for list of training tapes available and ordering information.

Initial Phase Work with Individual Involuntary Clients clarification of the restrictions and freedoms of the program, can together decrease the reactance that Keith may be feeling due to this pressured contact.

Referred Clients Referred clients may be amenable to such referral or may feel pressured by it. The practitioner should (1) explore what brings the referred client into contact from their viewpoint; (2) review referral source information; (3) review advantages and disadvantages of doing what the referral source suggests; (4) identify rights; and (5) clarify options. The referred client is entitled to an explanation of the circumstances that have led to contact from the viewpoint of the referral source. This explanation should be objective, nonjudgmental, and concrete. As the referral may contain confidential information or diagnostic labels that may stimulate reactance, the information should be paraphrased to avoid either violation of confidentiality or inappropriate labeling. Openended questions can be useful and avoid the assumption that the client has the same perception of the problem as the referral source. The practitioner might explore these issues with statements such as: 1. “Can you describe, from your perspective, what brought you here?” 2. “I have some information from the referral source. Would you like to hear it?” 3. “In the rest of our session we need to explore the choices you might make (develop agenda for session). The biggest one is whether you want to decide to become a client here or not.” 4. “Would it help if we looked at the pluses and minuses of the decision to become a client here?” (Review advantages and disadvantages for deciding to become a client.) 5. “If you decide to become a client here, there are some agency policies that you should know about.” (Describe nonnegotiable policies.) 6. “You have certain rights” (explain rights); “and we also have several choices in what we do and how we go about it” (describe available options). For example, Mrs. Simmons was referred to Walter, a county mental health counselor by her child welfare worker. Mrs. Simmons, accused of child abuse a year earlier, had agreed to a consent decree that stipulated that she would meet regularly with her child welfare worker around child management issues in exchange for the agency not taking her to court. Mrs. Simmons was not now attending those sessions and the working relationship between Mrs. Simmons and the child welfare worker was distant. Mrs. Simmons was in a nonvoluntary relationship with the child welfare worker because of the

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Practice Strategies for Work with Involuntary Clients consent decree; her contact with Walter was not directly part of that agreement. Therefore, she could choose whether or not to become a client of the mental health center. The initial interaction between Walter and Mrs. Simmons is reproduced below.2 Walter begins with a description of the circumstances of the referral. His description is followed by a very negative response from Mrs. Simmons about that referral. This response might have been more muted had Walter first asked Mrs.  Simmons to describe her own understanding of the reasons for the referral. walter: I’m meeting with you because the social worker involved with you and your son Jamie has indicated that there is a consent decree that says you have to meet with the social worker and follow through on recommendations. Apparently, there’s some problem in terms of you keeping appointments, and I wanted to see if there was something I could do to help you look at what gets in the way, and see if we could plan some way around them. mr. simmons: Yeah. You can get him off my case. He doesn’t listen to me. It’s got to be his way or no way at all. I’m sorry, but I think I know my little boy a little bit better than that, and I know my own mind. walter: Well, what appears to have led to this consent decree is a petition that was brought by the social worker before the court, and the petition indicates that there’s been a lot of problems in school with Jamie hitting other kids, kicking other kids, apparently throwing a piece of wood and hitting a kid in the eye. One time he was banging his head on the wall. Another time he was choking himself with some sort of a necklace, and I guess I’d like to know how you see these problems. Walter clarified that he wanted to hear her side of the story and reported the intake information received in an objective and nonjudgmental fashion. He also requested her viewpoint. He might also have empathized here with Mrs. Simmons’s anger about working with the social worker. This might also be the time to introduce her rights and choices, for example: walter: I think it might help if we talked a little about your choices here. While you have to continue working with the social ser vice agency because of your consent decree, you and I can decide whether we want to work together. If you decide to work with me, we can work on the things you are concerned about. We can also decide whether to take the social worker’s concerns into account. You might also pursue getting reassigned to another 2

This tape, entitled Nonvoluntary Client Contracting, by Walter Mirk, is available from Ron Rooney at the University of Minnesota.

Initial Phase Work with Individual Involuntary Clients social worker. We also need to look at what might happen if you decide not to become a client here and return to working with the social worker.

Mandated Clients Mandated clients are entitled to (1) state the cause of contact from their viewpoint; (2) a description of legal, nonnegotiable requirements; (3) a review of negotiable options, alternatives, and consequences; (4) an explanation of rights, and (5) a review of free choices. Since reactance can be expected to be high, available choices should be clarified from the beginning. Statements that the practitioner might use during this section of the interview include: 1. “Can you describe, from your perspective, what brought you here today?” 2. “I would like to share with you the information I have from the referral source. Is that okay with you?” 3. “You and I need to meet because . . .” (objective description of cause of contact). 4. “What you and I have to do is . . .” (factual description of nonnegotiable requirements). 5. “In the rest of our session we need to explore the choices you might make” (develop agenda for session). 6. “You are entitled to” (explain rights). 7. “You are free to” (explain free choices and alternatives, and consequences). 8. “We also have some choices in what we do and how we go about it” (describe available options). The following dialogue takes place at the start of the initial meeting between Paul and Bill, his probation officer. Paul is preparing to enter an adult correctional facility, so the number of nonnegotiable requirements is high.3 Bill begins by offering Paul a choice, asking him how he would like to be addressed. Then, Bill is transparent in his reasons for taking notes during their meeting and his own agenda for the session. He should also ask Paul for other things he would like to see covered in the session. Since Paul may be less likely to express high reactance if he describes the requirements himself rather than has them read to him, Bill asks Paul for his view of what he is required to do. Bill then continues to describe additional referral information that he has about 3 This dialogue is edited from a training videotape entitled Socialization with a Probation Client, with Bill Linden as practitioner. It is available from Ron Rooney at the University of Minnesota.

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Practice Strategies for Work with Involuntary Clients nonnegotiable requirements and explains Paul’s rights in terms of confidentiality in this setting. During the meeting, the client is treated with respect, choices are offered when possible, and there is transparency and clarity offered around rules and procedures. bill: Mr. Anderson, my name is Bill Linden, and I’m a probation officer. I’ve been asked by the court to supervise your probation. First of all, let me start off by asking what do you prefer to be called? paul: Call me Paul. bill: Okay, Paul. Basically what we need to do today is to begin to gather some information to help me in supervising your probation as well as to get an understanding as to what the conditions are. As we talk today, I’m going to be taking some notes, so I can keep the particulars of your case separate from anyone else’s. Do you have any problems with that? paul: Go ahead. bill: Can you tell me what your understanding was of the sentence you received from the court? paul: From what I understand from what my lawyer says, I’m going to have to go to the work house here on Monday, and I could have done a lot worse. But anyway, I’ve got to go to the work house, and I’m not quite sure what I have to do around that. They said something about four or five months, but I might be getting out early if I keep a clean act. bill: Let me then let you know the information I received from the court just prior to our meeting. Now my understanding is that you were initially charged with two felony counts. Count 1 was burglary and count 2 was receiving and concealing stolen goods. In return for you pleading guilty to burglary, the state dismissed count 2, the receiving of stolen goods. The court sentenced you to thirteen months in prison with a stay of execution and five years of probation. Does that sound familiar to you? paul: Yeah, that was it. bill: Now what that basically means is you’re going to be on probation for five years. And as long as you follow the conditions of probation, you won’t have to do the thirteen months of prison. paul: What do they mean by probation? Do I have to show up and talk to somebody like you every month? bill: There are a number of conditions of probation, one of which is that you have to maintain contact with me and keep me informed as to where you’re living and working. paul: Do you come over and visit? bill: Sometimes. I do try and work the supervision around your work schedule, so that probation doesn’t interfere with your working. I want to also let you know, Paul, that the information you provide is confidential. The

Initial Phase Work with Individual Involuntary Clients only ones that can have access to that will be individuals with written permission from you, except for other people in the correctional community. Other courts can get it, other probation officers can get it. But anyone outside of the criminal justice system cannot have access to this information without your expressed approval or by court order. While Bill reviews confidentiality rights here, he should go on to explore alternatives and free choices that Paul has. Paul could appeal the sentence, or decide how he was going to do the time.

Socialization Guidelines Socialization, or preparation for assuming the roles of practitioner and client, follows the steps in initiating contact. Socialization involves developing an understanding of the roles of the practitioner and client, clarifying the limits and requirements of the work and developing an understanding of the expectations of the client (Trotter and Evans 2012). Socialization is another key clue in pursuing legal, ethical, effective practice with involuntary clients since clarity of expectations and roles is associated with better outcomes for mandated clients in child protection and criminal justice settings (Trotter 1996, 2004). Unfortunately, one study of probation officer/client meetings found that role clarification skills were only used infrequently by probation officers, if they were used at all (Trotter and Evans 2012). This suggests that these skills may sometimes be underused in settings that serve mandated clients. While one goal in mandated settings is to increase compliance with legal requirements, socialization efforts should also reduce reactance and respect self-determination in areas other than nonnegotiable legal and agency requirements. The practitioner should carry out socialization by doing the following: (1) conduct any required assessment; (2) assess response to pressured contact; (3) express empathy for pressures experienced by the client; (4) note values expressed by the client; (5) employ selective confrontation around nonnegotiable items; and (6) reaffirm choices and negotiable options (figure 8.3). 1. Conduct any required assessment. Assessment with voluntary clients typically involves exploration of strengths, weaknesses, goals, desires, and awareness of the systems of which the client is part. Such voluntary assessments often assume that the process is in pursuit of a mutual plan. While mandated assessments may ideally end in a mutual plan, they must be conducted regardless of whether the involuntary client wants to participate. For example, when the practitioner is mandated to assess risk to the client or others, the assessment itself may be a nonnegotiable aspect of contact. In

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Practice Strategies for Work with Involuntary Clients Figure 8.3

Socialization phase steps 1) Conduct any required assessment

Choose to discontinue contact

no

Continue as voluntary client

with self or other referred client

with mandated client

Does self or other referred client feel pressure to continue in contact?

yes

3) Express empathy for pressures experienced

2) Assess response to pressured contact

4) Note values expressed

5) Use selective confrontation on non-negotiable items

6) Reaffirm choices and available options

some cases, investigative protocols have been developed that aid the practitioner in assessing danger in a relatively objective manner (D’Andrade, Austin, and Benton 2008). In many others, specific protocols are unavailable and practitioners must craft their own. Too often extensive assessments are used with involuntary clients that far outstretch both legal requirements and the client’s own wishes for the assessment. Hence, practitioners conducting such assessments often experience disappointment and frustration when the client is unwilling to pursue more than a required minimum. The general issues in conducting involuntary assessments are to determine: • What information is the practitioner required to collect in order to make decisions or recommendations? • What information might be useful for making required recommendations or decisions but is left to the discretion of the practitioner? • What information is irrelevant to explicit or implicit requirements for assessment that might, however, be collected should the involuntary client give consent to pursue an issue voluntarily?

Initial Phase Work with Individual Involuntary Clients Assessment is an ongoing process that only begins at intake. The practitioner working with involuntary clients must be aware that initial assessment takes place in a context of pressured contact. Consequently, observations about client behavior might best be seen as a sample of how that client behaves under pressured circumstances. 2. Assess response to pressured contact. If the exploration of the cause of contact reveals outside pressures or mandates, no matter how tactfully or objectively such pressures are explored, many involuntary clients will respond negatively. A negative response is predictable and should be anticipated in situations involving a threat to valued freedoms (Brehm 1976). Among the predictable responses are anger, hostility, or frustration directed at the person setting the limits or requirements, denial of wrong or harm, considering self as victim, blaming others, hostility toward the practitioner, or attempts to regain control over the desired behavior. Practitioners have often interpreted these responses as evidence of internal dysfunction, guilt, or deviance, rather than considering the possibility that they are normal responses to a situation that stimulates reactance. The practitioner can avoid premature labeling of such responses as evidence of pathology or resistance and consider that they may indicate reactance responses or the use of self-presentation strategies such as intimidation, supplication, selective confession, or ingratiation to defend against labeling. Even if negative responses are normal and predictable, they are usually uncomfortable for the practitioner and can trigger a negative reaction to the client. Such responses often can be reduced by expressing empathy for experienced pressures. 3. Express empathy for pressures experienced by the client. Negative responses can be so strong that the involuntary client cannot “hear” what is being said or participate fully in the session unless those feelings are given attention. While the practitioner may privately suspect that some of the involuntary client’s difficulties have been brought on by his or her own actions and hence not feel much empathy for the client’s responses, the practitioner can be selectively empathic about the involuntary client’s feelings of being forced or pressured into contact against his or her will. It can be helpful for practitioners to recall their own reactions in coerced situations to better understand and empathize with the involuntary client’s reactance. For example, a practitioner might say: “I’ll bet it’s hard coming in here when you didn’t choose to be here. There are probably other things you’d rather be doing and other places you’d rather be.” 4. Note values expressed by the client. Involuntary clients often reveal their values and strengths in their response to pressured contact. The practitioner can note those values as things to be aware of and utilized as positive motivation for subsequent contracting or noted in selective confrontation about how client behaviors might jeopardize them.

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Practice Strategies for Work with Involuntary Clients After Bill completed the summary of the many nonnegotiable requirements involved in Paul’s entry into the correctional system, Paul became angry about the many losses of freedom he was soon to encounter and denied responsibility for his actions. Bill responded to the reactance at this point, avoiding a power struggle, saving selective confrontation for later in the interview. He became aware through Paul’s responses that his goals included having enough money to pay rent, possibly holding a job, and freedom to have a good time. bill: Paul, you appear to be kind of angry at this point. paul: Well, I don’t know, it wasn’t that much stuff. What the hell, they had plenty more stuff. I mean they had about five televisions and stereos. Hey, I needed the stuff, I needed some money. I’ve had three jobs in the last two years, and they all went to hell. I needed to get some money, I’ve got rent to pay and stuff. I want to go to a bar and have a good time just like everybody else. I’m entitled to it. bill: What I’m hearing you say, Paul, is that you are pissed off because you needed some money and don’t feel you deserved the type of sentence that you got. paul: Yeah. It wasn’t that much. What the hell. bill: And I think most people would be mad in your situation about entering prison. But then I’d also ask you to take into account that you’ve got some choices to make and I hope you won’t let your anger interfere with that. It is okay for you to be angry. When Paul denies responsibility for the crime, denies harm to the victims, and suggests that they could spare the stolen goods he needed, it is as if there is a cartoon caption over his head saying “denial of responsibility.” While many practitioners would confront Paul’s refusal to accept responsibility at this point, Bill selectively empathized with the pressure experienced while not agreeing that the victims of the crime are to blame. The presence of denial suggests that confrontation will not be effective at this point, since Bill is not yet likely to be a persuasive source of influence. Employ selective confrontation around nonnegotiable items. Confrontation refers to techniques used to help a client discover blind spots, discrepancies, and inconsistencies between thoughts, feelings, attitudes, behaviors, and their consequences that perpetuate client difficulties (Hepworth et al. 2016). Confrontation is also a persuasion method designed to affect attitudes, beliefs, and behavior. Like Paul, many involuntary clients question the validity and interpretation of facts presented to them about the cause of contact or the fairness of requirements. An escalation spiral of charges, defenses, and countercharges frequently ensues. We saw such a spiral occur in the beginning of the chapter in the interaction between Dora and her caseworker. Such escalation often contributes to a negative assessment by the practitioner. Practitioners often

Initial Phase Work with Individual Involuntary Clients wish that involuntary clients would admit responsibility for their behavior or accede to the demands of others. It seems unlikely that many involuntary clients will have the communication skills to deescalate and move from a content to a process level by saying, “Hold on. It seems that we are in an escalation spiral here. I am angry and so are you and we are not listening to each other. Let’s back up and start over.” Hence, responsibility for such de-escalation rests with the practitioner. Some believe that confrontation is necessary in some cases and that some clients need to suffer enough discomfort to motivate them to change. Particularly in areas of practice with highly stigmatized clients, such as in the field of substance use disorders, batterer programs, and child welfare agencies, there has been high value placed on confrontation and triggering motivation to change. Research and practice assumptions are not always well connected. Taking responsibility is seen as an essential step in effective treatment (Levenson 2011; Miller and Rollnick 2012; Reich 2005; White and Miller 2007) but there is evidence that information about the effects of drinking without any kind of acknowledgement of responsibility can be beneficial to people with alcohol use disorders (Juarez 2001; Burke, Arkowitz, and Dunn 2002). In fact, a heavily confrontational style, such as might be used by a practitioner to insist his client acknowledge his drinking problem, has been associated with an increase in the problem behavior (Miller and Rollnick 2012). Confrontation can trigger a stronger reactance response. Miller and Rollnick (2012) argue that as practitioners take a strong confrontational stance on a problem, such as a substance use disorder, clients often respond with strong arguments against the practitioner’s statements and often become more convinced that no problem exists after the discussion than they were before it began. Many practitioners are unsure about when to confront or how to do so in ways that remain respectful and demonstrate empathy. Confrontation is most appropriate when a law or policy has been violated or a violation is imminent, when danger or harm has occurred or is imminent, or when a clients’ own goals are threatened by their behavior. Hence confrontation occurs most frequently with mandated clients who have violated laws. Confrontation with nonvoluntary clients is less frequent and occurs around conditions of danger, harm, or obstacles to their own expressed goals. Confrontation is rarely appropriate if beliefs or actions are not illegal, or are violations of policy, dangerous, or unrelated to clients’ goals. Confrontation techniques range on a continuum of intrusiveness into personal choice from low to high intrusiveness. At the low end of intrusiveness are times when the practitioner chooses to not to use confrontation at all. Following the criteria for appropriateness of use of confrontation described in the preceding text, such a decision is appropriate if clients’ behav ior is not illegal, harmful, or a threat to their goals. Following these guidelines,

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Practice Strategies for Work with Involuntary Clients Figure 8.4 A confrontation continuum 7. Abusive confrontation 6. Intensive confrontation

High

5. Assertive confrontation 4. Inductive questioning 3. Self-confrontation

Low

2. No confrontation

Intrusiveness 1. Lack of confrontation Levels 2 or 6 can be appropriate uses of confrontation. Levels 1 and 7 are inappropriate.

practitioners can choose to confront about some issues and avoid confrontation around others (figure 8.4). The first level of appropriate confrontation is the use of self-assessment techniques to facilitate self-examination. Circumstances often exist in which behavior or attitudes may be interfering with client goals or legal mandates, or in which danger is possible but not imminent. In such circumstances, the completion of a written assessment of past behavior and attitudes relevant to the reason for contact can provide a relatively unobtrusive form of self-confrontation (Kopp 1988, 1989). Such a method promotes self-evaluation to facilitate change as a model for self-confrontation and avoids the increase of reactance, which can be caused by more direct methods of confrontation. Many involuntary clients may be stimulated to recognize dissonance between behaviors, attitudes, and goals without arousing much reactance. Self-assessment techniques may be most appropriate early in contact and prior to the development of an effective working relationship. The technique should not be used with the expectation that many clients will have an “ah ha!” experience in which they quickly become aware of dissonant behavior on their own. The expectation should be

Initial Phase Work with Individual Involuntary Clients that the technique will “plant a seed” so it is relatively unobtrusive and hence provides little risk to the development of an effective working relationship. Such self-assessments should be phrased in objective, nonjudgmental terms. Means of stimulating self-confrontation can be used much more frequently than other methods of confrontation, and with minimal risks. While these techniques may be insufficient for heavily defended clients, their use can still provide information to guide the practitioner’s use of higher levels of confrontation. If behavior includes law violations and imminent danger, selfassessment may be skipped or quickly followed with the next level: inductive questioning. At a second level, practitioners can raise inductive questions that draw involuntary client attention to a potential discrepancy or inconsistency between behaviors, attitudes, beliefs, goals, and consequences. Discrepancies between verbal and nonverbal expressions or actions can also be explored in a questioning, nondirective fashion rather than as statements of fact or interpretation (Draycott and Dabbs 1998). Inductive questioning is relatively unobtrusive and therefore can be used effectively early in a relationship without arousing much reactance. It may be used selectively around items in the self-assessment in which danger is probable or consequences are more serious. Inductive questioning can also be overused, especially with clients who do not respond to the more indirect linkages suggested. Using inductive questioning to explore ways that behaviors conflict with client goals can be an effective approach to use with nonvoluntary clients. In the following section of the interview between Walter and Mrs. Simmons, Walter continues to gather information from the client’s perspective about the previous allegations of child abuse and then uses selective confrontation. After exploring further what had occurred with Mrs.  Simmons, the school, and Jamie, Walter moves to empathically confront with an inductive question: walter: Do you think sometimes Jamie’s behaviors in the school are some of his own doing? mrs. simmons: I know he’s not an angel. But he’s not as bad as what they’re making him out to be, either. He’s just a typical, normal little boy that, yes, every once in a while, he does get into trouble. But not all of it is his fault. walter: It’s got to be pretty frustrating and very difficult for you to have this problem with Jamie and the school. I’ve seen you a couple of times with Jamie. And from what you’re telling me now, and what I’ve seen in the past, I know you really love your son. And sometimes, as much as you love your son, it’s got to be pretty difficult to deal with some of his behaviors. A sequence of inductive questions can also be used to “plant seeds,” to build dissonance or discomfort over a lack of fit between behaviors, attitudes, and goals or values. Bill had noted earlier that Paul did not believe he had a problem

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Practice Strategies for Work with Involuntary Clients with alcohol and that he appeared frustrated over losing three jobs in the past year. After the series of inductive questions, Bill suggests that Paul’s alcohol use disorder may be a problem that has gotten in the way of working. He also attempts a role reversal by suggesting that Paul see things from the employer’s viewpoint. When Paul mentions that he was fired from his last job for being late, Bill asks: bill: Why was it that they said you were late? paul: I had a hangover. bill: You had a hangover. Had you been out drinking pretty heavily the night before? paul: Sunday night. Had to go to work the next day, thought what the hell. bill: Has that happened before? paul: Sure. bill: How many times? paul: Go out with all the gang. Lots of times. bill: Lots of times? paul: Sure. Go out with the guys. bill: Have you had other employers say to you that you’re not working up to par, that they feel like maybe you’re drinking? paul: No. They just say maybe I could do a better job next time. I think I do a pretty good job. bill: So they say that you could do a better job. You feel you’re doing okay? paul: I’m doing fine. I don’t understand. Maybe I’m in the wrong field. But I like doing what I’m doing. bill: So you like auto body, you’d like to stay in that field? paul: Sure. bill: Interesting enough, right there, you’ve presented some ideas where I can begin to see how the presentencing investigator did see the possibility of a chemical abuse problem. If you are working—now just think about this— and you’re going out and getting drunk and that drinking affects your ability to work. What would you think if you were an employer paying someone thirty bucks an hour and they couldn’t do the job? Near the end of the interview, Bill again asks Paul to put himself in someone else’s shoes. bill: I want to give you something to think about, and then during our next meeting, I want us to be able to talk about it. You are telling me that you want to stay out of trouble in the future. Let’s say that you’re staying out of trouble, and you do purchase a stereo and let’s say, someone comes in and steals the stereo. I want you to then think about how you would react, and what you would like to have happen to the individual that took your

Initial Phase Work with Individual Involuntary Clients stereo. All I’m asking is that you think about that. I don’t want an answer now, I want you to think about it. Okay? And also think about how that’s in line with your goal of wanting to stay out of trouble in the future. When behavior involves law violations or imminent harm, the practitioner must often progress to the next level: assertive confrontation. Assertive confrontation refers to making specific statements in declarative form about discrepancies in thoughts, feelings, behaviors, and consequences rather than posing them as questions. Assertive confrontations should include statements about proposed linkages between dissonant attitudes, behaviors, and goals based on specific instances; separate free behaviors from requirements and constrained choices; be conveyed in an atmosphere of warmth, caring, and trust in which concern rather than blame is communicated; be presented tactfully but clearly enough that the client gets the point; be well timed and focused on key issues; and be followed with empathy. A template of assertive confrontation is as follows: I’m concerned because you (want/believe/are striving to) ___________ (describe desired outcome) but your ___________________________ (describe discrepant action, behavior, or inaction) is likely to produce ______________________________ (describe probable negative consequence). (Hepworth et al. 2016) Assertive confrontations are frequently employed with mandated clients around law violations, nonnegotiable aspects of contact, and dangerous behavior, and are also appropriate when client-expressed goals are jeopardized by behavior. When danger is high, lower-level confrontation steps are often skipped. Other wise, assertive confrontation might follow unsuccessful attempts at inductive questioning. If, however, the behavior or attitude is neither a law violation nor a danger to self or others, nor a conflict with the involuntary client’s expressed goals, it is questionable whether assertive confrontation should be used at all. Confrontations are most likely to be successful when they come from a respected source who identifies specific problematic behav iors and consequences. As noted in the preceding interaction between Bill and Paul, at first the practitioner is unlikely to be a respected source. Consequently, confrontation will probably not be effective at the beginning of contact and hence should be used sparingly and concentrate on nonnegotiable items. The practitioner can sometimes empathize with the client’s feelings about contact and then add the confrontation, using a linguistic sequence substituting the word “and” for “but” in the sentence. This linguistic sequence affirms the validity of both the empathic statement and the confrontation rather than stating them in terms that suggest that the confrontation negates

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Practice Strategies for Work with Involuntary Clients the empathetic statement (Saunders 1982). For example, the practitioner could say, “I hear your frustration that your child does not obey the way you feel he should and striking your child with a belt, raising welts is not a legal way to get him to obey you.” Child protective ser vice investigations frequently require confrontation around nonnegotiables. In the following interview segment, Betty, a child protection worker, is meeting with Diane, the single mother of two small children. Diane reported that she left her children in the care of a babysitter for an evening. Police, however, found the three- and five-year-old children playing unattended in a park at 3:00 a.m. across a busy street from the housing development in which they lived. Diane had completed an outpatient treatment program for an alcohol use disorder. This incident is the third report of behavior assessed as neglectful since Diane completed the treatment program. Collateral reports have indicated that Diane is not following the aftercare program and is using alcohol again. Betty has to present the facts that led to the contact, explore Diane’s explanation, and empathize with her response, while remaining firm and clear about the agency’s nonnegotiable demands. She also identifies some common concerns, such as the children’s safety, and begins to explore options to meet requirements. Diane began by saying that she was not responsible for what happened to the children since she left a babysitter in charge. betty: It does sound, Diane, as if you thought you were leaving your children in safe care. You are concerned about their welfare as we are. And one of the things that the law expects parents to do is make safe decisions in picking babysitters. So if kids were found alone wandering in a park late at night, the laws say that parents are responsible for that. And so that’s why the police took them in. diane: I’ll never use her again. I’ll never use her again. betty: That would be a wise decision on your part. I think, Diane, if this were the first time that we had this kind of situation together, that would be the direction we would want to go. We would try to help you make better arrangements for babysitting. However, we need to look at the fact that this is the third time this year that the kids have been on a police hold. diane: This wasn’t my fault. This was not my fault. Maybe other times it was, but this was not my fault. You’re just making a big deal out of this. betty: Are you saying, Diane, that you feel blamed, that this time feels different to you since you had made what you thought were good plans for the children? diane: Yes, I had a babysitter. It was her responsibility. betty: While you feel this time was different, it is the third report we have received. So, we don’t feel that it’s safe for the kids to come home right now.

Initial Phase Work with Individual Involuntary Clients There is another reason why we think that the children might be safer in foster care right now. We have also had a community report, Diane, that you have been seen drinking while with the children. diane: It’s not anyone’s business if I drink! I already completed a treatment program. Who called in? I have enemies. You can’t trust everyone who calls in. betty: You are right that drinking is your own business, as long as your children are not in danger. You are also right that we can’t always trust callers. It does seem as if drinking is playing a part in your childcare at this point. For this reason, I am going to recommend that if you want to regain custody of the children, that you complete another alcoholism assessment and any treatment they recommend. That may involve an inpatient treatment and a halfway house program. It may also be a return to an aftercare program. The assessment might also show that you don’t need any kind of treatment now. diane: I already did that once. I already did that. betty: I know that you did. You successfully completed the program. But the problem is that your aftercare doesn’t seem to be working. diane: I think this is all a big exaggeration. The only thing that happened here is that the babysitter left, and that’s not my fault. betty: I understand that you feel that this is an overreaction, Diane. You do have some choices about what happens from here. One is that you can decide to work with us and to come to an agreement on a contract about completing an assessment, and the other is that you can decide to go to juvenile court and talk to the judge. diane: I’m not going to court. I’m not going to court. You took my sister to court, and she doesn’t have her kids anymore. I’m not going to court. betty: So given those two options, you’d rather work with us than go to court. diane: I don’t have any choice. ’Cause I’m not going to court. betty: Okay, it doesn’t feel like much of a choice. You would prefer that we forget the whole thing. If you do choose to work with us rather than go to court, we expect you to complete the assessment and we will support the recommendations they make. I have a list of places that could provide an assessment for you. You can pick from this list or suggest another place that we might use. Remaining empathic while being firm around nonnegotiable requirements requires skill and patience. Betty presents options that Diane accurately perceives as coerced choices since the agency is unwilling to negotiate around an assessment for an alcohol use disorder.

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Negotiation and Contracting The socialization steps presented above lead to negotiation and contracting. Contracting is designed to enhance motivational congruence and increase voluntarism through exploring available choices. We begin with an exploration of the distinction between the “good” relationship and the negotiated relationship. Four negotiating and contracting options with mandated and nonvoluntary clients are then presented, followed by a discussion of obstacles to negotiation and contracting. The “Good Relationship” and the Negotiated Relationship Most treatment approaches suggest that the development of a relationship is essential to productive change. Unfortunately, for the practitioner working with involuntary clients, the model for such relationships has been the voluntary relationship. This model “good” relationship assumes contact with clients who are willing and motivated to be engaged in a collaborative, contractual ser vice and that practitioners can help by attending to client concerns in a warm, empathic, and genuine fashion (Cingolani 1984). Clients who oppose such collaboration are often labeled resistive. Consequently, practitioners working with involuntary clients often find that their client relationships are not “good.” In fact, power and authority issues exist in all practitioner-client relationships, whether mandated or not (Palmer 1983). In addition to employing expert authority, which is invested in practitioners by client confidence in their ability, practitioners also employ legitimate power through the authority of their position, role, and agency. Finally, reward and coercive powers are also inherent in most practice relationships. One can explore power relationships more directly by considering the negotiated relationship, which acknowledges use of authority. For example, practitioners working with mandated clients use reward, coercion, and legitimate powers to act as enforcers to induce compliance. They can also act as negotiators who represent the agency in bargaining with the client, as mediators in the interaction between the client and society, as advocates who identify with client interests, and as coaches who collaborate with clients to enhance their capacity for dealing with the environment (Cingolani 1984). Contracting is a negotiation process that results in a mutual agreement that specifies client and practitioner roles, goals and target problems, client rights, methods to be used, time limits, tasks agreed upon, and criteria for deciding whether goals are reached (Seabury 1979). If mutual agreement on all goals, roles, and methods is an integral part of contracting, then contracts are rarely feasible for mandated and nonvoluntary clients (ibid.). In addition, involuntary clients cannot easily withdraw from the contract and often suffer consequences for failure

Initial Phase Work with Individual Involuntary Clients to comply with its terms. Finally, mandated clients often find such contracts to include unbalanced accountability as the contract is often used more to hold them accountable to the practitioner and agency than vice versa. Involuntary ser vice plans are documents in which the agency spells out nonnegotiable requirements, rights, and consequences for failure to meet requirements. These ser vice plans are frequently used within child welfare agencies. Sometimes the goals and requirements on these plans are mutually agreed upon. In other circumstances, clients do not feel they have much of a voice in this process. In the past decade, increasing recognition of the importance of using collaboratively created ser vice plans has changed this process in many child welfare agencies and more plans are created collaboratively by the team than were previously. However, some clients still feel as if the service plan is given to them, versus created by them (Smith 2008; Reich 2005) and some research supports that for many families, the requirements on the ser vice plans do not meet the specific needs of each family (D’Andrade, Austin, and Benton 2012). In only 60 percent of cases, ser vice plans included all necessary ser vices and no inappropriate ser vices (those addressing problems not identified within the family). Such involuntary ser vice plans have distinct limitations. When plans are developed with minimal or no client contact, they might better be described as notices of agency intent that detail what the agency and practitioner wish to happen and consequences to the mandated clients for failure to follow these plans. Such notices are analogous to traffic citations that inform the motorist of charges, evidence, legal rights, and constrained choices such as making a court appearance or paying a fine. While situations exist in which such involuntary case plans and notices of intent may be unavoidable, such plans cannot be expected to contribute to motivational congruence or the self-attribution that would permit results to last longer than would the threat of punishment. The semivoluntary contract is an alternative to the voluntary contract and the involuntary ser vice plan. It acknowledges outside pressures and mandates by specifying nonnegotiable requirements and policies, consequences for failure to meet them, and specifies client freedoms and rights. It also includes negotiable options and client-perceived problems. In such a perspective, conflict is defined as normal and the practitioner focuses on constructive ways to manage the conflict. Pursuit of semivoluntary contracts assumes that contracting is an intervention process that goes beyond fulfilling external accountability requirements to become a powerful service method designed to enhance compliance, motivational congruence, and self-attribution. All mandated clients have to the option to choose not to comply with legal mandates and nonnegotiable requirements and instead accept legal penalties. The practitioner can use an informed consent strategy to review the pros and cons of that decision. But, if mandated clients are willing to work with practitioners, many clients can avoid these penalties. Many mandated clients are

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Practice Strategies for Work with Involuntary Clients Figure 8.5 Voluntary contracts, semivoluntary contracts, and involuntary case plans Voluntary contract * mutual agreement on goals, problems to be addressed, methods to be used, time limits

Involuntary case plan * specifies requirements and consequences

* often not negotiated * analogous to traffic citation * should require notification of rights, alternatives, copy of document, and signature

For nonvoluntary clients (“invisible involuntary”):

For mandated clients

Semi-voluntary contract * specifies requirements and non-negotiable policies

* includes client choices, views of problems

* includes rights, alternatives * includes negotiation

able to work with practitioners on semivoluntary contracts when constrained choices are explored. There are four strategies for exploring such choices. First, mandated clients can decide to comply with legal mandates and nonnegotiable requirements. Second, the practitioner can help mandated clients find their own reasons for complying with mandates through a reframing or agreeable mandate strategy. A mandated client using this strategy might say that she was attending treatment ser vices, but to work on her own goals, not on the referring agency’s goals. Third, mandated clients and practitioners can come to agreement through provision of an inducement in addition to working on nonnegotiable requirements through a quid pro quo strategy. Finally, some clients may be motivated to be compliant with the mandate simply to get rid of the mandate and avoid negative consequences. Practitioners can acknowledge that motivation with clients.

Initial Phase Work with Individual Involuntary Clients Nonvoluntary clients can often move from semivoluntary to voluntary contracts through strategies parallel to those for mandated clients that explore constrained choices. The practitioner can first use the informed consent strategy to advise them of their freedom from legal requirements to accept or reject ser vices based on an analysis of the costs and benefits of that ser vice. Nonvoluntary clients can also choose to accept ser vices for their own reasons regardless of outside pressure. They may choose to blend their own concerns with those of the outside pressure through the reframing or agreeable mandate strategy. Nonvoluntary clients can choose to accept ser vices in order to receive an incentive through the quid pro quo strategy. Finally, they can choose to accept ser vices in order to “get rid of the outside pressure.” Though voluntary contracts are preferable, semivoluntary contracts may be beneficial for many nonvoluntary clients. For example, when the nonvoluntary client enters a program or institution with a host of requirements and policies as a “package deal” (i.e., accept these requirements and policies or “choose” to refuse ser vices), a semivoluntary contract may reflect the nature of the constrained choice made by the nonvoluntary client more accurately than a voluntary contract.

Steps in Negotiation and Contracting Steps in the negotiation and contracting phase are: (1) explore the client’s view of existing problems; (2) explore reframing for an agreeable mandate strategy; (3) explore a quid pro quo option; (4) explore a “get rid of the mandate or outside pressure” option; or (5) explore an informed consent option. These strategies may be used in a different order and varying combinations. Variations for work with mandated and nonvoluntary clients are presented. 1. Explore the client’s view of existing problems. Many involuntary clients present their own views of problems during the socialization phase. Such client views are often missed because they are not based on the “right” motivations and may be labeled as lack of motivation, refusal to take responsibility, denial, or defensive behavior. The practitioner should listen carefully for expressions of client beliefs, values, and motivations during this phase without labeling them as expressions of no motivation, but rather understand them as expressions of current motivations, values, attitudes, and beliefs. For example, when Mrs. Torres, a single parent with a full-time job, was in danger of having her child removed from an extremely cluttered home that posed a serious fire hazard, she protested that she had already begun efforts to renovate her home. Jean, the child protective ser vice worker, notes that Mrs. Torres has made efforts and compliments her. She will later suggest that

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Practice Strategies for Work with Involuntary Clients Mrs. Torres’s efforts may fit in part with the external pressure to make her home a safer place. mrs. torres: These are my things, you know. I’m going to get around to it sometime. In fact, when we moved in, I got some stuff cleaned up right away. But I’ve really been busy. It’s okay, it’s good enough, it’s better. We’ve got room here to get through now. And I do have a few more things to do. jean: I know that these are your things. I can also see that you really have made some efforts. What have you worked on so far? mrs.  torres: Well, before we moved in we painted the cupboards in the kitchen. Can you see it out there? jean: Yes, they look great. That room really shows that you have been making some efforts. Rather than labeling Mrs. Torres’s efforts as merely minimizing danger or denial of the existing problem, Jean supports the efforts she has made. As Mrs. Torres may feel overwhelmed with the responsibilities of working at a full-time job, managing a house, and parenting a teenager, Jean should also have empathized with the feelings of being overwhelmed. She will also explore the provision of a homemaker to assist Mrs. Torres in her efforts. Initial attitudes, beliefs, and concerns of mandated clients often include motivations that may be blended with mandates to enhance compliance. For example, Beth was an adolescent who had traveled widely through the child welfare system with stops in residential care, substance use disorder treatment, group care, foster care, and her own home. She had just worn out her welcome in a relative placement with her Aunt Barb. Nancy, her child welfare worker, was operating under a requirement that Beth needed to be living in a stable, permanent placement. While Nancy was exploring the circumstances of Beth’s latest move from her Aunt Barb’s, Beth said, “I don’t want people telling me how to run my life. I don’t want it no more. If it ain’t my boyfriend, it’s Barb; if it ain’t Barb, it’s you; and if it ain’t you, it’s my parents. All of you guys are running my life and all you guys got me is nowhere.” 4 Rather than labeling Beth’s expression as a refusal to accept responsibility for her own part in problems, Nancy might note Beth’s implied motivation by suggesting, “It sounds like you have had it with other people making decisions for you.” If involuntary clients have not already expressed problems or concerns in the socialization phase, they are now asked for their views of problems that exist or situations that could be improved. The involuntary client can reply by 4 This interview segment comes from a training videotape entitled Permanency Planning: Use of the Task- Centered Model with an Adolescent Toward Independent Living. The Contracting Phase, with Nancy Taylor. The video is available from the School of Social Work at the University of Wisconsin.

Initial Phase Work with Individual Involuntary Clients describing a problem, stating that no problems exist, or making no reply at all. These responses can further be examined for fit with outside pressures or mandates. Such concerns may be similar to the mandate or outside pressure, unrelated to the mandate or outside pressure, directed at avoiding the mandate or outside pressure. In some cases, no response to pressures is expressed. Four contracting strategies will be described later to address these contingencies. 2. Explore reframing for agreeable mandate strategy. The practitioner can explore expressed concerns, values, or motivations for fit with outside pressures or mandates. The agreeable mandate is similar to reframing strategies in which practitioners are trained to join clients and families rather than insist that they work on the “right problems for the right reasons.” In the solution-focused approach, this seeking of a goal that the involuntary client wishes to pursue is called co-construction of goals (Tohn and Oshlag 1996; de Jong and Berg 2001). For example, a client referred to counseling after being arrested during an altercation with her husband may state that she wants to contract to work on “controlling her anger issues” rather than addressing the violence in her relationship. This co-constructed goal addresses the issue in a way that is congruent with the client’s perception of the problem while still working on the presenting issue of violence in the relationship, which occurs when the client becomes angry during an argument. a. Variations for mandated clients. Practitioners working with mandated clients seek to blend mandated concerns with client motivations such that mandated clients may choose to work on those required concerns for their own reasons. Use of this strategy does not mean that the practitioner joins or “hooks” the client without being clear about his or her own motivation. Mandated clients must be informed that mandated, nonnegotiable concerns will be included. Three variations can be explored with mandated clients that blend client concerns with mandated concerns. Mandated referrals often state or imply deviant labeling and an assumption of responsibility that involuntary clients are unwilling to accept. Mandated clients may, however, discover their own reasons for complying with the mandate. For example, when Jean was working with Mrs. Torres on the child protection issue related to a fire hazard, she found that while Mrs. Torres did not consider the state of her home adequate grounds for removal of her child, she acknowledged that she did not have enough help from her daughter in keeping the house clean. She wanted to have the house cleaned for the holidays, she wanted a safe environment for her child, and she wanted the child welfare agency to stop being involved in her life. Mrs. Torres agreed to a contract when the practitioner pointed out that she had already begun making some efforts on her own to clean up, that she might be assisted with a homemaker, that she could get the agency out of her hair, and that she could also avoid a possible placement.

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Practice Strategies for Work with Involuntary Clients When mandated clients are faced with coerced choices about requirements, they can often choose the way they respond to those requirements. As contact often begins in crisis, the Chinese definition of crisis as a “dangerous opportunity” is particularly relevant in this discussion. For example, if involuntary clients note that the problem had been building up for a while but they had not acted to change it, the practitioner might say: You have been wrestling with these issues for a long time. You may have thought about getting some help with these issues on your own and now something has happened that forced you to be here. You can make some choices in this situation about how you want to use your time and what you want to get out of this. You might choose to take your chances in court. You might choose to go along and ride it out, doing what you are required to do. You might also choose to use this opportunity to take a look at some of the concerns you have already been aware of. Similarly, mandated clients might be asked to recall if there was ever a time in their past that something good came out of doing something they did not want to do. When had they made the most out of a bad situation? When had they made “lemonade out of lemons”? Could this be a time to make lemonade again? Following this strategy, Bill, the probation officer, helps Paul explore possible problems he might choose to work on. bill: I want to find out if there are some things you would like to get out of probation, some things that you and I could work on together. paul: Not to get in this situation again. bill: Okay, you don’t want to be in this kind of situation again in which you are having to serve time for a crime. paul: It doesn’t work. bill: Okay. Is there anything else you and I can work on together that you would like to get out of probation? Not what the court is saying, but what you would like to get out of probation? Some mandated clients perceive a concern similar to the mandated reason for referral without accepting responsibility for causing the problem. For example, many children of families who are involved with child welfare ser vices have mental health disorders that include challenging behaviors (Heneghan et al. 2013; Horwitz et al. 2012). Parents accused of child maltreatment may recognize parenting challenges and child behavior problems while not identifying their own role in the situation. The practitioner could provisionally accept their view of the problem while stipulating that legal, effective alternatives

Initial Phase Work with Individual Involuntary Clients of child discipline must be substituted for the illegal, unsafe strategies that have been used in the past. Sometimes the mandated concern and the client-expressed problem can be reframed into a new statement that includes both by grouping them at a higher level of abstraction. For example, Beth, the adolescent who thinks that “too many people are trying to run her life,” was faced with the mandate that she live in an approved placement. Her concern and the mandated problem were blended in a reframed agreeable mandate: Beth thinks that too many people are trying to run her life. She wants to explore independent living. Such a reframing affirms the validity of the client’s own concern without blaming or attaching a deviant label to it, while remaining firm about nonnegotiable requirements. b. Variations for nonvoluntary clients. Nonvoluntary clients can choose to avoid the outside pressure altogether, to work on their own concerns without regard for that pressure, or to work on a reframed view that includes both the outside pressure and their own concerns. For example, Mr. Porter was an elderly patient hospitalized with a broken hip who wished to return to his home upon discharge. He was, however, locked in a struggle with medical staff about discharge plans. He did not accept the plans developed by hospital personnel and found ways to circumvent those plans he had not participated in developing. While medical staff members were reluctant for Mr. Porter to return to an unsafe environment and recommended nursing home care, Mr. Porter resented intrusions into his independence. In working with Mr. Porter, his hospital social worker presented several options. First, he could choose to avoid the outside pressure altogether. As there was no legal mandate at this point, the medical social worker reaffirmed that he could legally choose to return home against medical advice. She proceeded to present a two-sided argument to assist him in making that decision. Should he choose to return home without assistance, he would be taking chances that he might be reinjured and need to return to the hospital. The social worker also reminded Mr. Porter that he had expressed a wish to return home safely and not to return to the hospital. Hence, he could choose to work on his own concerns without regard to the outside pressure. The social worker then explored the possibility that his concern with returning home safely and not returning to the hospital could include the hospital staff’s concerns about his safety. When his own goal of returning home safely was reaffirmed, Mr. Porter became more willing to consider staff advice about how to make that return happen successfully. The staff meetings that had been structured to convince or pressure Mr. Porter to accept staff views were then restructured. When staff agreed to take the role as consultants to assist him in planning for a safe return, Mr. Porter and staff negotiated an agreement that included safety provisions he found acceptable, such as assistance in repair of a broken banister and arrangements for a visiting nurse.

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Practice Strategies for Work with Involuntary Clients The previous strategies assume that many involuntary clients do not wish to work on “the right problems for the right reasons” in the sense of acknowledging the problems attributed by others. This is of course not always true as some involuntary clients genuinely seek help despite the outside pressure or mandate, and accept responsibility for both the problem and the resolution of it (O’Hare 1996). Some involuntary clients readily acknowledge attributed problems, saying things such as: “I know that I need to get in touch with my inability to control my impulses”; “I need to accept my disability”; “I need to get in touch with my codependency issues”; “I need to pay attention in class”; “I need to keep a job”; and “I need to stay sober and accept my responsibilities.” Such rapid acceptance, including all the right words and motivations, may indicate internalization, ownership of responsibility for the problem, and insight. If, however, the admission sounds too good to be true, it may be. Such admissions may be an ingratiating self-presentation strategy designed to reduce pressure through rapid, selective confession. Such expressions may reflect the possibility that the involuntary client is “bilingual” and speaks the jargon of the helping professions. However, rather than labeling such expressions as manipulative or passive-aggressive behavior, the practitioner might consider less than full candor understandable and in fact reinforced in many settings. For example, involuntary clients experienced in residential, correctional, substance use disorder, or educational systems (among others) may have been rewarded for confessing or owning problems, staff at these programs may see these confessions as indications that they are “getting in touch with their issues.” There is no immediate way of knowing whether such admissions are genuine or, in fact, “too good to be true.” Practitioners may accept such admissions at face value while using validity techniques, such as gentle assumption or normalization (Shea 2012), to suggest that many in similar situations have mixed feelings or negative feelings about being pressured into contact. The agreeable mandate option is the most positive of the four strategies to be presented and should be frequently explored. If agreement is reached, it can lead to greater compliance of mandated clients, empowerment through making at least constrained choices, self-attribution, and longer-lasting change. The option requires both practitioner time and skill in reframing. Time is, however, often very limited at initial contact and a crisis state may preclude extended negotiation. In addition, the practitioner may think that agreeable mandates effectively link concerns but the involuntary client does not see or accept the linkage. Should the practitioner and the involuntary client settle on an “agreeable mandate,” they can then proceed to elaborate upon a semivoluntary or voluntary contract. If the problems cannot be readily reframed, the involuntary client’s expressed concerns do not fit the mandated or outside pressures, or

Initial Phase Work with Individual Involuntary Clients the practitioner wishes to explore additional sources of motivation, the practitioner then proceeds to consider the other strategies presented below. 3. Explore the quid pro quo or “ let’s make a deal” option. Often, minimal or weak intrinsic motivation for dealing with the mandated concern is found through the agreeable mandate option. In such cases, exploring use of inducements can strengthen compliance with mandates. In a quid pro quo version, the practitioner offers to supply an incentive to a mandated client to make compliance with the requirement more attractive. The practitioner can supply an incentive to nonvoluntary clients in exchange for their choice to work on a problem attributed by others. If no acceptable deal is made, the practitioner can continue to explore the strategies that follow. a. Variations for mandated clients. Since practitioners cannot barter on nonnegotiable requirements with mandated clients, this option can be used to support mandated compliance by working on an additional voluntary concern, providing incentives, or supporting choices in the form of compliance with the mandate. i. Work on an additional voluntary concern. When a problem is expressed that is unrelated to the mandated concern, practitioners can sometimes make a deal to assist with that concern in addition to working on the mandated problem. For example, Jean, the protective ser vice worker, became aware that Mrs. Torres thought that her daughter was not helping her enough around the house and generally did not follow her rules. While these problems were not directly related to the mandated concern with safety, Jean offered to help Mrs. Torres work with her daughter around house rules and her role in helping to make the home a safer place. In addition, Mrs. Torres often expressed her concern that her valuable things not be discarded in an effort to make the home safe by the standards of others. Jean agreed to help her protect her valuable things as long as they were not a safety hazard. ii. Provide an incentive. The practitioner can offer to provide an incentive to enhance compliance. For example, substance use disorder treatment programs sometimes use contingent vouchers to reward smoking or substance use cessation (Rohsenow et al. 2016). iii. Support choice within the bounds of compliance. Practitioners can support the selection of options in the way that requirements are implemented. For example, when Mr.  James became aware that he was going to be involuntarily hospitalized, he became extremely agitated and struggled with mental health staff. A mental health aide then clarified for him that the permission for involuntary hospitalization had been received and Mr. James could not immediately change that. He could choose, however, how he would go to the ward, and he could be helped to initiate a legal appeal after he got to the ward. If he continued to strug gle, he would be forcibly restrained and taken to the unit. If he could calm down, he would be able to walk up to the unit

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Practice Strategies for Work with Involuntary Clients accompanied by mental health aides but without restraints. Mr.  James calmed himself and chose to walk up to the ward, accompanied by the aides. b. Variations for nonvoluntary clients. Use of incentives with nonvoluntary clients must not involve rights, entitlements, and basic necessities, but rather entail additional benefits that the practitioner or agency is not required to provide. The success of this option depends on the ease with which the nonvoluntary client can acquire similar incentives in other ways. Hence, the quid pro quo option is subject to abuse with vulnerable clients from oppressed groups. For example, a Native American woman from Minnesota left her child with relatives out of state. When she did not return at the agreed-upon time, the relatives contacted social ser vices and requested that the child be placed. When the woman returned, she discovered that her child was in a white foster home. She was assessed as having an alcohol use disorder and the agency did not agree to release her child to foster care in Minnesota or return the child to her until she completed a substance use disorder treatment program and got a job. These requirements were illegal as Native American children are entitled to placement in Native American homes as a first option, without condition due to the requirements of the Indian Child Welfare Act. Similarly, transfer of the child to Minnesota was a right, not a privilege. In this case, establishing conditions for placement of the child in a Native American home and in Minnesota was illegal and an unethical abuse of a vulnerable client from an oppressed group. Capacity to parent the child might be appropriately assessed by social ser vices in Minnesota in a way that did not violate these legal and ethical rights. i. Work on an additional voluntary concern in exchange for compliance with external pressure. One example is bartering with clients with severe and persistent mental illness in which community support practitioners agree to supply a benefit sought by a client living in the community in exchange for an agreement to regularly take prescribed medication (Angell, Mahoney, and Martinez 2006). ii. Provide an inducement. A child welfare worker, who wants an adolescent client to attend a meeting at a community college for seniors, might suggest that she takes the client, and then after the meeting, they go out to dinner or grab coffee together. This incentive might be appealing enough to the adolescent, especially if he has a strong relationship with the worker, to attend the meeting even though he is reluctant to do so. In this case, since transportation and a meal were not a client right, it might be provided as a legitimate inducement. There are four concerns with the quid pro quo option. It is unethical to barter basic rights, entitlements, and necessities for compliance with mandated or externally pressured goals. Inducements must be an additional benefit beyond normal entitlements. As practitioners and agencies are sometimes tempted to cross this legal and ethical line, the strategy is subject to abuse with vulner-

Initial Phase Work with Individual Involuntary Clients able involuntary clients from oppressed groups who have limited alternative access to desired resources or may be unaware of their legal rights. For example, adolescent parents who are themselves wards of the child welfare system have limited sources of income as they seek to complete school or a GED and acquire job training while retaining their children (Teen Parenting Ser vice Network 2005). Child welfare agencies might be tempted to consider fostering compliance with agency goals of supporting birth control with cash incentives, which goes beyond the legal levels of support (ibid.). Second, this option may “buy” behavioral compliance without changing attitudes or promoting self-attributed change. Some practitioners and settings may reject behavioral compliance without prior attitude change as “working on the right problems for the wrong reasons,” insisting on acceptance of mandated or externally pressured changes for the right reasons. While such acknowledgment of attributed problems might be desirable, insistence on attitude change as a precondition for behavioral change is rarely successful. This option makes it more likely that behavior will change and attitude change may follow. However, compliance should not be expected to be maintained indefinitely unless that compliance becomes intrinsically rewarding or rewarded in the environment. To support self-attribution and longer-lasting maintenance, the inducements should be small and phased into natural reinforcement. Use of this option also presumes that the practitioner has access to valued resources, is empowered with discretion to make deals, and has the time required to negotiate. Many agencies have policies that discourage making special arrangements on the grounds that they are unfair to other clients who are not offered such options. Hence, much of the legal reform in work with public agencies has focused on removing discretion and establishing uniform procedures. Even when negotiation is permitted, practitioners often lack access to incentives and have limited time for exploring them. With these reservations, the examples above suggest that with imagination and sensitivity, practitioners can be aware of issues that can act as ethical incentives for clients. Finally, practitioners must learn how to negotiate. As negotiation requires the practitioner to engage in an exchange of proposals and counterproposals, practitioners have to learn how to continue negotiation without personalizing the problem even when an unacceptable counterproposal has been presented. For example, when Jean offered to advocate for the placement of a housekeeper to assist Mrs. Torres in cleaning up her home, Mrs. Torres responded that she wouldn’t mind having a homemaker if she was under her control. Jean then clarifies the conditions under which a homemaker might be provided. mrs. torres: You know, I wouldn’t mind having a homemaker if I could tell her what to do. Now, I don’t want you guys to be running my house. I mean

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Practice Strategies for Work with Involuntary Clients this homemaker, I’d be in charge of her, I could tell her what to do, you guys wouldn’t tell her to come and take all this stuff out? jean: Well, that’s a good question about who would be in charge. I am here to make sure that you and Julie are safe. So the homemaker would be working for the agency as part of our plan to help you get the house into a safe condition and not directly working for you. You could work with her in identifying the valuable things you want to keep and the things that you just consider junk. 4. Explore the “get rid of the mandate or outside pressure” option. Many involuntary clients express no concern or acknowledge only the pressure to see the practitioner as a concern: “Other than being here with you, I’ve got no problems.” Such responses are often interpreted as denial, resistance, or failure to accept responsibility rather than accepted as an indication that the involuntary client does not acknowledge or recognize the identified problems. The practitioner can take the initiative by suggesting that the mandated situation or pressure from others itself may be a problem that the client might wish to eliminate. Clients often agree that getting mandated ser vice providers out of their lives is a goal they would like to accomplish (Rosenberg 2000). In this “get rid of the mandate or outside pressure” option, the involuntary client may agree to contact in order to avoid or eliminate pressure rather than by acknowledging the validity of the outside pressure or mandate or through actions to receive an incentive. Hence, this option relies on punishment avoidance motivation, rather than the inducement and self-attribution motivations characteristic of the first two options. If the involuntary client accepts this option, the practitioner can proceed to formalize a semivoluntary contract with the client. Should no agreement be reached, the practitioner can proceed to an informed consent strategy. a. Variations for mandated clients. Mandated clients often respond to mandated pressure as they would to punishment, regardless of whether that pressure is designed in part to help or rehabilitate the client. Rather than continuing to argue about the merits of working on the mandated problem, acknowledging a motivation of punishment avoidance or elimination can be a useful step toward some motivational congruence. For example, some involuntary clients find the option to end the contact early more acceptable than contracting around a problem they consider invalid. Since many adolescent clients on court-ordered supervision are averse to regular contact with a practitioner, the practitioner can capitalize on this motivation by negotiating frequency and number of contacts based on compliance with a set of required tasks. This option can sometimes be used at a point when more positive motivations have not been found. For example, after the home investigation revealed that Mrs. Torres would need to clean and remove boxes for Julie to be safe, she did not respond placidly to this news.

Initial Phase Work with Individual Involuntary Clients mrs. torres: I don’t know why you people are making such a big deal. The people down the street are yelling and fighting and I hear them screaming and playing music; and here I got a few too many boxes and you people come in here and tell me how to run my life. This is my house and these are my things, you shouldn’t be able to tell me I have to get rid of them. Why don’t you investigate those people, who are about three houses down, they’ve got trash out in their backyard and they are always yelling and screaming in the middle of the night. And here you are picking on somebody like me. I’m working, taking care of my kids, you guys make me sick. jean: I can see that you are very angry because of my comments about the boxes in the other room. mrs.  torres: Well, of course I’m angry. You come in here, you high and mighty, you think you’re so good. Why wouldn’t I be angry, did you ever have anybody tell you about your house, that they don’t like it? jean: No, that has not happened to me, but I’m sure that I would be angry too. mrs. torres: Well, I am. I am. jean: I can hear that you are angry. If we got a report on your neighbors, someone would have to conduct an investigation. mrs.  torres: Well, I ought to report them and get you off my back. I’m working hard. jean: You want me out, huh? mrs. torres: Yes. jean: Well, again, I’m here because we need to make sure Julie is safe. And the way to do that is to help get the house into a safe condition. If you want me out, as soon as Julie is safe and the house is safe, I’m out. This option may also be used simultaneously with other more positive contracting strategies. After the above exchange, a semivoluntary contract was agreed upon with Mrs. Torres that included the following: (1) she wanted her home clean for the holidays and to retain custody of Julie (agreeable mandate); (2) she would receive the assistance of a homemaker for a limited period; (3) Jean would work with Mrs. Torres and Julie to help them work together in cleaning up (“let’s make a deal”); and (4) Mrs. Torres wanted to “get you people out of my hair” (get rid of mandate). b. Variations with nonvoluntary clients. While nonvoluntary clients can choose to avoid working with the practitioner, they may also choose to work on ridding themselves of the outside pressure without acknowledging its legitimacy. For example, many schoolchildren are referred to counselors and social workers for a variety of attributed problems such as inattention, truancy, and inadequate study skills. While they frequently do not acknowledge these teacher-attributed problems, they often acknowledge other problems: “Other students provoke me, get me in trouble with the teacher”; “The teacher picks

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Practice Strategies for Work with Involuntary Clients on me.” Hence, if the problem is framed according to an acknowledged problem such as “to get the teacher off my back,” a semivoluntary contract may be reached (Epstein and Brown 2002). For example, Walter summed up the situation with Mrs. Simmons, who was in a nonvoluntary relationship with the county worker over care of her child. walter: From what you’re telling me, you are pretty concerned about what’s going on at the school. The school has concerns and you have your own concerns. You think that something needs to change between Jamie, the school, and yourself. mrs. simmons: Yeah, something definitely needs to change there. walter: If we can get things changed at school, so that the other kids and teachers aren’t picking on Jamie, and so that his behavior improves there, that will satisfy the court. If we start making some progress, the court would probably dismiss that consent decree early. You’ll get them off your back. It will also get the school off your back. It also sounds as if Jamie’s behavior at home could also be the focus of some attention. It can’t be a lot of fun to go to work in a high stress job, then come home and have the teacher calling you and saying, “This or that happened today, and I want you to do something about it.” And then for you to tell Jamie you want him to do something, and he tells you, “No.” It’s got to be frustrating. And I think that maybe we can look at that too, if you’d like. Since this option focuses on removing a threat of punishment, it entails less positive motivation than the first two. Negative reinforcement strategies may enhance compliance without leading to self-attribution. Consequently, this option runs the risk of buying compliance only for the length of the contract and, like the quid pro quo strategy, may be seen by referral sources and agencies as working on “the right problems for the wrong reasons.” It does, however, connect with client motivation to restore freedom and hence may reduce reactance and enhance compliance. An additional concern is that practitioners with access to coercive power may be tempted to overuse it. For example, practitioners working with mandated clients may frequently find punishment avoidance motivation immediately available and may be tempted to begin with it. In order to support motivational congruence and selfattribution, it should be attempted after or in conjunction with the more positive strategies described earlier. 5. Explore the informed consent option. Should none of the above achieve a level of motivational congruence, the practitioner can pursue a final informed consent option. Mandated clients can be reminded of their right to accept the consequences for failing to work on legal requirements or choose to comply with the minimum acceptable level to satisfy the requirement. Nonvoluntary clients can be reminded repeatedly through the contracting sequence that they

Initial Phase Work with Individual Involuntary Clients can choose not to accept ser vices. The decision not to accept ser vices should, however, include information about potential consequences of that choice. a. Variations for mandated clients. Some mandated clients experience such a negative reaction to forced contact that even agreeing to “get rid of the mandate” is not acceptable since it symbolizes some compliance in a disagreeable process. Hence, some mandated clients may choose to accept a legal penalty or the threat that a penalty will be imposed, or choose to comply with the bare minimum. Those choices and their consequences can be clarified including the potentially self-defeating consequences of deciding not to contract. By refusing contracting options, the mandated client places most decision making in the practitioner’s hands. For example, after having several contracting possibilities rejected by a teenaged client referred for delinquency, one practitioner proceeded to write her assessment in the client’s presence. When the client asked what she was doing, the practitioner explained that since he had not chosen to participate in contracting, she was proceeding to carry out her job requirements and develop a plan without his input. Some mandated clients reconsider when the consequences of failure to reach agreement are clarified and earlier options can be reexamined in search of a semivoluntary contract. If the mandated client does not reconsider contracting, the practitioner can empathize with pressures felt and proceed to reaffirm the nonnegotiable requirements of contact. The practitioner’s role will essentially be one of enforcer at this point in contact, though more voluntary contracting may be possible later. Failure to reconsider may indicate high reactance and, if so, that assessment is based on attempting several strategies to reduce reactance rather than on a premature conclusion at the beginning of contact. Some writers have suggested that high reactance in the form of opposition to all practitioner initiatives may call for use of a defiance-based paradoxical strategy. For example, if lack of compliance with practitioner initiatives can be predicted, then the practitioner might prescribe the opposite of what is desired (Shoham and Rohrbaugh 1997). Caution in use of defiance-based paradoxes is recommended with mandated clients. While evidence suggests that paradoxes can sometimes be effective in achieving compliance with practitioner goals, that achievement often occurs without self-attribution of gains. The short-term compliance gains may also jeopardize the potential for influence later in the relationship since persuasive influence may be more likely to occur if involuntary clients come to see the practitioner as trustworthy. b. Variations for nonvoluntary clients. As the decision to accept or reject services is the legal and ethical right of nonvoluntary clients, any form of heavyhanded pressure is inappropriate. The client’s right to self-determination should be respected. Hence, outreach efforts to potentially “at risk” clients, such as teenaged single parents of newborns, should provide information that can

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Practice Strategies for Work with Involuntary Clients assist in making informed choices. For example, the practitioner might plant a seed with inductive questions about possible future difficulties experienced by others in similar situations and give the client information about resources they can seek should they come to have concerns in the future. This section has presented contracting strategies designed to enhance compliance with mandates and nonnegotiable requirements and also to facilitate motivational congruence, self-determination, and achievement of clientdefined goals. Use of the contracting options should empower the practitioner and involuntary client toward more frequent semivoluntary or voluntary contracting solutions. Practitioners skilled in these strategies should be able to reduce client reactance in the initial phase of contact, increase compliance with mandated goals and nonnegotiable policies, and achieve more frequent motivational congruence. While these hypotheses are based on theory and research reviewed earlier in the book, they will require further testing with specific target problems and client populations before they can be accepted as effective. In addition, many obstacles to the use of these strategies can be anticipated in advance. Obstacles coming from involuntary clients, practitioners, and agencies can be anticipated when there is a lack of resources, competence, or skills, or adverse beliefs. Lack of Resources, Competence, and Skills Lack of adequate resources, competence, and skills can impede negotiation and contracting. Many involuntary clients lack competence, skill, or experience in contracting. Since contracting is largely a cognitive process, some clients lack the capacity to negotiate complex contracts. Further, practitioners sometimes consider that since some clients make impulsive decisions or act based on factors the practitioners consider irrelevant, they cannot effectively participate in contracting. We noted in chapter 4 that Wilmer’s decision to take antipsychotic medication was not based on an acceptance of its value for its own sake. Whether or not the client’s decision-making process is one that the practitioner considers acceptable, clients continue to make decisions. Use of the options in simple, concrete form should produce greater motivational congruence and success than if such congruence is not pursued. Lack of resources, competence, and skills can also occur with practitioners and agencies. Social ser vices frequently struggle with limited resources, often resulting in large caseloads and limited attention to individual clients. Consequently, practitioners can sometimes barely carry out the minimum mandated requirements while keeping up with their paperwork. They may have little time to work on problems other than mandated or required concerns. Such overload can lead to standardized rather than individualized case plans, crisis-driven work, and “going through the motions.”

Initial Phase Work with Individual Involuntary Clients In addition, practitioners may not be permitted discretion to make deals such that they have little leverage over the packaging and form of requirements. Court orders and agency nonnegotiable policies are sometimes written such that discretion in interpretation is unclear, or discretion is actively discouraged. Funding bodies may require mandated goals and not encourage individualizing those goals. For example, the frequency of contacts between a probation officer and client may be dictated by results of an assessment instrument rather than negotiated with the mandated client. Consequently, involuntary clients may desire a resource that the practitioner cannot provide and hence an acceptable exchange may not be attainable. Even when resources and discretion are available, effective use of the options requires practice and increasing skill in reframing and bargaining through separating the nonnegotiable from the negotiable. Use of the contracting options will not resolve resource deficits or increase discretion, and additional strategies are needed to influence such system needs. In the short run, the practitioner might be advised to attempt using the options as time permits. As experience and competence in use of the strategies increases, it should be possible to use them on a larger proportion of the caseload. In addition, involuntary contacts often occur in a state of crisis, which leads involuntary clients to fight with all their strength to preserve the status quo. Providing help with the perceived crisis is often an essential first step. Practitioners and agencies also have crises. For many key involuntary positions such as child protection work, turnover is high and new practitioners enter work with limited training. Sudden additions to an already pressured caseload may put the practitioner in a crisis state, whether or not the client is actually in crisis. Finally, agency resource limitations can create a crisis mentality in the agency. The strategies presented here are proactive and can, in the long run, reduce some types of client and practitioner crises by ensuring that there is motivational congruence with at least some clients. Since even semivoluntary contracts involve an exchange of goods and services acceptable to all parties, sometimes an acceptable exchange is not reached. As involuntary clients may decide that requirements are unfair, unreasonable, or impossible to attain, they may decide to improve their situation outside of negotiation. When coerced choices entail “godfather’s choices” between unacceptable alternatives such as accepting ser vices or being prosecuted, many involuntary clients will not consider these as options. Since perceived intrusiveness of a threat to freedom varies such that what is considered overwhelming by one person may be acceptable to another, agreements may be reached with some but not with others. Practitioners should advocate for fair, nondiscriminatory options. If they do not succeed in modifying unfair options, then high client reactance, apathy, and powerlessness may result as a consequence of overwhelming unfair requirements.

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Practice Strategies for Work with Involuntary Clients Adverse Beliefs The contracting process may also be inhibited by adverse beliefs on the part of clients, practitioners, and agencies. These assumptions include the beliefs that clients should have the “right” motivation, not just be working on the “right” problem, and the working assumption that contracts and case plans represent paperwork formalities rather than inherently valuable intervention processes, distrust between client and practitioner, and conflicting goals. Practitioners working with involuntary clients are often influenced by approaches that insist on early ownership of responsibility for harm caused and for the success of change efforts. While self-attributed change is desirable, insistence on early ownership of responsibility may produce a counterproductive stalemate and prevent later influence. Consequences of such beliefs in required early ownership of responsibility may be a continued struggle to outsmart involuntary clients and ultimate reliance on power to reward and punish. Practitioners operating under the belief in the necessity of the right reason for the right problem may have to accept that they must continue to pull teeth and to work harder than involuntary clients who may appear oblivious to problems or the need to change. Failure to produce coerced change may reinforce pessimism and contribute to beliefs that congruence is not possible, that clients are not changeable, and that lead to further client labeling. The options presented here suggest that while complete congruence is frequently impossible, some congruence is often better than none. Use of the strategies does not mean practitioner acceptance of full responsibility for outcomes but rather acceptance of responsibility for facilitating congruence. It may be easier for a practitioner to reach this position if the agency has also come to terms with what can and cannot be changed. To use a baseball analogy, use of the strategies should increase the practitioner’s batting average: possession of skills in facilitating congruence does not mean that the practitioner will have a hit each time at the plate, but he or she will likely connect more frequently that someone without these skills. Averaging 3.5 hits in ten opportunities is often enough to win batting titles and may be a desirable goal for practitioners working with involuntary clients. In addition, contracts and case plans are often considered paperwork rituals by both involuntary clients and practitioners. Practitioners may approach them as nonnegotiable requirements that satisfy the needs of invisible state or agency auditors and visible supervisors. There may be few positive consequences for writing them effectively and negative consequences for lateness, checking the wrong box, or inconsistent use of the form. Practitioners may also have found that such paper transactions bear little resemblance to a reality in which involuntary clients sometimes provide superficial agreement, provide signatures without intending compliance, or may not even see the case plan. Similarly, involuntary clients may have experienced such “agreements”

Initial Phase Work with Individual Involuntary Clients in the past as a railroaded formality. Use of semivoluntary contracts requires some belief in the value of the process by practitioners. Involuntary clients without prior experience in other systems may be more optimistic about their value. While contracts should build trust, there are many reasons practitioners suspect lack of candor from involuntary clients and involuntary clients have similar suspicions of practitioners. As the practitioner is not the agent of the mandated client, those clients have reason to be careful in deciding what information they will share. Their own perceived problems may have appeared petty and were punished in the past as a lack of accepting responsibility for “the problem.” As suggested earlier, early confessions may have been rewarded in the past, whether or not they were sincere. Such experienced involuntary clients may have found that you may not have to comply completely as long as you say the right words. Similarly, involuntary clients have reasons to be suspicious of practitioner candor. Practitioners and agencies often have hidden agendas. Mandated practitioners are not in place primarily to serve involuntary clients. Practitioners may practice manipulative, hooking strategies in which the axiom “start where the client is” is an instrumental technique used “to get them to where you want them to go.” Hence, strategies of superficial agreement on one set of goals while in fact pursuing a hidden agenda to get at the “root problem” is common practice. Some writers have suggested that complete candor may impede effectiveness as the client system may oppose any overt change effort (Haley 1990). Similarly, ser vice decisions are not always made on the merits of the case but according to agency policy and resources. For example, while reducing out-of-home placement costs has played at least a part in the current movement toward home-based ser vices, this reason is not always shared with families. In addition, agencies may not expect or wish for the contract to succeed. If they assess high probabilities of failure, they may be unwilling to take chances and in fact be prepared to go through the motions and make reasonable efforts. While greater candor on all sides might make for a better world, it would be more realistic at this point to accept lack of complete candor as expectable in involuntary transactions, without labeling it as a client characteristic. Greater candor may be facilitated by modeling it: Talking about power and its requirements and limits may increase trust. Such candor entails clarity about nonnegotiables, consequences, and practitioner hopes for changes beyond those required. While complete candor is probably impossible for either side of the transaction, the amount of energy devoted to hidden agendas should be reduced since modeling candor may facilitate greater effectiveness. Lack of trust is also related to conflicting goals, both shared and unshared. Involuntary clients may agree to goals that they are ambivalent about reaching. For example, clients sometimes enter Alcoholics Anonymous groups with

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Practice Strategies for Work with Involuntary Clients ambivalence about whether they wish to abstain from drinking. Similarly, agencies have multiple, conflicting goals in which they must simultaneously placate different constituencies such as taxpayers, supervisory boards, state oversight agencies, advocacy groups, and professional associations. Responsibilities to involuntary clients may play a small role in such considerations. In such circumstances, agencies may have given the message to the practitioner openly or covertly to make the involuntary client change by any means necessary, in which collaborative methods may be preferred but other means are approved if deemed necessary. The organization may believe that intervention can be used deterministically to change behavior and attitudes regardless of client wishes. Such pressures often lead to involuntary ser vice plans that include a large number of nonnegotiable requirements designed to comply with the wishes of outside parties. Such ser vice plans might be termed “cover your posterior” or “kitchen sink” contracts designed to demonstrate to outside constituencies that all bases have been covered, though there may not be enough hours in the day to touch all those bases. While such arrangements may appear to outside parties as thorough case plans, under the premise that the more treatment the better, they may in fact be doomed to fail. These plans may be used to demonstrate lack of client competence when in fact their purpose may be to demonstrate that an effort has been made, though in fact the effort may be primarily cosmetic. Difficult issues are raised when such contracts are developed to protect involuntary clients and their vulnerable dependents. The safety of others must not be compromised. Creating contracts that have no reasonable chance of succeeding should never become standard practice. Clients, practitioners, and agencies may also be opposed to the negotiation process. Alienated involuntary clients may see practitioners with name tags as members of occupation forces. Negotiation may be perceived as trickery to get them to do what they do not want to do. Negotiation may also be perceived as a sign of weakness that can be overcome with intimidating self-presentation. Practitioners and agencies may also distrust negotiation. For example, it is sometimes believed that delinquent youth need a corrective experience with authority in which it is important to present a firm, fair set of requirements that cannot be undermined and overwhelmed. From this viewpoint, delinquent youth need and subconsciously want a structure that will hold them accountable. Consequently, negotiation might be seen as presenting a weak role model of authority, of coddling when firmness is required. Such beliefs imply that negotiation might give away critical power and authority and model susceptibility to intimidation and manipulation. Constructive models of authority do not, however, require rigidity on all issues. Firmness on nonnegotiable requirements and flexibility on negotiable items may be an alternative

Initial Phase Work with Individual Involuntary Clients model of authority. Skills are then required in separating the nonnegotiable from the negotiable. Agencies and practitioners should explore the extent to which the obstacles described in this chapter occur in their practice. When these obstacles are effectively addressed, the practitioner will be able to proceed to develop a formal contract. Consequently, we proceed in the next chapter to present guidelines for developing a formal contract and initiating mutually developed task plans for implementing that contract.

Discussion Questions 1. Socialization and contracting takes time. Practitioners often report that they barely have time to carry out essential elements of an assessment/investigation and that engaging potential clients is not a high organizational priority (Richards, Ruch, and Trevithick 2005). What are the implications of not engaging clients at this point? 2. It has been suggested from the stages-of-change perspective that many clients will be in the precontemplation or contemplation stage regarding their acknowledgment of attributed problems. What are the implications for the validity of action plans and contracts developed at this stage? 3. Practitioners attempting persuasion may represent agencies that some clients do not believe to be acting in their best interest. What are the implications for the potential success of such efforts? 4. What have you experienced related to organizational beliefs that involuntary clients need to work on “the right problems for the right reasons”? What are the implications of your beliefs?

References Angell, B., C. Mahoney, and N. Martinez. 2006. “Promoting Treatment Adherence in Assertive Community Treatment. Social Service Review 80 (3): 485–526. Brehm, J. 1976. A Theory of Psychological Reactance. 2nd ed. New York: Academic Press. Burke, B. L., H. Arkowitz, and D. Dunn. 2002. “The Efficacy of Motivational Interviewing and Its Adaptations.” In Motivational Interviewing: Preparing People to Change Addictive Behavior, eds. W. Miller and S. Rollnick, 2nd ed., 217–250. New York: Guilford. Cingolani, J. 1984. “Social Conflict Perspective on Work with Involuntary Clients.” Social Work 29(5): 442–446. Corcoran, J. 2003. The Transtheoretical Stages of Change Model and Motivational Interviewing for Building Maternal Supportiveness in Cases of Sexual Abuse. Journal of Child Sexual Abuse 11 (3): 1–17.D’Andrade, A., M. J. Austin, and A. Benton. 2008. “Risk and Safety

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Practice Strategies for Work with Involuntary Clients Assessment in Child Welfare: Instrument Comparisons.” Journal of Evidence-Based Social Work 5 (1–2): 31–56. D’Andrade, A. C., and R. M. Chambers. 2012. “Parental Problems, Case Plan Requirements, and Ser vice Targeting in Child Welfare Reunification.” Children and Youth Services Review 34 (10): 2131–2138. de Jong, P., and I. K. Berg. 2001. “Co-constructing Cooperation with Mandated Clients.” Social Work 46 (4): 361–374. Draycott, S., and A. Dabbs. 1998. “Cognitive Dissonance 1: An Overview of the Literature and Its Integration into Theory and Practice in Clinical Psychology.” British Journal of Clinical Psychology 37 (3): 341–353. Epstein, L., and L. Brown. 2002. Brief Treatment and a New Look at the Task- Centered Approach. 4th ed. New York: Macmillan. Forrester, D., J. McCambridge, C. Waissbein, and S. Rollnick. 2008. “How Do Child and Family Social Workers Talk to Parents about Child Welfare Concerns?” Child Abuse Review 17 (1): 23–35. Haley, J. 1990. Strategies of Psychotherapy. New York: W. W. Norton. Hanson, M., and L. A. Gutheil. 2004. “Motivational Strategies with Alcohol-Involved Older Adults: Implications for Social Work Practice.” Social Work 49 (3): 364–372.Heneghan, A., R. E. Stein, M. S. Hurlburt, J. Zhang, J. Rolls-Reutz, E. Fisher, J. Landsverk, and S. M. Horwitz. 2013. “Mental Health Problems in Teens Investigated by US Child Welfare Agencies.” Journal of Adolescent Health 52 (5): 634–640. Hepworth, D. H., R. H. Rooney, G. Dewberry-Rooney and K. Strom-Gottfried. 2016. Direct Social Work Practice: Theory and Skills. 10th ed. Boston, MA: Cengage Learning. Holland, S. 2000. “The Assessment Relationship: Interactions between Social Workers and Parents in Child Protection Assessments.” British Journal of Social Work 30 (2): 149–163. Horwitz, S. M., M. S. Hurlburt, A. Heneghan, J. Zhang, J. Rolls-Reutz, E. Fisher, J. Landsverk, and R. Stein. 2012. “Mental Health Problems in Young Children Investigated by US Child Welfare Agencies.” Journal of the American Academy of Child and Adolescent Psychiatry 51 (6): 572–581. Jones, M. 1990. “Working with the Unmotivated Client. National Criminal Justice Reference Ser vice.” In Violence Hits Home: Comprehensive Treatment Approaches to Domestic Violence, eds. S. Stith and M. Williams, 115–125. New York: Springer. Juarez, P. 2001. A Randomized Trial of Motivational Interviewing and Feedback on Heavy Drinking College Students. Unpublished master’s thesis. University of New Mexico, Albuquerque. Kear- Colwell, J., and J. Pollock. 1997. “Motivation or Confrontation: Which Approach to the Child Sex Offender?” Criminal Justice and Behavior 24(1): 20–33. Kopp, J. 1988. “Self-Monitoring: A Literature Review of Research and Practice.” Social Work Research and Abstracts 24 (4): 8–20. Kopp, J. 1989. “Self-Observation: An Empowerment Strategy in Assessment.” Social Casework 70: 276–284. Levenson, J. S. 2011. “ ‘But I didn’t do it!’: Ethical Treatment of Sex Offenders in Denial.” Sexual Abuse: A Journal of Research and Treatment 23 (3): 346–364. Littell, J., L. Alexander, and W. Reynolds. 2001. “Client Participation: Central and Underinvestigated Elements of Intervention.” Social Service Review 75 (1): 1–28. Littell, J. H., and H. Girvin, H. 2004. “Ready or Not: Uses of the Stages of Change Model in Child Welfare.” Child Welfare 83 (4): 341.Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Preparing People for Change. New York: Guilford.

Initial Phase Work with Individual Involuntary Clients O’Hare, T. 1996. “Court-Ordered versus Voluntary Clients: Problem Differences and Readiness for Change.” Social Work 41 (4): 417–422. Oliver, C., and G. Charles. 2016. “Enacting Firm, Fair, and Friendly Practice: A Model for Strengths-Based Child Protection Relationships.” British Journal of Social Work 46 (4): 1009–1026. Palmer, S. E. 1983. “Authority: An Essential Part of Practice.” Social Work 28(2): 120–125. Pecora, P. J., J. K. Whittaker, A. N. Maluccio, and R. P. Barth. 2012. The Child Welfare Challenge: Policy, Practice, and Research. Piscataway, NJ: AldineTransaction. Petrocelli, J. V. 2002. “Processes and Stages of Change: Counseling with the Transtheoretical Model of Change.” Journal of Counseling and Development 80 (1): 22–30.Reich, J. A. 2005. Fixing Families: Parents, Power and the Child Welfare System. New York: Routledge. Richards, S., G. Ruch, and P. Trevithick. 2005. “Communication Skills Training for Practice: The Ethical Dilemma for Social Work Education.” Social Work Education 24 (4): 409–422. Rohsenow, D. J., R. A. Martin, J. W. Tidey, S. M. Colby, and P. M. Monti. 2017. “Treating Smokers in Substance Treatment with Contingent Vouchers, Nicotine Replacement and Brief Advice Adapted for Sobriety Settings.” Journal of Substance Abuse Treatment 72: 72–79. Rosenberg, B. 2000. “Mandated Clients and Solution-Focused Therapy: ‘It’s Not My Miracle.’ ” Journal of Systemic Therapies 19 (1): 90. Saunders, D. 1982. “Counseling the Violent Husband.” In Innovations in Clinical Practice, eds. D. A. Keller and L. G. Ritt, 1: 20. Sarasota, FL: Professional Resource Exchange. Seabury, B. 1979. “Negotiating Sound Contracts with Clients.” Public Welfare 38: 33–38. Shea, S. C. 2012. “The Interpersonal Art of Suicide Assessment.” The American Psychiatric Publishing Textbook of Suicide Assessment and Management, eds. R. I. Simon and R. E. Hales, 2nd ed., 29–56. Washington, DC: American Psychiatric Publishing. Shoham, V., and M. Rohrbaugh. 1997. “Interrupting Ironic Processes.” Psychological Science 8 (3): 151–153. Shulman, L. 2015. The Skills of Helping Individuals, Families, Groups, and Communities. 8th ed. Baltimore, MD: Brooks Cole. Smith, B. D. 2008. “Child Welfare Ser vice Plan Compliance: Perceptions of Parents and Caseworkers.” Families in Society 89 (4): 521–532. Smith, M., M. Gallagher, H. Wosu, J. Stewart, V. E. Cree,, S. Hunter, S. Evans, et al. 2013. “Engaging with Involuntary Ser vice Users in Social Work: Findings from a Knowledge Exchange Project.” British Journal of Social Work 42 (8): 1460–1477. Teen Parenting Ser vice Network. 2005. Year in Review: Fiscal Year 2005. Chicago: UCAN. Tohn, S. L., and J. A. Oshlag. 1996. “Solution-Focused Therapy with Mandated Clients: Cooperating with the Uncooperative.” In Handbook of Solution-Focused Brief Therapy, eds. S. D. Miller, M. A. Hubble, and B. L. Duncan, 152–183. San Francisco: Jossey-Bass. Trotter, C. 1996. “The Impact of Different Supervision Practices in Community Corrections.” Australian and New Zealand Journal of Criminology 29 (1): 29–46. Trotter, C. 2004. Helping Abused Children and Their Families. Sydney, AU: Allen and Unwin. Trotter, C., and P. Evans. 2012. “An Analy sis of Supervision Skills in Youth Probation.” Australian and New Zealand Journal of Criminology 45 (2): 255–273. White, W. L., and W. R. Miller. 2007. “The Use of Confrontation in Addiction Treatment: History, Science and Time for Change.” Counselor 8 (4): 12–30.

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Chapter 9

Task-Centered Intervention with Involuntary Clients

Ronald Rooney

If application of the guidelines discussed in the preceding chapters results in a preliminary semivoluntary or voluntary contract, there is a variety of specific intervention models to choose from, according to setting and type of problem. For example, particular chemical dependency treatment models or alternatives to aggression approaches might be selected for work with chemically dependent clients and men who have problems with violence. Some of these models are developed in part 3 of this book. This chapter presents adaptations of one model, task-centered casework, that can be useful across many involuntary problems and populations. The foundation constructed in part 1 of this book is empirically based. It draws on diverse theories and assumes a multisystems approach. Further, the foundation strongly emphasizes motivational congruence and careful limits on paternalistic prescriptions about client problems. Each of these features is a component of the task-centered approach, as described in the text that follows. Other task-centered features, such as time limits, are adapted only in part, since work with involuntary clients is often long term. While the taskcentered approach is not the only general model to serve as the basis for adaptations, it is hoped that the techniques developed here will be useful on their own and might also serve as models for how other approaches might be adapted. Based in the task-centered approach, techniques for formalizing the contract and developing initial tasks in semivoluntary contracts and involuntary ser vice plans are presented. Four adaptations of the task-centered approach to work

Task-Centered Intervention with Involuntary Clients with involuntary clients are presented in specifying target problems, establishing clear goals, developing general tasks, and establishing time limits. The chapter continues with guidelines for developing initial client tasks, initial practitioner tasks, anticipation of obstacles, providing a rationale for task completion, necessary incentives, guided practice, and summarization of task plans. Guidelines for middle-phase intervention follow. They include progress review, task review, assessment of obstacles, dealing with crises, and task plan revision. Special attention is devoted to confrontation because confrontation is more likely to be successful in the middle phase of work than earlier. The chapter concludes with consideration of issues in termination with involuntary clients.

Introduction to the Task-Centered Approach The task-centered model is a time-limited, empirically based approach to intervention that focuses on the reduction of specific, agreed-upon target problems through the planning and implementation of client and practitioner tasks to be carried out in the environment (Reid 1992, 2000; Epstein and Brown 2002; Rooney, 2010). The task-centered approach has been tested in work with the aging, family agencies, foster care, public schools, corrections, and mental health facilities (Epstein and Brown 2002; Reid 1997). While the field studies used to test the model vary in quality and rigor, they consistently report that clients appear to be helped with their primary target problems, especially when the problems are specific and relatively limited in scope (Reid 2000). The task-centered model is based on two explicit values: (1) the client’s expressed, considered wish is given precedence over other problems as defined by the practitioner, the agency, or significant others and (2) knowledge developed from empirical research is valued more highly than knowledge based primarily in theory or practice experience. As introduced in chapter 2, this approach distinguishes between problems attributed to the client by others and problems that the client acknowledges, with emphasis on the latter (Reid 1978). Focus on acknowledged target problems minimizes deadlocks, is congruent with client interests, facilitates independence and right of choice, and maintains as much client control over fate as possible. Since involuntary clients are regularly faced with attributed problems, it is important to know that use of the task-centered approach does not prevent the practitioner from exploring attributed problems and needs as well as acknowledged problems and wants. The task-centered practitioner may work simultaneously on mandated and voluntary problems, and indeed mandated problems cannot be ignored when the consequences may be severe losses to client interest and well-being. Normally, mandated problems are agreed to on the condition that the client’s own target problems are accepted by the practitioner (Reid 1978). The approach

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Practice Strategies for Work with Involuntary Clients distinguishes between attributed problems that are legally mandated and those that are not. If an attributed problem is not legally mandated and the client’s view appears incomplete, the task- centered practitioner may raise other problems or ways of looking at problems and attempt to make a persuasive case for those additional views. However, the client is free to reject the practitioner’s suggestions unless the problem happens to be legally mandated. Exceptions to use of the approach occur when the client is currently incompetent, incapable, homicidal, or suicidal. In such cases, the practitioner may have to act to prevent clear and present harm (Epstein 1988). Clients are aided in reducing target problems through the development of tasks that are planned in the session by the practitioner and client and are implemented by the client or practitioner outside of the session. Tasks are further specified into general tasks that are broad plans of action and operational tasks that are the specific plans that a client might undertake between one session and the next. For example, completing job applications might be a general task and developing a first draft of a resume before the next session might be an operational task. The normal time limit for the approach is six to twelve sessions, and clients can usually be helped to reduce two or three target problems within this time period. Since some clients have continuing longer-term contact with practitioners, the model includes provisions for recontracting, moving to a monitoring status, or linking to other forms of treatment. The task-centered practitioner attempts to set change into motion in target problems through a self-understanding, verbal, reflective strategy (Reid 1978). Such work is enhanced by practitioners who convey acceptance, respect, and understanding to clients. Hence, task-centered practitioners try to actualize warmth, empathy, and genuineness within a problem focus (ibid.).

Adaptations of the Task-Centered Approach to Work with Involuntary Clients The task-centered approach has been studied in a variety of mandated and nonvoluntary settings including child welfare, residential treatment, aging, probation, juvenile detention, chemical dependency, and public schools (Pazaratz 2000; Epstein and Brown 2002). While certain aspects of the approach fit well with involuntary work, other aspects are less compatible (figure 9.1). Several advantages of the task-centered approach for work with involuntary clients have been described in the literature. Foremost among these is goal focus, which helps practitioners focus on feasible action and reduces preoccupation with unattainable goals (Goldberg, Walker, and Robinson 1977). This goal clarity can help specify vague surveillance duties that other wise often take the form of aimless visiting, “purposeless probation,” and “hovering” over clients

Task-Centered Intervention with Involuntary Clients Figure 9.1 Advantages and disadvantages of the task-centered approach in work with involuntary clients

Advantages * adds clarity * focus on feasible rather than uncontrollable

* use of tasks fits needs for accountability * distinguishes between acknowledged and attributed problems

* enhances motivational congruence * fits time-limited problems and settings * crisis sometimes provides motivation Disadvantages * does not totally fit work with mandated clients who acknowledge no problems

* must be supplemented with knowledge about specific problems

* some settings and problems do not fit brief treatment

* does not fit entirely supervisory or custodial contact

(ibid.). Work on limited goals is often also possible while at the same time progress on other problems may be slower. Finally, goal specificity matches social ser vice trends that emphasize accountability and objective measures of ser vice delivery. The task-centered approach also assists in pursuit of motivational congruence. Emphasis on client-acknowledged problems moves away from preoccupation with totally imposed treatment plans by enhancing client collaboration and respect, clarifying expectations and rights, and distinguishing between mandated and voluntary problems. Third, planned brevity and focus on client tasks fits many involuntary settings that feature brief contact or require action to determine recommendations for terminating contact. Finally, the crisis state in which initial involuntary contact often takes place can provide at least temporary motivation to work on attributed problems through redefinition to

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Practice Strategies for Work with Involuntary Clients include agreed-upon target problems. Such contracting around the crisis can then provide direction and assist in restoring equilibrium. The task-centered approach fits less well with the needs for practice with involuntary clients in other areas (Marsh 2008). Since the task-centered approach is a model of voluntary, or at least semivoluntary, contact, it does not readily apply to work with mandated clients who do not acknowledge any problems or agree to work on tasks. In addition, time limits are not compatible with extended contact in settings such as residential treatment. Also, while studies conducted in public ser vices have indicated that one-third to one-half of public social ser vice clients could be served within the task-centered approach (Goldberg, Walker, and Robinson 1977), other circumstances remain in which contact is primarily supervisory, custodial, or supportive. Agency purposes can also be so problem focused that the scope of additional target problems that clients might wish to address is limited. For example, chemical dependency counselors may be instructed to address chemical use problems and provide outside referrals for additional client-defined problems. In addition, clients sometimes express target problems that conflict with the protection of the interests of others. Finally, the task-centered model is primarily a structure for providing ser vice that must be augmented by information on particular problems and supporting theories. Several adaptations to the approach have been developed to facilitate work in involuntary settings. First, in settings that have a par ticu lar problem focus, task-centered work can be facilitated by limiting the permissible scope of target problems. Second, the powerful role played by referral sources and mandated agencies with involuntary clients has resulted in guidelines to maintain close involvement with referral sources, informing them regularly of progress and agreements. Third, in long-term treatment settings such as community care of clients with serious and persistent mental illness, continuation contracts have been used in which a series of task-centered contracts may be completed with the same client. These sequences may occur one after the other or with breaks in which monitoring or non–task-centered contact continues. Fourth, case management contracts are sometimes developed that include tasks that link clients to other forms of treatment such as drug treatment. Finally, specific information about particular target problems can be consulted in the development of tasks. For example, task-centered work in foster care includes a focus on tasks to facilitate parental visitation that is informed by foster care research (figure 9.2).

Formalizing the Involuntary Contract Guidelines to formalize the involuntary contract adapting the task-centered approach are now presented. They include specifying target problem conditions

Task-Centered Intervention with Involuntary Clients to be changed, establishing clear goals, developing general tasks, and establishing time limits (figure 9.3). Specifying Target Problem Conditions to Be Changed Intervention plans can be more focused if the specific conditions of the problems to be rectified are identified. Target problem conditions include those that occur with some frequency and those that are either present or absent. For example, the number of job applications completed, a condition that can be measured with some frequency while securing court permission for independent living, is a present/absent condition. In some cases, assessment tools are available that can be used to measure the extent of a problem (Okamoto and Le Croy 2004; Usher 2004). In other cases, practitioners may need to develop their own indicators of the problem conditions. When conditions are identified, a baseline measure can then be taken of the current extent of the problem to develop a standard of progress toward resolution. For example, a client might have made three job applications in the past week as the baseline for a condition of job-seeking efforts. Similarly, the baseline for securing court permission for independent living might be that no such permission has been given. Too often involuntary practice has included the unilateral establishment of target problem conditions by the practitioner rather than the mutual development of indicators. In the following section, Nancy and Beth, introduced

Figure 9.2 Adaptations of the task-centered approach to involuntary settings Limiting the permissible scope of target problems Use of continuation contracts when contact is long-term Maintenance of close involvement with referral sources Adding knowledge about specific problems in task development

Use of case management contracts

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Practice Strategies for Work with Involuntary Clients Figure 9.3 Task-centered contract

Specify problems

Establish clear goals

Development of general tasks

Establish time limits and review dates

in chapter 8, attempt to identify conditions around the target problem of “too many people are running my life,” based on Beth’s reports that her foster parent, her parents, her boyfriend, and Nancy herself too often tell her what to do. Hence, how often people tell her what to do would be one target problem condition. They also previously identified exploration of independent living as a possible solution to this problem. An additional mandated problem was that “Beth does not now live in an approved placement that meets legal standards for permanency.” This mandated problem led to a present/absent condition of approved placement. In the following segment, Beth and Nancy identify that having a job or being self-supporting and having parental permission would all be conditions required for securing permission for independent living as one form of approved placement. Notice how Nancy elicits these conditions in part from Beth, rather than listing them herself. This technique should have a by-product

Task-Centered Intervention with Involuntary Clients of reducing reactance, as adolescents frequently seem to trust their own explanations more than those of practitioners.1 nancy: What do you think the requirements for getting independent living would be? beth: Finding a place, getting a job. nancy: So finding a place to live and getting a job would be required. beth: Yeah, house hold stuff. nancy: You mean like furniture? beth: Furniture, dishes. nancy: Do you know what the court would expect of you? Do you know what the law is as far as going back to the judge and saying, “I want in dependent living”? beth: I have to have a job. nancy: Yes, you have to have a job or a way that you can demonstrate that you’re going to be financially independent of your parents. Right? beth: Right. Less verbal or cognitively impaired clients may need more assistance in specifying problems and conditions. For example, Mike was an adult with a developmental disability who was living in an adult group home. As case management ser vices were not mandated for Mike, he could choose not to work with a case manager. Jane, a case manager for a county agency, met with him to explore whether he might wish to use her ser vices. If he were pressured to work with Jane or work on problems that he did acknowledge, Mike would have become nonvoluntary. By focusing on Mike’s concerns, Jane’s contact with Mike quickly moved toward voluntary contact. Notice how Jane helps Mike specify problems in the group home.2 jane: So, you have told me that things aren’t going so well at Bertha’s group home. Why don’t you tell me a little bit more about what is not going so good? mike: Every thing’s just going rotten. jane: Tell me some of the things that aren’t going so well. mike: Bertha ain’t the best 1

This dialogue segment is from a videotape entitled Permanency Planning: Use of the TaskCentered Model with an Adolescent Toward Independent Living. The Contracting Phase. Contact Ron Rooney at [email protected] for more information about access to this video. 2 This videotape, entitled Task- Centered Case Management, with Jane Macy as the practitioner, is available from Alexander Street Press at https://alexanderstreet.com.

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Practice Strategies for Work with Involuntary Clients jane: So you’re not real happy with her right now? mike: Nope. jane: What kinds of things is she doing? mike: Every thing. jane: Like? mike: Hmmm. jane: What kinds of things is she doing that you’re not real happy with? mike: Only giving us five cigarettes a day. jane: Okay. So your cigarettes are getting limited. mike: Right. Jane is beginning to explore the target problem that “Mike is not happy living in his group home.” Among the specific conditions identified are the limited number of cigarettes Mike can smoke a day. Later, curfew times and amount of spending money are also identified as conditions. Establishing Clear Goals Development of concrete, realistic, measurable goals assist in monitoring progress such that all parties can determine whether the conditions of the contract are met. Goals may be addressed toward reducing or increasing the frequency of target problem conditions. For example, Beth might want to decrease the number of times other people tell her what to do. For a present/ absent condition such as a recommendation for independent living, receiving a positive recommendation might then be the goal. Goals may also include movement to a new situation in which the target problems are less likely to occur. For example, Jane and Mike developed a goal of living in a less restricted situation. Practitioners sometimes have reservations about developing specific goals or agreeing to goals that they consider unwise. For example, some practitioners hesitate to develop specific goals for fear that they will be locked into goals that later prove to be either unworkable or too rigid if new circumstances arise. While new law violations may indeed influence recommendations about the conclusion of ser vice, notifying mandated clients that this could occur is preferable to operating without goals. Vague goals often lead to vague efforts. More specific goals can empower the involuntary client by narrowing the scope of efforts. In addition, involuntary clients sometimes express goals that the practitioner considers unfeasible or inappropriate. For example, when contacted by her parents, whose parental rights had been terminated, expressing a wish for their adolescent daughter Cheryl to return home, Cheryl told her foster care worker that she wanted to return to her biological parents and would under-

Task-Centered Intervention with Involuntary Clients mine any foster placements or adoption planning. Simply rejecting or dismissing the goal on the grounds that it appears unfeasible or unwise may have little to do with Cheryl’s commitment to the goal. A wiser course might have been to ask Cheryl to list all the reasons why she would want to return home to her biological parents. Next, the practitioner might ask her to list any reservations she had about this idea and any obstacles to such a plan. The practitioner might add suggestions to both lists. Such efforts do not guarantee that the involuntary client’s wish for an apparently unfeasible goal will change. They do, however, respect the involuntary client’s right to express desires. Efforts can then be undertaken to explore their feasibility. When working as a foster care social worker, the senior author of this book once asked a twelve-year-old who was unlikely to ever return home to her biological parents where she would want to live. She indicated that she would be happy living with an aunt out of state. Her wish was not taken seriously. A year and a half later, she had indeed gone to the out-of-state aunt when other options failed. In Beth’s case, Nancy had reservations about the feasibility of her goal to achieve independent living. Rather than dismiss the goal, she was straightforward in helping Beth see the factors that would influence such a recommendation. Development of General Tasks While goals refer to the outcome sought, general tasks are the means toward reaching those goals. It is important to distinguish between goals and general tasks for two reasons: (1) general tasks are sometimes completed even though goals are not achieved; and (2) goals are sometimes achieved while general tasks are not completed. For example, a man participating in a domestic violence treatment program might carry out tasks to complete anger logs, attend sessions regularly, and practice relaxation. Despite completion of the tasks, he might also continue to be violent and the recommendation to the court is more likely to be influenced by the outcome of the efforts than completion of tasks. Clients may sometimes also reach goals by alternative means than those originally planned. For example, a Native American client who wished to regain custody of her child, who had been placed in foster care, achieved success by controlling her alcoholism problem through work with a Native American religious group rather than through participation in a white aftercare program. Beth’s goal was to gain a positive recommendation for independent living and her general tasks included exploring housing possibilities, employment, schooling, and soliciting parental permission. Additional general tasks could have included practicing assertive behavior that would decrease the situations in which others were in a position to tell her what to do. Mike’s goal of living

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Practice Strategies for Work with Involuntary Clients in a situation with more freedom could be pursued by simultaneous exploration of rectifying conditions in the current group home and exploring other living arrangements. Hence, arranging visits to alternative living situations was included, as well as discussions with Bertha about the current living situation.

Establishing Clear Time Limits Much contact with both voluntary and involuntary clients occurs at times of crisis that frequently have a natural time limit of approximately six weeks. In addition, studies continue to show that whatever the planned length, ser vice frequently lasts ten or fewer sessions (Wells 1982). Finally, establishment of time limits takes advantage of a goal gradient effect in which client and practitioner activities appear to increase near the end of a time-limited period. Involuntary contact is sometimes necessarily long-term, as in the case of continuing case management relationships with clients with disabilities and serious and persistent mental illness, and in work with clients in institutional settings. Such long-term contact can lead to lack of focus and burnout on both sides of the desk. Both practitioners and clients can help maintain focus by cutting large problems and goals into smaller segments. Progress can then be evaluated at the completion of these break points and decisions made about continuing on the same goals, changing goals, changing forms of service, and terminating contact. For example, when the senior author of this book worked with a single-parent client who was attempting to regain custody of her eight children placed in foster care, achievement of this goal was not feasible over the short term. It was, however, feasible to establish an initial, renewable contract with the goal of securing unsupervised visitation with the children by the end of the first twelve-week contract. When that goal was achieved, the contract was renewed with a goal of regaining custody of one child in the next twelve weeks. Several additional time-limited contracts were negotiated over the subsequent eighteen months.

The Task Implementation Sequence A clear, specific strategy follows contract formalization and focuses on both mandated and agreed-upon target problems and goals. The task implementation sequence (TIS) was designed to guide practitioners in the development of a sequence of tasks to reduce the intensity of target problems (Reid 1978). Steps in the sequence to be reviewed and adapted here include development of initial client tasks, initial practitioner tasks, anticipation of obstacles, provision of a rationale, appropriate incentives, rehearsal, and task summarization (figure 9.4).

Figure 9.4

Task implementation sequence Development of initial client tasks

a) determine problems to begin with b) explore past problem solving c) explore client ideas about tasks d) practitioner suggestions for tasks

Development of initial practitioner tasks

Anticipation of obstacles

Provision of incentives

Provision of rationale

Rehearsal, guided practice, role play

Summarization

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Practice Strategies for Work with Involuntary Clients Development of Initial Client Tasks Research on the task-centered approach indicates that client expression of verbal commitment to carry out a task is a stronger predictor of task completion than the source of the task, whether it was the client’s or the practitioner’s idea (Reid 1978). However, it might be expected in the pressured circumstance of involuntary contact that reactance would be reduced if the involuntary client’s task ideas are considered first. Five factors should be considered in the development of initial client tasks: (1) determine which target problems the involuntary client would like to begin with; (2) find out how the client has attempted to resolve this problem in the past; (3) explore the involuntary client’s ideas about what tasks might be attempted; (4) suggest client tasks; and (5) develop required tasks for mandated clients. 1. Determine which target problems the involuntary client would like to begin with. In general, the target problems that are approached first should be those that would make the most difference if resolved and those that can most feasibly be reduced. However, nonvoluntary clients have no legal constraints on the order of target problems they begin to address. Mandated clients are generally more constrained in regard to the order of problems addressed. While mandated clients frequently have a list of nonnegotiable tasks that they must complete if they are to avoid legal consequences, it is frequently impossible to undertake all requirements simultaneously, and mandated problems often have no required sequence. In such cases, involuntary clients may recommend the order in which problems are addressed. While some practitioners have suggested that given freedom to choose, involuntary clients will “start with the easy ones and avoid the hard ones.” Developing momentum through successful completion of tasks can make it possible to complete more difficult tasks later. Unfortunately, there is often a negative generalization when the involuntary client is overwhelmed with competing requirements in the beginning. If there are compelling reasons for some problems to be undertaken before others, joint or sequential selection might occur in which the involuntary client might pick the first problem out of a required list and the practitioner might pick the second, and so on. In the following exchange, Jane (introduced earlier in this chapter) briefly describes what task-centered work would entail and helps Mike decide which problem he would like to begin working on. jane: You’ve told me that you’re pretty unhappy about your living situation and where you’re working right now. So it sounds like there’s the possibility for us to do some work together on these problems. mike: I agree.

Task-Centered Intervention with Involuntary Clients jane: We can work together around these two and try to figure out together how we could make them feel a little bit better for you. We can figure out what you can do, what I can do, and kind of piece by piece see if we can get this feeling better for you. mike: Good. jane: What’s the one that’s making you most uncomfortable, what’s the thing that you want to work on first? mike: Moving. jane: Moving. You want a new place to live. mike: Right. Notice that Mike is already tipping his hand about his solution to the problem of being unhappy in his living situation: he wants to move. Jane notes this and will return to it, while exploring other solutions to his current unhappiness about his living situation as well. 2. Find out how the involuntary client has tried to resolve this problem in the past. The practitioner can then move to review prior problem-solving efforts. Such review sometimes uncovers good problem-solving skills that may have been impeded by a crisis. In other cases, the review may indicate that the problem is a new one that the involuntary client has little experience in resolving. After exploring possibilities for adapting to the current living situation and finding little promise in them, Jane begins to explore Mike’s knowledge of alternative living arrangements. jane: Let me go back and make sure that I’m remembering every thing correctly. When you moved up here, part of the reason that we said that you wanted to live here was that there weren’t too many choices about where to live in the town where your folks were, and you wanted to be closer to work. And that’s why you ended up at this par ticu lar group home. Right? mike: Right, I agree. jane: So that’s how you got here. Now it seems like we need to talk about what some of the other options might be about where to live. Have you thought about where else you might want to live? mike: Not right off hand, no. jane: Do you know anybody else that’s left the group home? mike: No, I don’t jane: I was wondering, because if you knew somebody that left, we could talk about where they moved to. Do you know some of the other folks that you work with out at the plant, where do they live? What kind of places do they live in?

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Practice Strategies for Work with Involuntary Clients Jane continues to pursue Mike’s knowledge of alternatives before moving to add her own knowledge of potential resources. In other cases, review of past efforts may uncover unsuccessful prior efforts. Such exploration may provide information about a lack of problem-solving skills or a misunderstanding of an other wise effective method. For example, a client once told the senior author that she had tried time-out to discipline her child but it didn’t work because after she would lock him up in his room for several hours, he would demolish his room! As he was preparing to suggest time-out as a method that she might try, he began to see how she might have misunderstood the specific, time-limited nature of the time- out procedure. 3. Explore the involuntary client’s ideas about what tasks might be attempted. Practitioners should attempt to help clients develop initial tasks that are clear, specific, and likely to succeed. Successful completion of such initial tasks should help create a positive momentum that can contribute to completion of more complex tasks later. After reviewing prior problem-solving efforts, the practitioner can initiate brainstorming about possible tasks to attempt. As reactance may be activated by starting with the practitioner’s own ideas, the involuntary client’s ideas about which tasks to attempt should be explored first. Involuntary clients frequently have good ideas about how to proceed or present ideas that can be made workable with a little revision. The practitioner should encourage any promising ideas and even those ideas that appear less promising give clues about the client’s general problem-solving ability. In the following exchange, Nancy begins to explore Beth’s ideas about possible tasks to attempt toward achieving independent living and also clarifies what kind of job she wants to seek. nancy: On the problem of job seeking, what do you think would be a reasonable way to start between now and next week? beth: Go out looking for a job. And then there is the newspaper. nancy: Going out and making applications and getting a newspaper are good ideas. How else have you heard about jobs in the past? You’ve worked at a restaurant. How did you find that job? beth: Through friends. nancy: So you could talk to some friends about jobs that they might know of that would be available. Do you have any restrictions on the kind of jobs you want to get? beth: I don’t want to work in no nut house like Randy’s Restaurant. nancy: So you don’t want to work in a place where there are a lot of difficult people to deal with? beth: Yes, a lot of drunks.

Task-Centered Intervention with Involuntary Clients This exploration of possible client tasks should enhance involuntary client feelings of empowerment. By listening to Beth and supporting any promising ideas, Nancy is helping Beth figure out what she is willing to try. Sometimes practitioners have additional ideas that might revise client suggestions or expand their options. 4. Suggest client tasks. Practitioners often have useful ideas for client tasks based on empirical research, experience, and practice wisdom. Involuntary clients often reject these suggestions if they are pressured into the “best” solution rather than offered suggestions as part of a brainstorming process. The practitioner should become expert at helping involuntary clients solve problems and not expect to be able to solve all problems. At the same time, the practitioner should not agree to work on problems blindly without consulting available sources. Practitioners should become familiar with evidence to support particular empirically supported task strategies (Corcoran and Vandiver 2006; Mullen and Bellamy, 2008). In addition, practitioners can draw from their own practice experience with similar problems, and that of their peers, supervisors, and consultants. As initial tasks should be clear, specific, and likely to succeed, practitioners can also use their expertise in fine-tuning client suggestions to make them more feasible. In the following section, Nancy suggests revisions to make Beth’s job-seeking efforts more specific and feasible. nancy: What do you think about getting a couple of newspapers for a week? Does your aunt get a newspaper? beth: No. nancy: So you would have to go out and buy one. You might look through a newspaper at least every two to three days and circle the ads that look interesting to you. How does that sound? beth: Okay. nancy: So you have the money you would need to get a paper for a week or so? beth: Yeah, that’s no problem. nancy: We could find a newspaper around here and circle some today if you want. beth: No, that’s okay, I can do it at home. nancy: You might then also talk to some friends that might know something about job openings. I would suggest that you write down all the possibilities that you come up with and bring them in for us to look at. You could go ahead and apply for some if you want to, but it would be enough to get us started to have a list of possible jobs. How does that sound? beth: Okay.

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Practice Strategies for Work with Involuntary Clients 5. Development of disagreeable tasks. Mandated clients always have required tasks to complete and nonvoluntary clients often encounter disagreeable tasks as part of a “package deal” of agreeing to be served even within a contract that includes some of their own concerns. If a mandated client does not object to completing a required task, then no special provisions beyond the above suggestions for client and practitioner tasks are needed. The broader problem, then, is assisting both mandated and nonvoluntary clients in completing tasks≈that they might consider disagreeable. The following six guidelines are designed to facilitate both treatment adherence and empowerment by offering constrained choices. It should be noted, however, that required or disagreeable tasks should be kept to a minimum and should not stretch beyond the guidelines for limiting self-determination and exercising paternalism (figure 9.5). 5a. Consequences of a choice not to complete the required task can be explored. Even when choices are so constrained that failure to complete the disagreeable task is likely to lead to punishing consequences, the mandated client can choose not to complete the task and accept those punishing consequences. For example, eight children were removed from Mrs. Carter’s home because of child neglect and her drinking problem. Mrs. Carter continued to maintain that her drinking was of no concern to the court and balked at following through with a chemical dependency evaluation and treatment program. Rather than continue in a stalemated position, the practitioner informed her that she could choose not to have the evaluation or treatment. She should know, however, that in the next hearing, the judge would be informed of progress with the required evaluation. She could choose to hope that her task completion in other areas would favorably impress the judge without work on the perceived alcohol problem. Mrs. Carter preferred for the time being to run the risk of a negative response in choosing not to follow the court order completely. Later in contact, she came to recognize a need for further alcohol treatment on her own and entry into treatment was facilitated.3 Nonvoluntary clients also often face disagreeable tasks that, while not legally mandated, exert an unwelcome pressure. For example, some clients find that agencies have policies that require all family members to participate in treatment. If the family is unwilling or unable to comply with this requirement and if the agency policy is not negotiable, family members can be referred to other settings that do not have such policies.

3 A videotape of actual work done in this case entitled Return from Foster Care by Ron Rooney was made by the School of Social Ser vice Administration, University of Chicago. https://www.youtube.com/watch?v = zXwPXZCqUus

Task-Centered Intervention with Involuntary Clients Figure 9.5 Completion of disagreeable tasks Explore consequences of choice not to complete disagreeable task Focus on specific rather than global tasks Provide a rationale for disagreeable tasks Clarify free behaviors remaining

Facilitate choices in implementation including demeanor with which task is completed

Utilize two-sided arguments focusing on client’s perceived self-interest

5b. Focus on specific rather than global tasks. Reactance is likely to be high if the involuntary client perceives a global assault on valued freedoms. Reactance may be reduced by focusing on specific rather than global tasks. For example, Mrs. Torres was angry about what she considered to be overwhelming and unjust pressures to clean her house. Her opposition was somewhat reduced by focusing on specific tasks to remove fire hazards such as garbage with a goal of eliminating five boxes a week, establishing clear walkways, and obtaining a separate bed for her daughter. Small, specific tasks were developed such as agreeing to sort ten boxes and discarding the contents of five by the following week. 5c. Provide a rationale for disagreeable tasks. Involuntary clients are entitled to an explanation for why the task is required. It was explained to Mrs. Torres

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Practice Strategies for Work with Involuntary Clients that minimum standards existed for determining fire hazards and client safety. Involuntary clients might continue to disagree with the rationale, but they are entitled to an explanation. 5d. Clarify free choices remaining. Required tasks can be distinguished from other areas remaining in the free control of the involuntary client. For example, Mrs. Torres felt that the agency was pressuring her to discard valuable things she had inherited from her mother. The practitioner clarified that valued items from her mother were her own business and not the business of the child welfare agency. The agency was concerned only about safety hazards and would support her in keeping her valued inheritance if it did not continue to be a safety hazard. Indeed, the practitioner could assist her in seeking inexpensive storage facilities as a way of protecting her valuable things. 5e. Choices in implementation can be facilitated, including the demeanor with which the disagreeable task is completed. Involuntary clients can be given options for the manner in which they should implement disagreeable tasks. As described earlier in this chapter, practitioners can often negotiate the order of required tasks, including which ones to tackle first. For example, Mrs. Torres chose to begin by sorting her boxes and deciding what could be discarded, what could be given away or sold, and what could be kept. The practitioner assisted in securing a homemaker to facilitate this process. Obtaining another bed was postponed until these tasks were completed. Mrs. Torres was free to choose what materials would be kept, discarded, given away, or sold, as long as five boxes full of garbage were discarded. Practitioners sometimes contribute to their own frustration and that of the involuntary client by expecting not only that the disagreeable task be completed but also that the involuntary client should appear to enjoy it. By separating the behavior from the attitude displayed in completing the task, the practitioner can restore some freedom while recognizing that behaviors often change prior to attitudes. This practitioner attitude implies some tolerance for involuntary client complaints about not liking the task. The practitioner can empathize with the feeling of not liking to be pressured to do required tasks, while remaining firm about the consequences of failure to comply. For example, Mrs. Torres continued to complain about not liking the housecleaning tasks while also continuing to complete them. She would often complete them with a new twist, such as selling some clothes, which had not been discussed but was her right and did not violate the agreement to discard a certain amount of items. The practitioner can also solicit involuntary client input in fine-tuning required tasks. For example, alcoholism treatment programs sometimes require that clients read about alcoholism. There are often ways, however, that such required tasks can be tailored with client input. For example, Dick, the residential treatment counselor introduced in chapter 6, was able to negotiate with

Task-Centered Intervention with Involuntary Clients Keith about the amount of reading and the time frame for completing the required task of reading in the “big book.”4 dick: I’m sure you are familiar with the “big book,” the Alcoholics Anonymous book, from your first treatment. Keith, I’d like to know, do you like to read? keith: I hate it. dick: You hate to read. A lot of people do. I’m not a very good reader myself, and I can relate to that. The first five chapters in the big book are kind of a synopsis of what the whole program is about, where it started, why it was developed, what they wanted to do. There is a lot of reading in it; it is a big book. I wonder if 20 to 25 pages would be too much to read in a week? Do you think you could handle that? keith: I think I can handle that. dick: Well, why not, instead of concentrating on all the first five chapters, concentrate on just chapter number five? I think it’s only about twentyfive pages. Do you think you might have that done in a week? keith: Sure, I’ll do that. 5f. Two-sided arguments emphasizing client-perceived self-interest can be utilized. Practitioners may feel called upon to represent the community and others potentially harmed by the involuntary client’s behavior. Persuasion efforts, however, are unlikely to be successful when they focus on values not held by the client that the practitioner thinks the involuntary client should have. The practitioner should avoid nagging, browbeating, or attempting to induce guilt around values that the client does not hold. Focusing on the values that the involuntary client openly expresses should be more productive. Hence, Jean emphasized Mrs. Torres’s own expressed motivation to have the house clean for the holidays and the agency people out of her life. The consequences of choosing not to carry out the required task can be reviewed. Potential costs and advantages of choosing to complete the required task can also be reviewed with the involuntary client who ultimately makes the decision. Sometimes practitioners are unable to find values and motivations to support required changes for mandated clients. In such circumstances, practitioners can recognize problems in proceeding without motivational congruence by limiting their own expectations for progress beyond the impact of available compliance methods.

4 This selection is from a videotape entitled Socialization at Chemical Dependency Intake with Dick Leonard as practitioner. Contact Ron Rooney at [email protected] for information about access to this video.

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Practice Strategies for Work with Involuntary Clients Development of Initial Practitioner Tasks Explicit practitioner tasks can enhance a sense of partnership in resolving problems. Practitioner tasks should facilitate client efforts without doing things for involuntary clients that they can do for themselves. Hence, practitioner tasks are actions that the involuntary client cannot complete, would take too long for them to complete to be of value in addressing target problems, or those that are of no long-term value for the involuntary client to learn. The number of practitioner tasks depends also on available practitioner time and norms of the agency or setting. For example, practitioners often act to influence the social system to facilitate client action through arranging referrals and acquiring information (Reid 1978). If an involuntary client is unlikely to need such information or initiate such referrals on his or her own in the future, then the practitioner might offer to do it. The number of practitioner tasks may also decrease over time with increased client capacity. There are also many intermediate steps between tasks that are undertaken either solely by involuntary clients or solely by practitioners that can be negotiated. Could the involuntary client complete the task with additional resources? Would skill practice or rehearsal help? Would it help if the practitioner or someone else performed the task together with the involuntary client or accompanied him or her (figure 9.6)? For example, one of Beth’s requirements for achieving independent living was to secure parental permission. In the following exchange, Beth and Nancy negotiate a joint client-practitioner task of contacting Beth’s parents. nancy: How do you think we should let your mother and dad know about your plans? beth: That’s left up to you. I don’t want to talk to them. nancy: You don’t want to talk to them alone. How would you feel about me accompanying you to talk to them? beth: That would be okay. I’d like to find out before I go through all the hassle of doing it and then they don’t want to give me permission. nancy: Okay, so my task between now and then is to get in touch with your mom and dad to set up a joint session. Nancy might have explained her reasons for preferring to share the task rather than do it for Beth. If Nancy can assist Beth this time, she may be able to negotiate other things on her own next time rather than having to depend on Nancy.

Task-Centered Intervention with Involuntary Clients Figure 9.6

Considerations in completing practitioner tasks

Can client do task on own without help?

Is it advantageous for client to be able to do task in the future?

Practitioner task is undertaken to assist client in completing task. Usually entails facilitating client task, making referrals, conferring with resources, getting information.

Does practitioner have resources or contacts that will facilitate progress?

Can client complete task with skill practice? Can client complete task jointly with practitioner or someone else?

Can client complete task with resources?

Anticipating Obstacles Task plans can be fine-tuned by anticipating obstacles to their successful completion. The questions suggested previously for looking at possible joint client-practitioner tasks can also be tailored to any client or practitioner task: What might interfere with task completion? Does the client have adequate resources to carry out the task? Does the client have adequate skills to complete the task? The practitioner can begin by asking the involuntary client to think of things that might get in the way of completing the task and then add his or her own ideas to the client’s list. Practitioners may find that they are more likely to identify obstacles to tasks suggested by clients than to tasks that were the practitioner’s own idea. It would be wise for practitioners to ask involuntary clients for possible obstacles to practitioner-originated tasks as well as to those suggested by clients. If this review uncovers potential obstacles, then task plans can be revised to avoid them. For example, in the following exchange, Jane explores potential obstacles with Mike about a move from his current group home to Dexter, thirty miles away.

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Practice Strategies for Work with Involuntary Clients jane: What do you think might get in the way of moving to Dexter? mike: Maybe my buddies who I used to drink with. jane: So, the fellows you used to drink with live in Dexter. How might you handle their asking you to drink with them? mike: Refuse them. jane: You sound pretty definite about that. Have you been able to see them without drinking with them in the past? mike: Yes. jane: So, you have been able to do that already. We might have to keep checking on that one since I know that you have told me that you don’t want to go back to drinking. mike: I agree. jane: I can think of a couple of other things that might get in the way. I wonder if the transportation back up here to work every day would be hard for you since you would have that extra half-hour ride each day. mike: I agree. jane: Let me just sum up where we are with thinking about a possible move. On the plus side, we’ve got the fact that you know more people in Dexter and you’re closer to your folks, which is important. On the down side, you might have to worry about some of your old buddies trying to get you back to drinking. mike: Right, I agree. Jane and Mike have identified being around Mike’s buddies who continue to drink and the ride to and from work as obstacles. Additional tasks might then follow to prepare Mike for telling his buddies that he does not want to drink with them. He might also experiment with the bus ride a few times to see if he could handle that. Practitioners’ tasks can also result from obstacle analysis. For example, John lived in a community residence for homeless persons. One condition of this residence was that he actively seek employment and eventually other housing. His job-seeking efforts had been partly impeded by limited access to the community phone in the residence. In the following exchange, John and Cheri, his case manager, explore ways to facilitate his job-seeking tasks.5 john: I made some applications but they haven’t been calling me back yet. I wonder if I will even get a message with that phone out there in the center. cheri: It is a busy phone. We’ve talked about getting another line here at the center. We have talked about your taking the initiative to call them back 5 This selection is from a training videotape entitled Work with Involuntary Clients in the Middle Phase with Cheri Brady as the practitioner. contact Ron Rooney at rrooney@umn .edu for information about access to this video.

Task-Centered Intervention with Involuntary Clients to check on your application. If you were going to make those phone calls this week, can you think of anything that might prevent you from completing the calls? john: Well, the noise out there. It gets pretty rowdy out there, sometimes. But other than that, no. cheri: Well, I was wondering about that. Depending on what time of day that you called them, I’d be willing to let you use my office phone here if that would be helpful. john: Sure, it would. cheri: I know that you also said that you were not quite sure of what to say to them on the phone, not wanting to sound too “needy.” We could talk over what you want to say to them and maybe practice it a little before you call. john: I don’t feel comfortable making the calls out there, that’s for sure. cheri: What about if we practice here and then you could make the call here with me present or by yourself, however you want to do it? john: It would be okay to practice. I would rather make the calls then by myself, though. cheri: Okay. Let’s try that. Cheri and John have explored two options to making the call alone on the community phone. John has expressed preferences for how he would like to make the calls and Cheri has offered support in practicing the skills needed to make the call and feel more comfortable doing it. She might also move ahead to advocate more strongly for increased access for other residents to a more private phone.

Provision of Rationale Self-attributed change may be enhanced if the involuntary client has a clear idea of the specific reasons for how carrying out the task would be a step toward reducing the target problem and reaching the goal. As with exploring task ideas and identifying potential obstacles, practitioners can empower clients and support self-attribution by asking the involuntary client for the connection between the task and the agreed-upon problem before supplying their own ideas. If involuntary clients cannot think of reasons to complete the task, then they may be unlikely to complete it or do so only under pressure to comply. Similarly, if involuntary clients originate the task idea, they may be more likely to understand the rationale for the task than if the task idea came from the practitioner. As with anticipation of obstacles, practitioners frequently forget to explore the rationale for ideas they originated since that rationale is usually obvious to the practitioner, if not to the involuntary

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Practice Strategies for Work with Involuntary Clients client. This may be particularly true when the task is a required one for mandated clients or part of a “package deal” for nonvoluntary clients. In the following exchange, Dick reviews Keith’s required task for completing a selfinventory of prior drinking behavior and bringing the answers into the treatment group. dick: When you fill out the answers to the questions about your past history in the book, you will have something to share in common with the other men in the group. We find that men can often learn from each other’s past experiences through this kind of sharing in the group. keith: Okay. But some of those questions go way back to where you can’t even remember. dick: That’s true, they do go back quite a ways. How about going through the book and answering those questions that are really important to you, that promote feelings, and answer those questions first? Then come and talk to me about it, and we’ll see how far you want to go. Because in two weeks, I’d like you to tell the group some of the highlights of your life. Would you be willing to do that? keith: You have to tell them all the highlights? dick: That sounds like you think it could be embarrassing to share some parts of your past with people you don’t know very well. keith: Yeah, I don’t know these people. dick: You can make that decision as to what you want to tell them. By the time you do this, maybe the group will become more familiar with you and you will be better able to decide what you want to tell them. Okay? keith: Okay. While Dick has provided the program’s rationale for completing the selfhistory for sharing in the group, Keith raises reservations about sharing potentially embarrassing information with people he doesn’t know. Dick has attempted to empathize with that concern and clarified the choices Keith has in deciding what to share. Provision of Incentives Some situations require the involuntary client to carry out initial tasks that may be anxiety-provoking or have some punishing elements. In such circumstances, providing a concrete or symbolic incentive can be helpful in stimulating new behavior that is not at this point inherently reinforcing. However, in order to support self-attribution, concrete rewards should be only large enough to succeed and should be phased out early and replaced by symbolic rewards.

Task-Centered Intervention with Involuntary Clients In the following exchange, Joan, a social worker in an outpatient mental health center, is working with Jim, a depressed nonvoluntary client, who has targeted the problem of “not being motivated to do anything.” It is interesting to note that while Jim had a clinical diagnosis of depression, he does not acknowledge this attributed problem but focuses on the more specific acknowledged problem of lack of motivation. They have together identified washing his clothes, which had been piling up for weeks, as a desirable task in beginning to alleviate his lack of motivation. Earlier in the session, they decided to break up this large, depressing task into a series of steps, including obtaining enough tokens for the washers and dryers, sorting the clothes on one day, and taking down a first load on the next day. In the following exchange, they review possible obstacles to finishing this task and explore possible incentives to enhance completion of a disagreeable task. joan: Okay. So I will write down here that you plan to wash your clothes by Sunday. Can you think of any other things that might get in the way of your washing these clothes? jim: I hate washing clothes. It is one of the things I hate most. joan: So your head tells you, I hate to wash clothes. Is there something that can help you get over that, something you can tell yourself that might help you feel better about doing it? jim: Not that I know of. Not right offhand. joan: You mentioned earlier that you want some clean clothes in order to go back to school. jim: That whole issue is separate. I don’t see it as part of the same issue. joan: Okay, thinking about how you could use the clean clothes isn’t a helpful idea for you. Would it help if I give you a call maybe on Friday to see how things go with the first step of separating the clothes? jim: Yeah, that would be all right. joan: I also wonder if there is something special you can do for yourself when you try this hard first step. jim: You mean like a reward or something? joan: Yes, what would be something you could do to reward yourself for separating the clothes? jim: Maybe I could go out to a movie or something. Rehearsal Some tasks are of such complexity that breaking them down and rehearsing parts can assist in task completion (Bandura 1971). For example, Nancy could have practiced looking through the want ads and making a list of job possibilities with Beth during the session. In addition, interactional tasks can be

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Practice Strategies for Work with Involuntary Clients practiced in role plays. The practitioner can model how to complete the task, assist the client in practicing, assess together the strengths and weaknesses of that modeling, and then rehearse the desired behavior again (Reid 1978). For example, it was suggested that Cheri and John might have rehearsed the phone call to a potential employer. As adults are sometimes more hesitant than children are in carrying out role play, a modified form of role play can be employed in which the practitioner walks the client through the task with questions such as “What do you plan to say? What do you think he/she will say back to you?”

Task Summarization Practitioners frequently end a session by reading a list of client tasks and asking the client for affirmation that the list is accurate. Practitioners often interpret “uh-huh” responses as indications of understanding and commitment. Such practitioner recitations may indicate only that the practitioner understands what the task agreements are. In some instances, task summaries may be enhanced by use of a written task sheet with copies for both the client and practitioner (Rooney 1981). Such a sheet can be completed by either the client or practitioner, listing who will do what by what date. Using such a task list, the practitioner might begin to summarize by saying, “These are the tasks I have agreed to complete. What are the ones you are planning to do?” If involuntary clients can then recount tasks, compliance may be enhanced. If, conversely, the involuntary client leaves a task off the list, it may indicate reservations about completing the task. The practitioner may then add to and amend the summary provided by the client, exploring any reservations. For example, Cheri reviews tasks with John at the end of their session. cheri: So to review, I said that I would make my phone available for you to call potential employers and possible references before our next meeting. What were the things that you’re going to work on before we meet on Friday? john: I’m going to call Brown Tank tomorrow morning. And then I’ll put out a couple more job applications. I don’t know if I’ll have to call for references until I talk to them.

Middle-Phase Change Principles Chapter 3 described the use of influence methods including punishment, reward, and persuasion to enhance treatment adherence, self-attribution, and empowerment. It was noted that while reward and punishment methods can

Task-Centered Intervention with Involuntary Clients be used to support the development of a new behavior or reduce an undesirable behavior, continued use of such methods is unlikely to produce the self-attribution needed to support the maintenance of behavioral change. Consequently, middle-phase work should include reduced reliance on compliance-oriented methods and increased use of methods that enhance selfattribution, such as facilitating expression of verbal or written commitment by involuntary clients to task completion, facilitating choices in task selection and enhancing freely chosen behavior, and increased attention to natural rather than artificial rewards. As behavioral change often precedes attitude change, the socialization and contracting guidelines presented in chapter  7 emphasized behavioral changes more than attitudinal changes. Attitudinal change may, however, be more subject to influence in the middle phase if the practitioner has come to be considered a persuasive source of influence. Hence, selective practitioner confrontations may become more effective in the middle phase than was typically the case in initial contact. Attitudes and beliefs may be further influenced in the middle phase through trying out new behaviors on an experimental basis via the “foot-in-door” method in which the involuntary client may agree to try out a new behavior on an experimental basis. Should the new behaviors succeed, they may become naturally reinforcing and also challenge prior beliefs that they would be unsuccessful. Later in this chapter, further references will be made to these principles as they apply to practice guidelines. Case Management Many practitioners who work with involuntary clients do so as case managers. The case manager assesses need, links clients to needed resources, assumes responsibility for ser vice coordination, monitors progress, and advocates to ensure that the client receives appropriate ser vices in a timely fashion (Naleppa and Reid 2000; Johnson and Rubin 1983; O’Connor 1988). Case management is typically provided to clients with multiple attributed problems such as those with serious and persistent mental illness and those with disabilities. General goals of case management often include reduction of inappropriate utilization of ser vices, increased continuity of care, and empowering clients through access to ser vice. Individual case goals often relate to attaining adequate levels of client functioning in areas such as independent living and vocational skills. Definitions of case management functions vary, which contributes to confusion in implementation. Job descriptions have tended to focus on orga nizational arrangements defining what agency is responsible for arranging what ser vice with relatively little emphasis on practice techniques. For example, there is little agreement on how much of the role is administrative

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Practice Strategies for Work with Involuntary Clients and how much relates to client-worker interaction (O’Connor 1988). There are further variations in the autonomy and responsibility accorded the case manager and the complexity of the tasks to be assumed by him or her. Is the case manager primarily responsible for coordinating care provided by others or providing direct ser vice? Case managers are frequently enjoined not to “do counseling” with their clients but rather to link them with others who will provide such resources. In other circumstances, case managers may be permitted to counsel or intervene as problem solvers, yet find that large caseloads and heavy paperwork requirements often limit them to coordinating paper more than actual ser vices. Further, case management with clients such as those with severe and persistent mental illness has been considered difficult, unglamorous, and unrewarding. The emphasis on psychotherapy in community mental health centers has often meant that case managers have lower status and prestige than psychotherapists and consequently many case managers appear to be indifferent to intervening in the social system as it is lower-status work than seeking insight with psychotherapy clients (Johnson and Rubin 1983), though others suggest that case managers can play important roles in advocacy and empowerment with these client groups (Rose and Black 1985). Case managers can work with involuntary clients in at least three ways. First, some clients may be mandated to work with a case manager in the community as part of an involuntary outpatient commitment (Wilk 1988). Second, many clients have no legal mandate but may experience nonvoluntary pressure to work with a case manager as a precondition for receiving another ser vice. Finally, some clients may be willing to work with a case manager but feel constrained when such work focuses on attributed needs rather than client wants. Case managers working with involuntary clients can act to empower them by advocating for their choices using the guidelines provided for negotiating and contracting. For example, when Mike first became Jane’s client when he moved into the community after living in a residential institution, he came with recommendations from that institution that he “needed” to work on his impulsive expression of anger. Jane considered his expression of anger not to be a legal mandate but rather a possible obstacle that might interfere with his achievement of his own perceived goals. She chose to focus on what Mike was angry about, such as unhappiness with his living arrangement, rather than his expression of anger as a primary focus. Within this focus on an acknowledged target problem, Mike became voluntary. The processes of task development may, however, focus more on linkages with other resources than on tasks to be completed directly with the case manager.

Task-Centered Intervention with Involuntary Clients Linking Clients with Resources Involuntary clients frequently identify problems that involve utilizing other ser vices. Research on the linkage process suggests that fewer than half of clients referred for ser vices are actually linked with the designated resource (Kirk and Greenlee 1974). The resource linkage process varies according to the source of the suggestion and the strength of the pressure. The involuntary client can perceive the need for the resource first, the need can be identified by the practitioner or a referral source, or the resource may be required as part of a legal mandate. The practitioner should attempt to help the client make an informed choice about pursuing the linkage by sharing available knowledge about the quality of ser vices. If the client perceives the need, the process includes a straightforward assessment of whether an adequate resource might be available from within the agency. If that resource is available internally, then the linkage might be made directly. For example, Jane provided Mike with information about the living possibilities available and facilitated visits in which he could make his own assessment. Should an appropriate resource be identified, a sequence of steps can be followed to facilitate the linkage. Simple directions in providing a name and address are sufficient for clients who are motivated to receive the ser vice and capable of following the directions (Epstein and Brown 2002). Providing the name of a contact person makes the linkage easier in circumstances that might involve a complicated intake process. Similarly, providing the client with a letter of introduction that describes the problem and what the client would like to have done can facilitate the linkage. The practitioner can also help by making a phone call to the desired resource. Finally, facilitating in-person contact can occur by accompanying the client or arranging for a friend, relative, or case aide to accompany the client to the resource. These more complex means of facilitating linkage are useful with clients who cannot follow complex directions or have some ambivalence about pursuing the resource. If the practitioner or another referral source initiates the suggestion for a resource that is recommended but not legally required, then a possible source of nonvoluntary pressure has been initiated. In this case, persuasion methods, including two-sided arguments, assessment of potential benefits and costs of pursuing the resource, or choosing not to pursue it can be used. Since the source of pressure is nonvoluntary, the client’s right not to pursue the resource should be emphasized. For example, Jane encouraged Mike to enter an independent living skills group that might help him prepare for living outside the group home. She emphasized that he could choose not to join this group; however, acquisition of those skills might make a move to new housing easier. Should the resource linkage be mandated, a similar sequence to nonvoluntary pressure can be followed with the added emphasis on legal consequences

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Practice Strategies for Work with Involuntary Clients should the resource not be pursued. Even in such mandated situations, the involuntary client can choose not to pursue the resource and accept the consequences, as did Mrs. Carter when she chose not to get a chemical dependency evaluation while aware of the fact that chemical use would be reported to the court. Should the client agree to pursue the resource, connections can be “cemented” through one of four methods. (1) The client can report back to the practitioner after contact; (2) the practitioner can contact the client after the connection; (3) the practitioner can schedule sessions before and after the contact; or (4) referral visits can be interspersed with the practitioner’s own sessions with the involuntary client (Weissman 1976).

Guidelines for the Middle Phase The task development process often kindles hope in the involuntary client and practitioner that progress can be made. These hopes are often dashed in progress review sessions in which the best laid plans have gone awry. Successful completion of all tasks should be considered the exception, however, rather than the rule. Task failure should not be interpreted as person failure. Focus on failure contributes to disillusionment, blaming, and reinforcement of helpless, powerless feelings. Hence, building positive momentum and avoiding blaming is a critical goal in the middle phase. The guidelines that follow can be employed by both case managers and practitioners who have more frequent and intensive client contact. The following guidelines are designed to build positive momentum through: (1) reviewing progress on target problems and mandated problems, (2) reviewing task progress, (3) identifying obstacles to progress, (4) dealing with crises, (5) employing appropriate middle-phase confrontation, and (6) revising and summarizing task plans (see figure 9.7). 1. Reviewing progress on target problems and mandated problems. Taskcentered work focuses on reduction or elimination of agreed-upon problems. Legally mandated clients are also engaged in reviews of progress on mandated problems, whether agreed upon or not. Review sessions should begin with a review of how these mandated, semivoluntary, or voluntary target problems appear to be changing or not changing according to the conditions of the problem identified in the contracting stage. It is useful to separate review of the problem conditions from the completion of tasks since problems sometimes change without task completion and, conversely, tasks may be completed without improvement noted in the problem conditions. For example, Beth reported that no one was now telling her what to do (a condition of her target problem) since her aunt kicked her out of the house! This was obviously not a

Task-Centered Intervention with Involuntary Clients Figure 9.7 Guidelines for the middle phase 1) Review progress on mandated and target problems

2) Review task progress

3) Review obstacles to task progress

5) Middle-phase confrontation

4) Deal with crises

6) Revise task plans; use of incentives, rehearsal, summarization

task, but did temporarily reduce that pressure. On the other hand, tasks may be completed without change in conditions. In the example below, John has completed some of the tasks related to pursuing a job without yet actually getting a job. The involuntary client’s assessment of change in conditions can be probed for specifics and practitioners should then add their own assessment of changes. In the following exchange, Cheri has a mid-phase review meeting with John, the nonvoluntary resident of a homeless program. John has missed two appointments with Cheri and does not appear eager to talk about his jobseeking efforts. Such apparently irrelevant discussion often occurs when clients are either having difficulties with their tasks or are not really sure they wish to work on the target problem. Cheri reviews that the last appointments were not kept in a matter-of-fact way without blaming. She supports his initial efforts while also noting John’s reservations about talking about job seeking. She empathizes with his discouragement.

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Practice Strategies for Work with Involuntary Clients cheri: Hi, John, I’m glad that we could finally get together. It’s been a while. It’s been three weeks since we’ve met. john: Has it been that long? cheri: Yes, it has. Originally we decided to meet at least once a week. How’s it going? john: Well, it’s going okay. I’ve got a lot of time on my hands. It’s been kind of fun spending some time down at the Dome with all the excitement down there. It’s been a lot of fun. cheri: Well, I’m glad to hear that you’re having some positive things happen in your free time. john: I’ve got a lot of that. cheri: Let’s just back up a minute, because I know that after we first met and went over what you were going to do about finding a job, we scheduled another appointment, and then you said you couldn’t come because you had another job interview. We both thought that that made sense to miss that meeting, because getting a job is the main thing that we’re working on together. I didn’t hear from you after that, we rescheduled and you didn’t come, and I’m wondering what happened. john: Well, I had the job interview and it went okay. And then he told me he was going to give me a call on Wednesday, and that’s the reason that I didn’t come in, and I hung out in the lobby out here waiting for him to call and waiting for him to call. And I just said the heck with it. And he didn’t call, so I just split. I went down to Frank’s and had a beer. cheri: I see. So you made an application and were waiting for a call. And you felt discouraged because you didn’t get the call. I can understand that it is hard to just be waiting. I’m glad you made the call and am sorry it hasn’t worked out yet. It will probably take a lot of applications, as you know, before we are successful with this. Maybe today we can work on ways to be more active in contacting the places where you have made applications. In the future, I would also appreciate it if you would let me know in advance if you can’t come to one of our scheduled meetings. 2. Reviewing task progress. The practitioner can now review task efforts, including both involuntary client efforts and practitioner tasks. Sometimes clients immediately report on task completion as part of the target problem review step. As tasks are often not fully completed despite diligent efforts, task efforts can be praised. Praise should not, however, be overemphasized, as too much praise may undercut self-attribution of changes. That is, involuntary clients might come to feel that they are completing tasks to please the practitioner rather than doing them because they will produce some personal benefit. Since task review often leads directly to review of obstacles in completing tasks, an example combining the two steps is provided below.

Task-Centered Intervention with Involuntary Clients 3. Identifying obstacles to progress. When tasks are initially developed, anticipating that some tasks probably will not have been completed successfully is one way of avoiding preoccupation with failure. In addition, after the practitioner praises task efforts, he or she can explore obstacles that blocked success on some tasks. Such obstacle exploration should focus on what got in the way rather than who. Examining a variety of possible causes for task failure can prevent the practitioner from prematurely concluding that tasks were not completed because of a lack of involuntary client motivation. Lack of incentive or rationale for a task is indeed a possible explanation for task failure, but several other possibilities should also be examined (see the following text box). The most basic question in obstacle analysis and identification is to find out whether obstacles have blocked the specific tasks or whether the problem is one that motivates the involuntary client, or both. If obstacles have blocked a specific task while the client remains committed to working on the target problem, the following include many of the possible explanations for the blocked effort: lack of client skill; lack of client capacity to complete the task; lack of practitioner skill in task development; the task was not adequately specified; inadequate resources; occurrence of an emergency or crisis; inadequate rationale for the task; lack of reinforcement; debilitating fear or anxiety; and adverse beliefs (Epstein and Brown 2002). If the problem does not motivate the involuntary client, the practitioner can examine whether: the involuntary client might have been pressured to acknowledge a problem attributed by others; the involuntary client is unaware of consequences of failure to work on a mandated problem; the involuntary client has conflicted wants such that work on this problem might jeopardize other benefits; or the involuntary client has little hope that the problem can be resolved. If obstacles have arisen that block a specific task, the practitioner can proceed to revise tasks mindful of those blockages. If the problem is not motivational, the practitioner can attempt to reframe the problem or examine incentives and consequences in the case of mandated problems. In the following exchange, Cheri reviews and praises task effort with John and probes for obstacles. She discovers obstacles related to the specific task and to the whole target problem. cheri: What else did you agree to do? john: Well, I agreed to look for job ads in the newspapers. But that’s real hard. cheri: How have you been going about that? john: I go through the newspapers. It’s not hard to do. But it’s like you sit down and read the newspapers, and I just feel this same kind of feeling when I’m waiting for the phone. I just want to crumple the thing up and throw it away.

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Practice Strategies for Work with Involuntary Clients Figure 9.8

Obstacle analysis

Obstacle analysis Was obstacle related to the specific task? • Lack of client skill • Lack of client capacity to complete task • Lack of practitioner skill • Inadequate specification of task • Occurrence of emergency or crisis • Task lacks rationale • Lack of reinforcement • Debilitating anxiety or fear • Adverse beliefs • Environmental obstacles • Lack of support • Lack of power Was obstacle related to the target problem? • Problem is attributed rather than acknowledged • Client is not aware of consequences of failure to work on mandated problem • Client has conflicted wants • Client has little hope that problem can be reduced

Several obstacle possibilities emerge here. The task of looking in the newspapers might have been inadequately specified and John may lack skills in reviewing the ads. Most pertinent are his mention of feeling discouraged that suggests that the task is not rewarding and that he has doubts about whether it will be successful. john: But there was an ad in there that I responded to cheri: Oh, you did? john: Down at Brown Tank. Yeah. cheri: Great. john: I filled out an application and mailed it into them. I mailed it into ’em, and then I wait. So I haven’t heard from them. It would be a good job. I’d like to have it. cheri: I’m glad to hear that you made an application. I also hear that just waiting and wondering is something you are frustrated about.

Task-Centered Intervention with Involuntary Clients john: This is not a pleasant place to be here. I don’t want to be here, but here I am. cheri: You really have been active before this in efforts to find a job and you’ve done a great job in the things that you agreed to do. And I can also tell that you’re feeling frustrated and overwhelmed about the situation and not real optimistic. I think it’s important to keep working at it and to keep doing the small things because that’s how you do get a job. I think that’s great that you sent in that application to Brown Tank. So now you’re waiting for them to call you? john: Yeah. They didn’t want people coming up there, so you had to mail in the application. So I mailed in the application, and there’s nothing else I can do except wait for them to call me or not call me. cheri: What is it that you would like to know about Brown Tank right now, as far as where you stand with them? Obstacle analysis now appears to be centering on lack of resources as John has not heard from Brown Tank. Cheri has praised John’s efforts and empathized with his frustration. His lack of hope may be realistic if he lacks skills or jobs are unavailable. Specific job readiness skills might be explored here. We will return to this exploration with John below in the sections on appropriate middle-phase confrontation and task revision. 4. Dealing with crises. Crises within the task-centered context are large-scale obstacles that block all task efforts. They are also defined as stress problems touched off by disruptions such as substantial change in the environment, loss of physical functioning, accident, or other losses (Epstein and Brown 2002). Involuntary clients are often members of oppressed groups with low incomes, inadequate housing, and limited access to health care such that environmental crises frequently occur. Rather than prematurely concluding that involuntary clients are crisis-ridden and disorganized, serious exploration of the nature of those crises is in order. Task-centered research in foster care indicated that clients experienced an average of three or more crises in twelve-session contracts yet were still able to have at least partial success in fulfilling the contract (Rooney 1981). Consequently, practitioner response to crises is important in not losing hope for further progress. Several possibilities can be explored when crises occur: Can the crisis be handled through focusing problem-solving efforts in one session? If the crisis is unlikely to be quickly resolved, should target problems be revised to include it or should it become a new target problem? If the crisis can be resolved within the session, can task work continue simultaneously on targeted problems? When crises are generated by client decisions, the practitioner can clarify consequences of those decisions without blaming. In the following exchange, Nancy discovers that a crisis has occurred. She helps Beth assess the extent and consequences of the crisis, revise the target

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Practice Strategies for Work with Involuntary Clients problem, and make plans for next steps. Nancy clarifies the new circumstances without judging or blaming Beth. Instead, she describes consequences that have resulted from choices Beth has made. nancy: It seems that a lot of changes have happened since the last time I saw you; why don’t you fill me in? beth: Well, Barb called the cops four times since you’ve been on vacation. The fourth time she had me and Jimmy removed from her premises by the cops and she wanted me to be taken up to juvenile hall and the cops said they couldn’t do it. And they let me go on my own until you got back. Just that I had to contact your supervisor. nancy: Which you did, I know that. beth: And here I am. nancy: So you’re out of Barb’s and you feel that there is probably no chance that you’ll be able to go back there? beth: I heard that she wanted me to come back but I don’t want to go back. nancy: So, you want to change your plan, which was to stay at your aunt’s until the hearing in June. The problem you wanted to work on of getting along with your aunt until you could get out on your own and support yourself on your own isn’t appropriate anymore? beth: Right. nancy: So we will need to retarget and think about the problem you have now in your living situation. You don’t have a job yet and I know that that has been very difficult for you to find one. The other change is that you’ll have to go to court earlier since you are not now living in an approved placement. I will have to notify the judge that you have moved out of Barb’s and he will have to approve or disapprove of the new arrangements. 5. Employing appropriate middle-phase confrontation. Within the taskcentered framework, confrontation can be considered a special form of obstacle identification undertaken by the practitioner. A continuum of confrontation was introduced in chapter  4, ranging from no confrontation to assertive confrontation. Assertive confrontations should be more successful in the middle phase if the practitioner has come to be trusted as a person who has the involuntary client’s interest at heart, is expert, and is likable. Even when assertive confrontations are carried out following the guidelines for use of descriptive, nonblaming statements described earlier, such confrontations are still frequently interpreted as a put-down, verbal assault, or inappropriate criticism. As assertive confrontation is more intrusive than inductive questioning, higher levels of reactance can be expected to be generated by its usage including possible boomerang effects in which behaviors and attitudes solidify rather than change. It often provokes anger, helplessness, anxiety, fears, or remorse.

Task-Centered Intervention with Involuntary Clients In the following exchange, Cheri combines use of inductive questions and assertive confrontation in her responses to John’s concerns about the program and his frustration with it. Notice that she empathizes with his feelings of frustration but does not confront them, focusing confrontation rather on the requirements of the program and obstacles to John’s own goals. john: Well, yeah, you know. And it’s not my fault. I’m not like these guys that sit out in the lounge. They are half loaded, they get in the bag, and they’re gone. I was a good worker up there in the mines. I was a good worker. It’s just— I just get so frustrated, because I’m down here. I went to the school, get laid off, I go to the school, they tell me, take the school. You can be a welder, you can do okay. Go down to the cities, make some money. So I take the school. I do all the things that I’m supposed to do, but it just doesn’t work out. I get pretty pissed off about what’s going on. ’Cause they tell you to do this, and you do it. They tell you to do that, you do that. And then you shake your head, and I’m supposed to go out, and this lady’s going to help me here. I’m still stuck here. What am I supposed to do? I don’t want to be here. This isn’t my idea of a picnic, here. cheri: I can see that you would rather be someplace else. You’re feeling like I’m here telling you what you need to do, too. Nothing seems to be helping. john: Well, it seems to me that I’m supposed to be here. cheri: You mean here, in my office? john: I mean like, what happens if I don’t come here? cheri: Well, that was one of the first things about your participating in this housing program that we talked about, when we first met. There were a couple of things, for you to be here, to live here and eat here, that you needed to agree to do, which you did do. Do you remember what those were? john: I agreed when I came here that I would do some of the handiwork around here in exchange for room and board. That I’d take care of myself. Well, mostly that I would do the odd jobs around here, some of the small maintenance things. cheri: You’ve done a great job, by the way. You’ve been the first one that’s been able to fix that window. That’s great. john: Well, thanks. And the other part is that I agreed that I’d come in here and see you. And that I would be active in my job search. cheri: Right. john: Which I did—I’ve been out there doing my stuff. cheri: Yes, you have been. One of my main roles here is to work with the people that are participating in this program to help them find employment and to be kind of a support person and to help get the ball rolling. It is important that you see me regularly.

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Practice Strategies for Work with Involuntary Clients john: I hear that. cheri: I know that you don’t really like being here, and I don’t want you to have to be here either. I want you to have a full-time job so you can be on your own. In the next exchange, Nancy carries out a series of assertive confrontations with Beth about not carry ing through with plans to contact an alternative school. She makes the confrontations with specific facts followed by expressions of empathy. nancy: So you wanted to contact the high school to see if you could enroll this quarter and get one more credit and have that for when you want to take your GED test and want to get a high school diploma, right? beth: Right. nancy: What about GED studying, are you thinking about doing that now or are you thinking about doing that in the future sometime? beth: I could do it now. nancy: What do you know about where you could study for your GED? beth: I could try to enroll in Fresh Start. I could take my GED but then I  couldn’t get the credit that I need. All I get is my GED and not my diploma. nancy: Beth, when we started four sessions ago, you were talking about Fresh Start at that point and you didn’t contact Fresh Start, and we talked about it at the second session and you said you had forgot and that you had been real busy, so you said you would contact them again, and you didn’t contact them the second week. Is there something about Fresh Start that is holding you back? beth: Right now I want to get that one credit because then I can get that diploma instead of just a plain old GED. And if I go to Fresh Start, I can’t get it because they don’t give credits at Fresh Start. nancy: Are there any other things about Fresh Start that turn you off? beth: The work, I don’t really, I don’t think I could get into building houses, or apartment houses. nancy: The construction work doesn’t appeal to you. beth: Not really. nancy: Did you say that to them when you were interviewing there? That it wasn’t work you thought you could really get into? beth: No, I didn’t say much of anything when I went there. nancy: Oh. Why didn’t you say anything to them about that? beth: ’Cause I wasn’t really sure. nancy: You were under some pressure to come up with a plan too, I know, at that time for the court.

Task-Centered Intervention with Involuntary Clients beth: Yeah, I was. nancy: It just seemed to me when you kept putting off contacting them that there must be something going on then. It just didn’t fit with the way you saw yourself. Or the way you wanted your life to turn out, so I think it’s a good idea but I don’t want you to come up with that idea just to have one more idea for me. I want the ideas to be ones that are impor tant to you. Consideration of confrontation so far has concentrated on use of inductive questions and assertive confrontation. In some circumstances, intensive confrontation that is longer-term and from multiple sources is appropriate. Intensive confrontations sometimes can be utilized when illegal behavior has occurred of a very serious nature or when serious harm to self or others has occurred or is imminent. If the concern is about self-harm, evidence should demonstrate that without intensive intervention, harmful, irreversible consequences are likely to follow. In circumstances that fail to meet these levels of harm or danger to self and others, involuntary clients should be able to choose to receive the intensive confrontation or avoid it. For example, the intervention techniques used to persuade persons with chemical dependency problems to consider accepting treatment can be considered intensive confrontation. In such circumstances, “intervention” is defined as presenting reality in a receivable way to a person out of touch with it (Johnson 1976). Many experts consider chemically addicted behavior not to be “ free” behavior under the control of the normal powers of will, but rather a driving physical and emotional need. According to this view, the driving need arouses a set of rigid defense mechanisms that are impervious to normal means of persuasion (Johnson 1990). Such interventions may take the form of a professionally guided intensive confrontation in which a group of family and friends meet for an extended period of time with the chemically dependent person to express both caring and concern. Persons considered likely to be influential with the chemically dependent person are asked to compose letters that recall specific situations of loving and concern and specific instances of the harm caused to self and others by the chemically dependent person’s behavior. Letters are edited to describe specific instances of harm without shaming or blaming. The chemically dependent person is asked to listen to the group while they read their letters before responding. After the response, specific options for dealing with the chemical dependency problem are strongly recommended. Variations of such intervention methods have included preparation of the spouse of the alcoholic to carry out the confrontation. In Thomas’s unilateral family therapy model, the spouse specifies a directive to enter treatment or decrease consumption and includes a consequence such as marital separation

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Practice Strategies for Work with Involuntary Clients if the alcoholic refuses (Thomas et al. 1987). Preliminary model testing of this form of Thomas’s unilateral family therapy method, including this programmed confrontation, has been supportive of the effectiveness of the technique. Thomas notes that while agreement with the programmed confrontation would be desirable in all cases, it is sometimes necessary to settle for less. In all cases, however, the spouse may be helped to consider his or her options if the intervention does not succeed and the chemically dependent person may move closer to acknowledging the problem. Sometimes alcoholics respond to the programmed confrontation by choosing to reduce consumption on their own. In this event, the practitioner attempts to gain a commitment from the chemically dependent person to enter a treatment program if reduction does not reach specific levels within a specific time limit (Thomas and Yoshioka 1989). It is interesting that Thomas reports that chemically dependent persons sometimes select an alternative that would address the alcohol problem but that is not the specific recommendation made by the intervener and spouse. For example, some clients insist on finding their own treatment program rather than the one recommended. One explanation for these responses can come from reactance theory. Presenting one option may stimulate more reactance than presenting two or more, including those generated by the chemically dependent person. Some treatment programs for persons who have committed crimes of physical violence, including sex crimes, make frequent use of intensive confrontation rather than a situation-specific approach. In such settings, discussions of use of intensive confrontation frequently focus on the type of persons who “need” intensive confrontation, those who are highly defensive, resistant, and sociopathic. Repeated use of intensive confrontation is sometimes based on beliefs that clients who commit crimes have erroneous thinking styles that maintain illegal, deviant behavior (Yochelson and Samenow 1993). These thinking styles are considered to include pervasive self-deception, refusal to take responsibility for actions, and a manipulative orientation that is impervious to all but the most intensive confrontation. Hence, it is argued that confrontation should not necessarily be in short doses or surrounded by messages of caring and acceptance. Rather, the dose must be large and the impact of the confrontation not dulled by acceptance of manipulative or self-deceptive behavior. Intensive confrontation is sometimes used in ways that conflict with the guidelines for confrontation presented earlier. Those guidelines suggested that: (a) confrontation should meet specific circumstances of law violation, harm, or danger or choice to receive it by the involuntary client; (b) it is most effectively and ethically delivered when it includes specific examples and is conveyed with caring, respect, and support by a person respected by the involuntary client;

Task-Centered Intervention with Involuntary Clients and (c) that it is unlikely to be either ethical or effective when it emanates from the frustration of the practitioner rather than from client circumstances. If confrontation is done inappropriately, it can lead to fear, anxiety, resistance, and heightened defensiveness (Reid 1986). Assertive and intensive confrontations can also lose their situation- and behavior-specific, caring qualities and become abusive confrontations in which the client is subjected to a blaming, uncaring onslaught. Factors influencing inappropriate usage of confrontation can include program and client variables, situational variables, and practitioner variables. a. Program and client variables. Confrontation is sometimes used in frequent, intense doses as the method of the program rather than as a confrontation for specific clients and circumstances. Such usage is described by those programs as necessary to influence par ticu lar kinds of clients. Such highfrequency usage of intensive confrontation can have expectable consequences in involuntary client behavior. Efforts to protect oneself from intensive confrontation may be interpreted as further evidence of resistant behavior with little attention to the degree to which intensive confrontation contributes to behavior that is labeled defended and resistant. This interaction has been called the confrontation-denial cycle (Miller and Rollnick 2012). This cycle should be expected to generate high reactance as a by-product of its usage. Further, if intensive confrontation is not carried out with accompanying messages of support from persons considered likable and trustworthy, the influence can easily be perceived as punishing rather than persuasive. If the influence method is perceived to be abusive, then it may reinforce the belief that might makes right by modeling intrusive behavior on the part of the practitioner. There is further concern about overgeneralizing the use of intensive confrontation methods beyond the circumstances that call for it. For example, frequent use of attacking methods that pressured encounter group members to change quickly led to a higher number and proportion of group casualties than in groups in which leaders employed more selective confrontation (Lieberman, Yalom, and Miles 1973). Inappropriate overuse of intensive confrontation methods might be avoided through increased use of self-assessments, inductive questions, and assertive confrontation early in contact. b. Situational variables. When motivational congruence with involuntary clients has not been achieved, practitioners often experience frustration with involuntary client failure to complete required tasks. While the intention may be to jolt the involuntary client in the interest of his or her ultimate well-being, there is little reason to believe that an uncaring onslaught will change attitudes or provide more than a brief release of tension for the frustrated practitioner. When frustration is vented with the practitioner acting as prosecutor or critical parent, change may occur but only through fear of punishment and enhanced de pendency. Further, such undifferentiated use may make clients less voluntary

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Practice Strategies for Work with Involuntary Clients by ignoring areas of possible motivational congruence, contributing to distancing from involuntary clients, and labeling them resistant. c. Practitioner variables. Finally, it has been suggested that some practitioners overuse or inappropriately use confrontation when they lack other helping skills. For example, Forrest suggests that some practitioners are consistently angry, manipulative, exploitative, and pathologically confrontive (Forrest 1982). Practitioners lacking empathy skills may try to overcome such lack of skills with overly reactive, negative confronting styles. Rather than assume that overuse of intensive confrontation is primarily a result of personality deficits of practitioners, the continuum of confrontation skills in the context of other helping methods may be more useful in extending the practitioner’s skill repertoire. The real issues, then, are flexibility in use of confrontation methods, the ability to determine when confrontation is appropriate, and if so, the intensity and a sense of the expectable consequences. Practitioners who rigidly use particular modes of confrontation might explore a more flexible use of confrontation, including in some cases less frequent use so as not to diminish the effect of appropriate assertive confrontation. Underuse of confrontation is also a problem. Practitioners trained to work with voluntary clients who value the “good relationship” may be hesitant to use confrontation for fear that it will damage the relationship. Remembering that involuntary clients who find themselves in a position of low power may be inclined to use self-presentation strategies and act with less than full candor can help in preparing for appropriate use of confrontation. Such practitioners should remember that the lack of confrontation in circumstances of potential harm, danger, law violation, or behavior that conflicts with client goals can be as damaging as inappropriate overuse. They can then experiment with increased use of inductive questions and assertive confrontation as appropriate, respectful methods that can enhance the working relationship. 6. Revising and summarizing task plans. The purpose of obstacle analysis and appropriate middle-phase confrontation is to improve the chances for more successful task plans. As in initial task planning, rationales for completing the tasks, possible incentives or rewards, and use of simulation or role play may be considered. Practitioner tasks may also be useful here in facilitating client action. In the following exchange, Jean and Mrs. Torres are making plans about the next steps in their work together related to making her home a safer place. Notice how Jean is specific and picks up on Mrs. Torres’s ideas about how to limit the tasks. Mrs. Torres also puts her stamp on the particular ways she intends to carry out the tasks. jean: Okay, how many shelves do you plan to clean? mrs. torres: Well, I think those three that are right by the cupboards where I want to keep the extra groceries are probably the most important.

Task-Centered Intervention with Involuntary Clients jean: Okay, that makes sense, since you will use them the most. So you plan to clean three? mrs. torres: Yeah, I’ll do that bunch right next to those cupboards, I’ll do those, because a lot of that I think can be thrown away. jean: That makes sense to do those three. mrs. torres: But I’ll have Julie help because some of that stuff she might want to keep. It’s a lot of spare parts, and stuff. jean: Yes, that would help. mrs. torres: If I’m going to do the shelves first, I think that I should only try to do four boxes. jean: Okay, I think that sounds good. If for some reason you get really ambitious, you know, and you really are on a roll, you can do more than what we agree on, you don’t have to stick to this. It sounds as if you and Julie worked well together doing the boxes and a lot of things got done during that time. So, if you decide to do more, you might try that. mrs. torres: Besides that, then we mark on the outside of the boxes what I’ve got in there. We got a marker and then we marked it down. Because since we moved then I forgot what is in what box, you know. jean: Yeah, that can get very confusing if you do that. mrs.  torres: Okay, I’ll start writing down, I’m going to make a list of things, I think I’ll put that on here. Yeah, because I’m going to make a list of all the different kinds of things that Julie could help me with and then she’d be able to choose. jean: That works well for you when Julie has a say in what parts she helps with.

The Termination Phase Approaches to work with voluntary clients often consider termination with trepidation and predict that many clients at this stage will feel abandoned and regress to earlier stages. If the client has come to depend on the practitioner as a major source of support and problem-solving expertise without having enhanced his or her own skills and support systems, then such feelings of abandonment are both understandable and predictable. Involuntary clients are less likely to experience such regrets. Since they did not seek contact, termination may be approached with relief that an unsought pressure will be removed. In fact, regrets may be a good sign since involuntary clients are likely to feel them only if contact had ultimately come to be valued. In fact, one family that that the senior author worked with as a result of required contact with an adolescent who was absenting from school noted as he finished his last session that the family sessions were “not so bad”!

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Practice Strategies for Work with Involuntary Clients Termination with mandated clients often involves practitioner decisions and recommendations about when to let go of contact. Such decisions can be difficult because rarely are all problems resolved. In addition, some clients continue to have frequent crises or do not have access to ongoing support. Decisions about termination can be made more easily when specific goals were established during the contracting phase. In the absence of such specific goals, the involuntary client is maintained in a relatively powerless state without a focus for energies and reactance may be reinforced. When such criteria focus on essentials rather than on the ideal, termination is more likely to be successful. The practitioner using the task-centered approach begins to prepare for termination in the first session by focusing clearly on the schedule of sessions, by reminding the client of the number of sessions completed and the number remaining. This focus on available time makes use of the “goal gradient” effect in which client and practitioner activities can be expected to pick up in pace when the end of a time-limited contract approaches. Second, practitioners can also gradually become less active in task formulation and obstacle analysis, expressing confidence in the client’s ability to resolve problems. Practitioners can also limit the scope of work undertaken in later sessions by narrowing or reducing goals to more feasible levels. It is often hoped that work done in time-limited contact will generalize to situations after contact is ended. Beth was interviewed after her contact with Nancy had ended and she had been approved for independent living. Below, the interviewer explores the possibility that task-centered work on her own target problems may have also taught a problem-solving process that might generalize when Beth approaches new situations.6 interviewer: You had been working with Nancy for quite a while but in February, she changed gears and worked a little differently with you. Did you notice any differences? beth: Yes, I wasn’t arguing with her as much. I felt that she was letting me take charge of my life and letting me make the decisions and not her. Which helped me a lot because I realized that it was all on my hands and nobody else and that made me sit down and think that I better get my stuff together and that helped a lot. interviewer: Over the last couple months you’ve done quite a few tasks or things that you worked out with Nancy. I’m wondering if you’ve learned anything about not just carrying out those tasks but solving problems on 6 This interview is included in a videotape entitled Permanency Planning: Use of the TaskCentered Model with an Adolescent toward Independent Living: The Middle Phase. 4751-c. Contact Ron Rooney at [email protected] for more information about access to this video.

Task-Centered Intervention with Involuntary Clients your own that you’ve been able to take to other problems, other than the ones you talked to Nancy about? beth: Well to me at first when I did have Nancy, they all just seemed like a pain in the butt, but now they have become more real that they are a problem, that they can be worked out in time. That you just have to spend a little bit more time on each one of them and not try to solve them all in one day because it just doesn’t work. interviewer: So one of the things you do differently is you don’t try to solve them all in one day? beth: Right. I take one step at a time if it takes a week for one problem, then it’s a week I have to spend on it. If it takes more, then it has to take more, but some can take just one day, but others take a month to figure out. And I learned from my problems, not to make mistakes twice. interviewer: I understand that you got a notebook of your own and you were writing down some of your own tasks for yourself. beth: Yeah, after me and Nancy had gone through the eight-week sessions I started writing down tasks that I thought were important to myself, that I had to do to succeed. And I still do that and I write down the daily things of what I have to do and the end of the day before I go to bed I’ll check them off. What I didn’t do goes on the next day’s list. It appears that Beth was quite aware of making more decisions and taking more personal responsibility for issues in her life. She has a grasp of prioritizing problems in order to reduce the feeling of being overwhelmed by them and she generates tasks for herself. Successful efforts in this time-limited contact do not mean that her life will continue without setbacks nor that she will never again have contact with social ser vices. How can the practitioner working with involuntary clients prepare for termination in such a way that such self-attribution is encouraged? Four options can be considered in the final phase: (1) termination, (2) extension, (3) recontracting, and (4) monitoring. Termination When the end of the time limit is reached, many involuntary clients and practitioners will be ready to terminate because problems are substantially reduced or a preset limit of sessions has been reached. Extensions can be negotiated if substantial progress has already been made and more can be expected with a few more sessions. For example, a client who wanted to increase her jobseeking skills extended her contract for two sessions when an important job interview was scheduled for a week after the scheduled final session. The extension was planned to prepare for that interview and to review the interview and the total contract in a final session. Recontracting refers to the development of an additional contract on new problem areas if the client and practitioner

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Practice Strategies for Work with Involuntary Clients both expressly wish to continue and there is good reason to believe that substantial progress will be made on the same or additional problems. Recontracting assumes that the agency will permit more lengthy contact. Recontracting may also be done when a large problem has been broken down into smaller time-limited sequences. Hence, the client may proceed to a second sequence if the first has been productive. It is often the case that case management contact continues after a period of more intensive contact has ended. Such monitoring works best when it is carried out for a specific, contracted purpose rather than waiting for something to happen or go wrong. Monitoring can take place through brief in-person and telephone check-up sessions. It can be useful to assess the maintenance of gains after a period of more limited contact. Monitoring may also occur to support linkages made to other resources (Epstein and Brown 2002). When a decision to terminate ser vices or shift to a different mode of contact has been made, a termination or transition session can include the following steps. 1. Review problem reduction on each target and mandated problem by examining change in conditions. Concrete data for assessing change can be shared. For example, Beth and Nancy reviewed Beth’s work on conditions that would be reviewed in court when the recommendation for independent living would be considered. Specifically, conditions of parental permission, having a place to stay and a source of income, or participation in an educational program were reviewed. In addition, Beth’s feeling that too many people were telling her what to do was also reviewed, finding that completing tasks had moved her to a more independent place in which there were fewer people in a position to tell her what to do. 2. Review tasks completed and obstacles encountered, focusing on successes and learning obtained from that process. Beth and Nancy reviewed her efforts to get a job and enter an educational program and the obstacles related to both. 3. Review the general steps in problem solving used in the case as a reminder of methods that can be used with remaining problems. For example, it can be recalled that steps included: (a) identifying specific concerns or target problems, (b) prioritizing mandated problems and voluntary problems that might make the most difference, (c) considering task possibilities and anticipating potential roadblocks, and (d) reviewing progress and attempting to “fix” tasks that did not work based on obstacle analysis. 4. Consider remaining needs on targeted problems and other problems of concern to the client. The practitioner helps the involuntary client to plan how he or she might go about maintaining changes. The practitioner should also help the involuntary client anticipate potential obstacles to this plan and to consider how those might be overcome. For example, Nancy and Beth discussed

Task-Centered Intervention with Involuntary Clients several problems that might occur after she was in independent living and how she might pursue help for them.

Conclusion This chapter has provided specific guidelines for carrying out task-centered interventions with involuntary clients. As a general rather than problemspecific model with an eclectic theory base, the task-centered approach has several elements that are compatible with involuntary client work. Use of the adaptations suggested should enhance motivational congruence and promote self-attribution. The adaptations should reduce reactance by breaking down large problems, which often make both involuntary client and practitioner feel helpless, into smaller components. The specificity of task development also enhances clear record-keeping and assists in developing mutual accountability. Adaptations have also been suggested for working with time-limited subcontracts when involuntary client contact is not brief. The task-centered approach is not a panacea for the problems of work with involuntary clients. Much of the task-centered approach appears to have been integrated into standard practice with clients in many settings (Kelly 2016; Franklin and Mikle 2013; Fassler 2007). It provides no magical answers in working with mandated clients who cannot agree on any concerns with the practitioner. Choices in the form of implementation and timing of required tasks have been suggested. Such techniques may assist some involuntary clients in coming to greater motivational congruence over time. Other wise, as stated earlier, involuntary work supported primarily by fear of punishment and promise of reward often achieves results that last only as long as those compliance methods are available. There is little substitute for motivational congruence in achieving self-attributed change. The chapter also presented the middle phase in which the review of initial task efforts takes place. However carefully developed, initial tasks often fail. Ways to review progress that focus on maintaining momentum and using selective confrontation were presented. Finally, guidelines for conducting termination that focus on objectives accomplished and linkage to additional resources for further work were provided.

Discussion Questions 1. Initial action plans often fail. How often do you find that such failures are assigned to lack of client effort or motivation instead of an objective review of obstacles?

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Practice Strategies for Work with Involuntary Clients 2. It is suggested in this chapter that confrontation is frequently overused and also underused. That is, some agencies and settings may use it in nonproductive ways and others may not use it when the situation requires. What are your attitudes and beliefs about use of confrontation? Can the continuum of confrontation ranging from self-assessment to intensive confrontation be useful as a guide? 3. This chapter introduces the concept of the disagreeable task. However well intentioned and potentially useful, some tasks feel arduous to clients. What is the value of acknowledging that the task may not be pleasant? 4. Practitioners and agencies sometimes have difficulty letting go of involuntary clients, thinking that if they were maintained in contact a little longer, more progress could be achieved. How do you and your agency decide when enough is enough? References Bandura, A. 1971. Psychological Modeling: Conflicting Theories. Chicago: Aldine-Atherton. Corcoran, K. and V. L. Vandiver. 2006. “Implementing Best Practice and Expert Consensus Procedures.” Foundations of Evidence-Based Social Work Practice, eds. A. R. Roberts and K. R. Yeager, 59–66. Oxford: Oxford University Press. Epstein, L. 1988. Helping People: The Task- Centered Approach. Columbus, OH: Merrill. Epstein, L., and L. Brown. 2002. Brief Treatment and a New Look at the Task- Centered Approach. 4th ed. New York: Macmillan. Fassler, A. 2007. Merging Task- Centered Social Work and Motivational Interviewing in Outpatient Medication Assisted Substance Abuse Treatment: Model Development for Social Work Practice. PhD dissertation, Virginia Commonwealth University, Richmond, Virginia. Forrest, G. 1982. Confrontation in Psychotherapy with the Alcoholic. Holmes Park, FL: Learning Publications. Franklin, C., and K. Mikle. 2013. “Brief Therapies in Social Work: Task-Centered Model and Solution-Focused Therapy.” Oxford Bibliographies. http://www.oxfordbibliographies.com /view/document/obo-9780195389678/obo-9780195389678-0188.xml. Goldberg, M., D. Walker, and J. Robinson. 1977. “Exploring Task- Centered Casework.” Social Work Today 9 (2): 9–14. Johnson, P., and A. Rubin. 1983. “Case Management in Mental Health: A Social Work Domain?” Social Work 28 (1): 49–54. Johnson, V. 1990. I’ ll Quit Tomorrow. 2nd ed. San Francisco: Harper One. Kirk, S., and J. Greenlee. 1974. “Denying or Delivering Ser vices.” Social Work 19: 439–447. Lieberman, M., I. Yalom, and M. Miles. 1973. Encounter Groups: First Facts. New York: Basic Books. Marsh, P. 2008. “Task-Centered Work.” In The Blackwell Companion to Social Work, ed. Martin Davies, 121–128. Oxford: Blackwell. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing. 3rd ed. New York: Guilford Press. Mullen, E. J., S. E. Bledsoe, and J. L. Bellamy. 2008. “Implementing Evidence-Based Social Work Practice.” Research on Social Work Practice 18 (4): 325–338.

Task-Centered Intervention with Involuntary Clients Naleppa, M., and W. Reid. 2000. “Integrating Case Management and Brief-Treatment Strategies.” Social Work in Health Care 31 (4): 1–23. O’Connor, G. 1988. “Case Management: System and Practice.” Social Casework 69 (2): 97–106. Okamoto, S., and C. Le Croy. 2004. “Evidence-Based Practice and Manualized Treatment with Children.” In Evidence-Based Practice Manual: Research and Outcome Measures in Health and Human Services, eds. A. Roberts and K. Yeager, 246–252. New York: Oxford University Press. Pazaratz, D. 2000. “Task-Centered Child and Youth Care Practice in Residential Treatment. Residential Treatment for Children and Youth 17 (4): 1–16. Reid, K. 1986. “The Use of Confrontation in Group Treatment: Attack or Challenge?” Clinical Social Work Journal 14: 224–237. Reid, W. 1978. The Task- Centered System. New York: Columbia University Press. Reid, W. 1992. Task Strategies: An Empirical Approach to Clinical Social Work. New York: Columbia University Press. Reid, W. 1997. “Research on Task- Centered Practice.” Social Work Research 21 (3): 132–137. Reid, W. 2000. The Task Planner: An Intervention Resource for Human Service Professionals. New York: Columbia University Press. Rooney, R. H. 1981. “A Task- Centered Reunification Model for Foster Care. In The Challenge of Partnership: Working with the Parents of Children in Foster Care, eds. A. Maluccio A. and P. Sinanoglu, 101–116. New York: Child Welfare League of America. Rooney, R. H. 2010. “Task-Centered Practice in the United States.” In Social Work Practice Research for the 21st Century, eds. A. Fortune, P. McCallion, and K. Briar-Lawson, 195–202. New York: Columbia University Press. Rose, S., and B. Black. 1985. Advocacy and Empowerment: Mental Health Care in the Community. Boston: Routledge and Kegan Paul. Thomas, E., and M. Yoshioka. 1989. “Spouse Interventive Confrontation in Unilateral Family Therapy for Alcohol Abuse.” Social Casework 70: 340–347. Thomas, E. J., C. Santa, D. Bronson, and D. Oyserman. 1987. “Unilateral Brief Therapy with the Spouses of Alcoholics.” Journal of Social Service Research 10: 145–162. Wells, R. 1982. Planned Short-Term Treatment. New York: Free Press. Weissman, A. 1976. “Industrial Social Ser vices: Linkage Technology.” Social Casework 57 (1): 50–54. Wilk, R. 1988. “Involuntary Outpatient Commitment of the Mentally Ill.” Social Work 33: 133–137. Yochelson, S., and S. Samenow. 1993. The Criminal Personality: A Profile for Change. New York: Jason Aronson.

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Chapter 10

Work with Involuntary Families

Rebecca Mirick

Families enter treatment for a variety of reasons, such as a child’s mental health issue, an adolescent’s challenging or dangerous behaviors, or an accusation of child abuse or neglect. Regardless of the reason, engaging families in treatment services can be challenging work as the practitioner must build an alliance with each family member, as well as the family as a whole (Horigan et  al. 2005). Family engagement is often unsuccessful, as families often drop out of treatment at high rates. This is particularly true for lower income, nonCaucasian families (Gopalan et al. 2010; Horigan et al. 2005; Ingoldsby 2010; Santisteban et al. 2006). Working with families can be intimidating. Practitioners are often outnumbered and sometimes overwhelmed by the number of people— and often conflicting definitions of the problem—in the room. An additional challenge is that in most work with families there is at least one family member (and sometimes all family members) who is not there voluntarily and may be resistant to ser vices (Robbins et al. 1996; Santisteban et al. 2006; Sotero et al. 2016). The family may have been referred or mandated by an agency or organization with which they are involved (e.g., Child Protective Ser vices, court) or pressured by an organization or person with whom they are involved (e.g., school, pediatrician, mental health practitioner). Even if they are not required to attend, family members may feel intense external pressure to participate from other helpers or internal pressure from other family members (Sotero et al. 2016). Although insufficient attention has been paid to working effectively with involuntary clients on an individual basis, within family

Work with Involuntary Families therapy this topic has been almost fully ignored (Snyder and Anderson 2009). This chapter presents a continuum of involuntary contact, ranging from voluntary treatment to nonvoluntary to mandated pressures. Exemplars of family-centered practice in child protection and adolescent delinquency are presented, including a description of common factors in these approaches and guidance for engagement. While it is beyond the scope of the chapter to develop a fully elaborated model for involuntary family work, specific guidelines are provided for the contracting phase. We begin with an interaction between a practitioner who works for a familycentered, home-based ser vices program and Mrs. King, the single parent of sixteen-year-old Christine. Mrs. King called a public child welfare agency requesting that Christine be removed from her home because she was not obeying house rules, skipping school, and likely using drugs. Mrs. King and Christine were then referred for a home-based ser vice assessment. Such services often require as a precondition that family members agree to work to remain together as a unit rather than separate, as some family members might prefer. Hence, while an offer of home-based ser vice is welcomed by many as a better alternative than placement out of the home, some are court-ordered to receive ser vices. Others may receive an offer of ser vice as an alternative to an involuntary investigation (Alternative Response in Minnesota 2006). The following exchange occurred during an initial home visit to explore the situation and make an offer for home-based ser vices. While the practitioner and Mrs. King talk, Christine sits staring into space, the earphones plugged into her phone planted firmly on her head as she listens to music. practitioner: I explained to you briefly about home-based ser vices on the phone. Home-based ser vices is a program that the county offers for families who are having difficulties similar to what you described to me. A team of workers would come into your home to meet with your family for at least an hour a week for six to nine weeks. In that time, we would talk about what’s going on and try and find some resolution to some of the difficulties that are going on in your home. mrs. king: You know, when I called Child Welfare, I thought that you were going to come and get her out of here. I just thought that you were going to come and tell me the procedure for getting her out of the house. We can’t have her here. practitioner: So, you thought that I’d be putting Christine into placement. mrs. king: I think, you know, that’s pretty much what I said over the phone . . . I’m telling you what I need. practitioner: I can understand that you are disappointed that we can’t offer the placement out of the home you wanted. We place children and adolescents out of the home in fairly restricted circumstances. We have

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Practice Strategies for Work with Involuntary Clients found in the past that if the problems aren’t worked on in the home, the child often returns after placement to the same situation. So, we are now offering in-home family-based ser vice to help you with the problems that caused you to want to get her placed out of the home. mrs. king: So you’re telling me how I’m going to be able to solve my problem, and I’m telling you what my problem is, and I know how to solve it. And that’s to get her out of the house here. I mean this stuff of having her still live here, I mean she’s just causing too much trouble. Though Mrs. King made a voluntary request for the involvement of child protection, she does not appear voluntary during the above conversation. In fact, she has just experienced pressure to participate is a different program than she requested, a program whose ser vices she does not want. While she would have been a voluntary participant in out-of-home care, she is a nonvoluntary participant in home-based ser vices. Furthermore, although the worker has not yet met sixteen-year-old Christine, she may be more an involuntary target than a voluntary client. Work with families is often involuntary, such as with Mrs. King and Christine, even if one or more family members initially sought ser vices. When engaged in assessment and treatment planning with families, practitioners often draw on family therapy perspectives. Such perspectives permit analysis of family communications and role structures that can be useful outside of voluntary family therapy. Similarly, family therapy techniques for assisting families in making behavioral changes have been attractive alternatives to methods that focus primarily on seeking cognitive or emotional insight. Family therapy perspectives, however, require many adaptations for work in involuntary family situations. Families who are involuntary are more difficult to engage in the work and drop out of treatment ser vices at higher rates than voluntary families (Rempel and Destefano 2002; Sotero et al. 2016). They are likely to disagree with the problem definition and may be resistant to ser vices (Sykes 2011). Disagreement with the problem definition, in fact, leads to a greater chance of treatment drop-out (Gopalan et al. 2010; Ingoldsby 2010). In addition, many practitioners work with families in roles and settings in which family therapy is neither the ser vice offered by the practitioner’s setting nor that sought by clients. In these cases, practitioners need to use a more collaborative approach with families, especially when at least one family member can be considered involuntary or when family members have very different conceptualizations of the problem. Incorporating a strengths-based approach into work with families can support collaborative family work and may offer a less directive, more effective approach for collaboratively engaging involuntary family members.

Work with Involuntary Families

How Are Families and Family Members Involuntary? In some cases, practitioners work with families in which some family members are more eager to participate in treatment ser vices than others. Other family members may feel pressured or coerced into participating in treatment ser vices by family members, or their participation might be completely involuntary, such as when an adolescent is told by a parent that she must participate in treatment ser vices. Regardless of the locus of the pressure, many family members receiving treatment ser vices are not fully voluntary clients (Sotero et al. 2016). Family contact often begins with an interview with one or more family members who are concerned about the problems of another, sometimes absent, family member (Sotero et al. 2016). In many cases, that family member is a child or adolescent and the problem has been conceptualized by the rest of the family as that individual’s problematic behavior (Santisteban et al. 2006). These “identified targets,” such as Christine in the example above, are often resistant to both treatment ser vices and the problem definition. They frequently participate minimally, occasionally rousing to defend themselves against parental accusations. Other family members often see the problem as residing solely in this “identified target” and are reluctant to participate themselves (Santisteban et al. 2006). In other situations, such as child protection cases, family participation in ser vices is mandated by an external agency. In these cases, the child protection worker may initiate contact or the family may initiate ser vices with an outside practitioner due to this mandate. In such situations, there may be no voluntary members of the family and the family may have very different conceptualizations of the problem than the practitioner or the referral source. For example, when a child is at risk of placement, the only problem the family identifies may be keeping the child at home and family contact is considered primarily as a means to fulfill requirements. These families are often viewed negatively both by practitioners and by community members because of their involvement with child protective ser vices. In many cases, parents experience significant stigma and shame (Sykes 2011). Shame can act as a barrier to engagement, particularly with involuntary clients (Forrester, Westlake, and Glynn 2012; Gibson 2014). In some cases, especially when ser vice involvement is highly stigmatizing, such as in child protection, or clients feel judged by practitioners, they may be preoccupied by feelings of shame to fully engage in treatment ser vices; they may avoid practitioners from whom they experience negative judgment or attempt to portray themselves in a more positive light, which often involves not fully investing in treatment ser vices in a straightforward manner (Gibson 2014). Practitioners themselves often view involuntary clients negatively, including descriptors such as “resistant,” “uncooperative,” “hostile,” and “difficult” (De Jong and Berg 2001; Sykes 2011; Tuck 2013). Practitioners often find these clients frustrating and difficult, and much

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Practice Strategies for Work with Involuntary Clients prefer working with clients who agree with the problem definition and engage in the work on the issue (Sykes 2011). With such negative practitioner perceptions and the nonvoluntary nature of the work, it is no surprise that family members who experience informal, formal, and mandated pressures to attend treatment ser vices are often, like Christine above, angry and resistant (De Jong and Berg 2001; Reich 2005; Sykes 2011). Such families may not buy into the necessity for ser vices or participate fully (Gibson 2014; Reich 2005; Sotero et al. 2016; Sykes 2011; Yatchmenoff 2005). Similarly, families are described as feeling powerless when working with ser vice providers in positions of power (Dumbrill 2006; Smith 2008), and are often seen as resistant to change despite orders, pleas, exhortations, and the combined efforts of many agencies. In fact, the practitioners assigned to work with them often feel frustrated and exhausted. The fact that such families are often headed by low-income, single-parent mothers from oppressed groups is often neglected in the literature. Several studies suggest that families are less likely to engage in treatment when they are single-parent families, of low socioeconomic status, and belong to an ethnic minority group (Gopalan et al. 2010; Nock and Ferriter 2005; Snell-Johns, Mendez, and Smith 2004). While some efforts have been made to address barriers due to poverty (e.g., transportation, childcare) (Gopalan et al. 2010), little is known about how to effectively engage families of other cultures, such as Latino immigrant parents (Ingoldsby 2010; Santiago et al. 2016; Santisteban et al. 2006), although they drop out of treatment at higher rates than Caucasian families (Gopalan et al. 2010). Professionals often interpret these families as lacking insight into the situation. In other words, the family is not in agreement with the practitioner about the definition of the problem (Sykes 2011). If only the family would acknowledge the same problems that we see them as having, and do so without being pressured to do it, there might be progress. In fact, practitioners often respond by pressuring clients to cooperate, sometimes through confrontation (Forrester et al. 2008; Reich 2005; Smith 2008), which can backfire and decrease compliance and increase resistance even more. There has been interest in fields such as child mental health and child protection in finding strategies to better engage these families, such as finding assessment clues from early contact that would predict successful engagement in the work (Yatchmenoff 2005). This quest for reliable diagnostic indicators has in part led to interest in the stages-of-change approach with its predictable phases and clear guidance to practitioners about how to respond in each phase (Littell and Girvin 2002, 2004). However, there are complications with overly broad application of an approach that was developed to explain health-related change for voluntary individuals to families meeting under pressure and facing multiple difficul-

Work with Involuntary Families ties, only some of which may be health related (Littell and Girvin 2002; 2004). Application of the stages-of-change perspective to a child welfare sample revealed, for example, that some groups of child welfare clients appear to be immobilized. Though they acknowledged a need for change, they appeared overwhelmed by circumstances and not hopeful about their ability to change (Girvin 2004). Still others did not acknowledge a need for change yet reported they were actively engaged in a process of change (ibid.). Although initially these appear to be contradictory findings, Girvin suggests that “while the SOC model describes states intrinsic to clients, readiness for change might be better understood as a complex phenomenon that is formed from interactions among client, social worker, and context” (2004:913). The stages-of-change models leaves out the situation of families who have been pressured to accept a particular problem. For example, some mothers with child welfare issues are pressured to “stay away from a dangerous man” or “avoid drugs” if they wish to regain custody of their children before mandatory time limits are reached (Adoption and Safe Families Act 1997). Often parents in these situations engage in passive resistance, where they agree with the practitioner because they see these issues as mandated steps toward regaining custody of their children, not because they recognize safety issues that need to be addressed to keep their children safe. In fact, research suggests that the child protection system often values this kind of compliance, sometimes even over actual behavior change (Smith 2008). As with the stages-of-change model, approaches to engagement with involuntary families conceptualize families’ struggles with engagement as individual challenges inherent in the family member. Miller and Rollnick (2012) suggest that often client resistance can stem from practitioner behaviors and that when faced with a challenging, resistant client, a practitioner should examine his or her own behav iors to see what might be changed. This is particularly true with involuntary clients, who usually enter the relationship resistant to the problem definition and treatment ser vices, even before ser vices begin. Research on child protection practice suggests that there are practitioner qualities and characteristics that help them to engage, such as taking a collaborative approach, using clear, honest communication, avoiding using power to coerce clients, and being respectful and culturally sensitive (Altman 2008; Dumbrill 2006). Work with involuntary client families occurs in settings and problem areas as diverse as child protection, child mental health, adolescent delinquency, family support programs, and agencies serving older adults. Within all of these settings, there is a continuum of involuntary family contact, from families where one member is nonvoluntary to families who are mandated to ser vices. Assessing the level of voluntariness of a family is a key first step toward effective engagement.

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A Continuum of Involuntary Family Contact An involuntary family transaction refers to contact between a helping professional and two or more family members in which at least one participant experienced external pressure to participate in that contact. This definition focuses attention on the presence of factors outside the person as influencing initial contact. The pressures range from formal and informal nonvoluntary pressures to mandated pressures. The family as a total unit may fit on a continuum of external pressure. In addition, individual family members may be scattered throughout the continuum, with some experiencing nonvoluntary pressure or mandated pressure while others are voluntary. Further, families and family members may become more or less voluntary during contact. For example, Mrs. King may have begun the request for ser vice as a voluntary client while Christine experienced informal nonvoluntary pressure from her mother to participate in that contact. The voluntary family is one in which family members seek assistance from a helping practitioner without outside pressures from legal, formal, or informal sources. For example, a couple may seek marriage counseling without either formal pressure or informal pressure from one spouse who is more committed to seeking help than the other. If the resource sought comes without any additional requirements from the agency or practitioner providing the resource, or if informal pressures are not present, then the family unit may be voluntary. As Mrs. King’s situation suggests, some family members may be voluntary as long as the problems they perceive are addressed and they do not experience mandated, formal, or informal pressure. The dilemma for family practitioners is that accepting the agenda of one person such as the parent often implies work with another family member as involuntary target. Hence, circumstances in which all family members are voluntary are the exception rather than the norm. Formal Pressures Formal pressure to participate in ser vices may take at least five forms: (1) a desired ser vice or resource is not available; (2) family ser vice is presented as the only alternative to a punishing option; (3) family contact may be a precondition or perceived to be a precondition for receiving a desired resource; (4) the original request for individual treatment is reframed by the practitioner as a family problem; and (5) family ser vice may be the policy of the agency. Each of these forms of formal pressure is presented separately with examples to illustrate them. 1. Desired service or resource is not available. Clients such as Mrs. King who make a voluntary request may become involuntary when that request is not

Work with Involuntary Families accepted. If their other options are limited, they may experience a constrained choice. 2. Family service is presented as the only alternative to a punishing option. Some families may experience a coerced choice to seek family counseling influenced by the expectation of avoiding major punishers controlled by outside agencies. Hence, adolescents and their families are sometimes presented with the coerced choice of accepting family treatment or entering a residential treatment program. When a child protection agency is involved, the ser vice plan consists of several family-focused interventions, although the entire family may not be present for them. While child protection workers tend to view ser vice plans as ser vices that will help parents, parents tend to see them as punitive, and something they must do to avoid a worse option, such as going to court or losing custody or parental rights of children (Sykes 2011). 3. Family contact is a precondition or is perceived to be a precondition for receiving a desired resource. Such preconditions may be intentional or unintentional, explicit or implied. For example, families seeking approval to become adoptive parents often find that a thorough family assessment is an intentional explicit precondition. Similarly, family members may encounter agency expectations that they attend counseling in support of the residential treatment of a family member. In other cases, family contact may be perceived as a precondition when the suggestion that it take place comes from a powerful person or agency that controls major resources. The precondition may be implicit. For example, some referral sources such as foster care workers may recommend family therapy with the implied message: “Take six months of family therapy and we will review your plans to regain custody of your child.” These implicit messages are more likely to be assumed when the person offering the message comes from an authority figure and the clients are in a position of lesser power. This imbalance occurs just in the power dynamic between practitioner and client, but it can also be emphasized when the client is in a position of power not just because of his status as a client, but also due to characteristics that might make him or her vulnerable, such as minority status in terms of race, ethnicity, level of education or immigration status. Although an implied mandate may be unintentional, unless free choices are clarified and the consequences of compliance or noncompliance with the suggestion are clarified, family members may construe a suggestion from an authority figure as an implied requirement. For example, Mrs. King may believe that she must agree to homebased ser vices as a necessary hurdle to show that lesser methods have not succeeded in their attempts to have out-of-home placement considered. While families experiencing a coerced or constrained choice to “seek treatment” may have little doubt about its involuntary nature, practitioners receiving the “request for service” may be less aware of the coerced or constrained nature of the request if they are unaware of the benefits and punishers

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Practice Strategies for Work with Involuntary Clients controlled by the referral source. Similarly, the referring practitioner may be unaware that the family is responding to a suggestion as if it were an implied requirement. 4. An original request for individual treatment is reframed by the practitioner as a family problem. As noted earlier, family members frequently come for help with concerns about another member of the family who is not present. They may voluntarily seek help to have a troublesome person “fixed.” If the practitioner agrees to “fix” the identified target, the family members initiating contact remain voluntary. Practitioners with a systems view of family problems may, however, search for indicators for how the family system supports the identified target person’s symptoms. If such practitioners attempt to reframe problems to the family system level, family members may experience a constrained choice to accept a “package deal” in order to receive attention on the problem that led them to seek help (Santisteban et al. 2006). Reluctance of family members to accept such a reframe is explained by Anderson and Stewart: “Most families are at least skeptical about, if not overtly resistant to, the concept of family therapy. The anxiety-producing experience of beginning any kind of therapy becomes complicated by the seemingly illogical request that the entire family come in to be seen when the problem clearly resides in one member. Why should the family be seen when it is Johnny who doesn’t like school or Mary who is “acting up” (1985:31). Practitioners using a solutions focused approach with families may, similarly, involve the whole family in order to co-construct a mutually agreed-upon definition of the problem and plan for a solution. As in the example above, however, parents and other siblings may not enjoy or appreciate this restructuring of the problem. Beyond family treatment, there are many other circumstances in which the practitioner may suggest that other family members should be brought into the work. For example, adult children who are concerned about the living conditions of an older parent may find that the practitioner includes the parent in the treatment planning rather than operate on them as involuntary targets of the intervention. 5. Family service may be the policy of the agency. Some agencies may have a policy of refusing to see the family unless all family members are present or strongly suggest family involvement, which can be perceived as a requirement. Family ser vice may be the approach used to treat the identified problem at that agency, whether it is eating disorders (Diamond et al. 2010) or adolescent behavioral problems (Santisteban et al. 2006). Informed consent incudes reviewing these requirements with families as well as the fact that other agencies may use different models (e.g., individual or group treatment) to address the same problem behaviors.

Work with Involuntary Families Informal Pressures In addition to formal pressures, family members often experience informal pressure from other family members. For example, siblings may initially attend sessions because “Mom and Dad made me come” or because family therapists requested that they attend in order to see the “identified client” in the context of family interaction. Many children and adolescents experience this kind of informal pressure to attend treatment ser vices due to parental identification of a problem. Mandated Treatment While nonvoluntary contact is probably the most frequent form of family contact, mandated family contact also occurs. Reasons for court-referred family treatment include substance use disorders, child maltreatment, and domestic violence (Snyder and Anderson 2009). Sometimes only one parent is mandated to receive ser vices, such as parenting classes or individual counseling, but the focus of this work is on family function, specifically how to keep the home safe for the children. The involuntary nature of such an arrangement is usually clear to the family and the practitioner. Expectations for reporting on family progress to the child protection worker or the court should be frequently discussed and the power issues involved are considered openly. This includes the consequences of failure to complete treatment or make specific behavioral changes. In the case of mandated treatment, the family problems are identified by the referring agency, not by the family. In many cases, the family may not recognize the problem nor be interested or motivated to address it (Snyder and Anderson, 2009).

Issues in Adapting Family Treatment Perspectives to Work with Involuntary Families While family treatment approaches have made important contributions to work with persons in nonvoluntary situations, there are limitations to exclusively relying on family treatment for guidance in such work. These problems include (1) lack of fit with setting, (2) lack of attention to other systems levels, (3) goal conflict, (4) the resurrection of resistance, (5) issues in definition of practitioner role, and (6) ethical issues. 1. Lack of fit with settings. Many practitioners work with families in settings that do not explicitly provide family treatment. For example, social workers often deal with practical problems such as assistance in finance and housing, dealing with illness, disability, locating and linking clients with resources, and

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Practice Strategies for Work with Involuntary Clients acting as public agents for the well-being of children. Practitioners may work in discharge planning, consulting in an emergency room, returning children from foster care, and mediating conflict in which problems of illness and poverty often predominate. Caseloads may vary from a few cases to hundreds. Clients served in such community organizations are often “not seeking the help offered.” Yet while such work “in the trenches” may be the mission of fields such as social work, prestige is often accorded to practitioners based on their distance from such work. Often traditional family treatment is not an option in these settings, but the theoretical underpinnings of this approach can be utilized along with other types of interventions, which include an ecological approach to problem solving 2. Lack of attention to other system levels. While family therapy has been greatly influenced by systems perspectives, there are great variations in the way those perspectives are applied. Many traditional family therapy approaches focused on the individual and family, at the exclusion of the other systems (e.g., school, child protection, hospitals, neighborhood, community) with which the family interacted. Many newer approaches to family therapy fully embrace the systems approach, including a consideration of the role of these external systems and sometimes targeting these external systems for intervention (Lebow 2005). In general, however, traditional family systems theorists treat the family as a closed system, omitting from their assessment any meaningful investigations either of the biological subsystems of individual family members or the social, economic, and organizational factors that may be suprasystems in which the family is enmeshed. Instead, there is a tendency to focus almost exclusively on interpersonal transactions rather than on systems (Lebow 2005). Some more recent family approaches have addressed these concerns by taking a more ecological approach and considering the influence of external systems such as peers, school, and community (Henggeler et al. 2009). 3. Goal conflict. Different family therapy methods have distinct underlying assumptions and, due to this, different goals. While traditional approaches to family therapy may have had varying goals, from seeking to enhance personal and interpersonal awareness to altering functioning through changing the family’s orga nizational structure and sequences of interaction, the newer approaches tend to more uniformly use the systems approach, and may even focus the intervention on the larger environment, not the family system (Henggeler et al. 2009; Lebow 2005). Some approaches suggest that family conceptions of problems may be caught up in problem definitions that will not actually permit change. Often, targeting one individual as the “problem” does not allow for the work to proceed effectively for the family; shifting this mentally for the family is key (Diamond 2005). For example, they might suggest that “getting Christine out of the house” is a view of the problem that will not permit real change. However, newer family therapy approaches emphasize the importance of collaborative work, working within the family’s

Work with Involuntary Families definition of the problem and goals. Therefore, one component of the practitioner’s early work with the family may be to work with the family to reframe the problem and the goals in a way that will allow real change to occur through the work (Diamond 2005). One example of this kind of shift would be to change the goal from “fixing” the identified client (often an adolescent) to “strengthening family relationships” by changing relationships between children and parents (Diamond 2005; Horigan et  al. 2005). This might include changing communication patterns, including conflict resolution, or restructuring roles. Other approaches to family therapy might have more specific, task-focused goals, such as “prevent out of home placement,” “decrease severe antisocial behaviors,” or “provide psychoeducation” (Henggeler 2002; Henggeler et al. 2009, Wells 2005). These second-order goals, such as improving family relationships, need to be clearly connected to the original problems that brought families into treatment. A further issue arises when the goals of the setting for the provision of ser vice conflict with the goals of the families who receive the ser vice. For example, family-based ser vices are often described as having the goal of “empowering families.” Yet the funding for such ser vices is usually at the public expense and not intended for reaching family goals per se but at least in part influenced by societal goals of reducing costs of unnecessary out-of-home placement. Early evaluation of the effectiveness of family-based ser vices tended to focus more on counts of unnecessary placements prevented than on measures of family functioning (Frankel 1988). Hence, empowerment might occur if family goals are agreed upon that are compatible with a larger system goal of preventing unnecessary out-of-home placement. Many clients of familybased ser vices may be readily convinced that in-home ser vices are a means to reaching their goals and hence may not be nonvoluntary, or only temporarily so. Parents of teens, however, frequently seek out-of-home placement and may accept home-based ser vices as a second-best alternative. 4. The resurrection of resistance. Conflicts between client-perceived goals and hidden second-order goals held by the practitioner can resurrect resistance. Perhaps because of the interactional nature of family work and the influences of a systems perspective, family practitioners have been more likely to consider family resistance in terms of interactional phenomena and less likely to attribute resistance to individual pathology. Consequently, use of the term “resistance” has had less negative connotations, including less blaming and more consideration of resistance as an expected phenomenon that is the practitioner’s responsibility to address. Coming from a more traditional family systems perspective, de Shazer (1982) suggests that the concept of resistance is a by-product of a homeostatic systems view in which resistance is seen as an individual condition opposed to change rather than a product of therapistfamily interaction. De Shazer reframes resistance as the family’s unique way of cooperating. In this view, the family tries to resolve problems in the best

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Practice Strategies for Work with Involuntary Clients way they know how. This form of cooperation is seen as a process rather than a condition (ibid.). The re sistance concept, according to de Shazer, locks practitioners into a relationship in which, like opposing tennis players, they need to win in order to control the relationships. De Shazer’s reframed view positions both the practitioners and the family on the same side of the net, trying to defeat the problem (de Shazer 1984). In contrast, within mandated treatment, resistance is often not just recognized, but pathologized. Families who are noncompliant with mandated ser vices often experience significant negative consequences (Reich 2005; Smith 2008). For example, within child protection, resistance is often seen as an indicator that parents have not recognized the significance of the problem and are not willing to make changes. The role of ser vice providers in the development and maintenance of this resistance is often not recognized or acknowledged (Mirick 2012). 5. Role conflicts. The role of the practitioner varies with the system he or she represents. For example, the purpose for public agency contact may be different than in child guidance and hence the practitioner may be a power broker or part of the system of power. Anderson and Stewart suggest that larger systems make family therapy difficult because they place therapists in the position of both therapist and policeman. When the practitioner is asked to do family therapy while simultaneously playing a role in which they must hold a threat over the family’s head that their income may be withdrawn or one or more family members will be placed in a foster home or institution . . . Families are understandably hesitant to admit a potentially threatening professional into their confidence. They really would have to be crazy to welcome such an intrusion into their lives . . . conducting any kind of therapy under these conditions must seem rather like trying to slay a very large dragon with a very short sword. (1985:223–224) These role conflicts are further complicated when the practitioner’s agenda differs from that of the family. Practitioners frequently perceive problems differently than family members and feel more commitment to change them (Sotero et al. 2016; Sykes 2011). When the practitioner takes on the role of the mastermind searching for leverage in changing a recalcitrant system, families may feel discounted. If the family’s view is discounted, the alliance can be disrupted and the relationship can quickly become adversarial (Forrester and Harwin 2011; Rosenberg 2000). While use of deceptive means may be effective in the short run, it is unethical not to provide fully informed consent (Regehr and Antle 1997). Further role conflicts occur when practitioners assume multiple roles with different family members. Practitioners may be engaged in individual treatment with residents of treatment institutions at the same time as they are acting as family therapists with other members of the

Work with Involuntary Families family. Child protection workers may be balancing engaging parents while also always considering the safety of the child. Anderson and Stewart suggest that it may be possible to play such dual roles if the family is positively motivated for the contact, if the practitioner can mobilize adequate support systems, if caseloads are small enough to permit frequent contact, and if the practitioners can manage to demonstrate to families that they genuinely care about what happens to family members (Anderson and Stewart 1985). 6. Ethical issues. As suggested in the preceding text, much work with families starts with a request that the behavior of one family member be “fixed.” If in fact that person’s behavior is the target for work, then this needs to be stated explicitly as the goal in order to be transparent about ser vices provided. It is important to provide true informed consent with mandated treatment and be sure to be clear about the benefits, costs, and goals of treatment (Regehr and Antle 1997). If, instead, the practitioner revises the identified problem to include the family as a whole, such as negative family relationships (Diamond 2005), then this needs to be done in a transparent, straightforward manner. De Jong and Berg (2001) emphasize the importance of keeping the client’s right to self-determination at the forefront of the work; even when collaboration strategies can be effectively used to increase client compliance with a treatment mandate, this kind of client manipulation should be avoided and self-determination should be emphasized instead (de Jong and Berg 2000; Miller and Rollnick 2012). Informed consent can be difficult with families in nonvoluntary situations. Pursuit of informed consent, including explanation of roles, possible discomforts, and risks as well as benefits, may greatly assist the engagement process and are important for ethical practice with involuntary clients (Regehr and Antle 1997). However, if the practitioner is inclined to use methods that rely on secrecy for their success, failure to describe them limits true informed consent. Such secrecy may be useful with voluntary families who have agreed upon the goals for treatment since they have the option of leaving if they are opposed to the methods. Additional ethical issues are raised when families are court-ordered to receive treatment on issues that differ from those that arise through the practitioner’s own assessment. Manipulation of involuntary families who pay a cost for withdrawing from treatment violates the limited provisions for paternalism.

Emergence of Family-Centered Interventions for Involuntary Families Ser vice delivery interventions designed to address families in a broader systems perspective have emerged that address many of the concerns raised earlier about involuntary work with families. Across many types of work with

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Practice Strategies for Work with Involuntary Clients families, a strengths-based approach is often incorporated into the policy and into the work with families. A strengths-based approach (Saleeby 1992, 2004) is based in the assumption that all families have strengths, resources, and skills. The practitioner collaboratively works with the client or family to help them discover and apply these strengths to resolve the presenting problem. Client empowerment and self-determination are key characteristics of this approach. Cowger (1994) identifies the importance of empowering all clients through the strengths perspective. Client empowerment is particularly important for involuntary clients because they enter the working relationship in a position of relatively less power than voluntary clients. A solutions-focused approach (de Shazer 1991) is one type of strengths-based approach that has been successfully used to work with both voluntary and involuntary families (Berg and Kelly 2000; Lloyd and Dallos 2008; Thompson et al. 2009). A solutions-focused approach supports clients in accessing internal and external resources to effectively address current problems. The approach includes well-known techniques such as scaling questions and the miracle question. The miracle question is a way to access clients’ conceptualization of a future without the problem. A practitioner asks the client a variation of this question: “Suppose, after you went to sleep tonight, a miracle happened and your problem disappeared. When you woke up in the morning, what would be different? How would you know that the problem was gone?” It can be combined with other approaches, such as a family therapy approach, as long as the practitioner adheres to the basic assumptions of the approach (Trepper et al. 2006). However, there are some limitations to the strengths perspective when it is applied to involuntary families. Sometimes techniques and strategies that are effective and empowering when used with voluntary clients do not work well with involuntary clients. For example, Rosenberg (2000) describes how the miracle question can emphasize the powerlessness of mandated clients, who often feel unable to change the problem which is defined by the referring agency or court. Many involuntary families are struggling with larger contextual issues, such as poverty, lack of resources, discrimination, and oppression. Berg and Kelly (2000) suggest that the ideals of the strengths perspective, that people have the internal resources to make necessary changes with support from the practitioner, may not address the significant lack of necessary resources experienced by many of these families. Child Protective Services The family preservation movement is another example of a strengths-based approach. It was influenced by approaches such as the Homebuilders Model, which focused on the delivery of intensive ser vices in the home or at a place convenient to families (Kinney, Haapala, and Booth 1991). In this model, child safety concerns are seen as existing in a larger systemic context of stresses on

Work with Involuntary Families caregivers such that counseling ser vices are matched with concrete or hard services. The movement gained considerable prominence with the promise that such ser vices could successfully avoid unnecessary out-of-home placement while strengthening families. Early evaluations bore promising results but later studies reported that the provision of such ser vices did not necessarily predict lower rates of placement than traditional investigative and case management ser vices did (Scheurman, Rzepnicki, and Littell 1994). Reviewers have suggested that these disappointing results were in part due to low overall rates of out-of-home placement even among the traditional ser vices and mixed results with different subpopulations such that families with certain types issues did better than other families (Littell and Scheurman 2002). For example, families in which child abuse was a factor responded better to such ser vices than did families in which neglect or substance abuse was a factor (ibid.). Since that time, child protection agencies have begun to adopt practice frameworks that are family-centered and strength-based (Kemp et al. 2014). The strengths perspective has been officially embraced by the field of child protection. Family-centered practice (FCP) is a strengths-based approach that has been widely used within child protection (Allen and Petr 1996; Children’s Bureau undated). FCP focuses on the preservation of the family relationships, if possible, by working with the whole family versus one family member, collaboratively working with families, empowering families’ decision making and respecting their self-determination, identifying and working with families’ strengths, and providing individualized ser vices that respond to each family’s unique needs (Allen and Petr 1996). However, child protection ser vices are engaged when a child’s safety is endangered due to alleged child abuse or neglect (Turnell and Edwards 1999; Popple and Vecchiolla 2007). The dual role of a child protection worker, to maintain the child’s safety and engage collaboratively with parents to preserve the family, when possible, is often challenging for child protection workers to balance (Oliver and Charles 2015). Sometimes practitioners identify using the strengths perspective, but in reality they are using only some components of this perspective due to the challenges of balancing their sometimes conflicting roles (Lietz 2011; Oliver and Charles 2015). This creates significant challenges in determining the effectiveness of this approach (Lietz 2011). Specific strengths-based approaches have been adapted within child protective ser vices, for example, one practice that has become increasingly popular in recent years (Asscher et al. 2014), family group conferencing, draws together family members, agency officials, and support persons designated by the family to develop a plan to address family concerns (Marsh and Crow 1998; Burford and Hudson 2001). This approach emphasizes the collaborative creation of a plan for children, including family participation (Asscher et al. 2014). Family group conferencing has shown promise for cultural sensitivity, as it allows family members to designate the persons most significant to their

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Practice Strategies for Work with Involuntary Clients problem-solving and considered resources as well as incorporating family rituals meaningful to the family (Waites et al. 2004). Alternative or family assessment response (AR) is another ser vice in which families with a lower priority of danger are given the option of having an AR worker assist them in identifying and addressing family needs (Alternative Response in Minnesota 2006). Similar to earlier family preservation ser vices, AR focuses on working together with families in their own homes to reduce child safety dangers. Early results have been promising (ibid.). Juvenile Justice System An intervention based on similar systemic principles has emerged to serve the families of adolescents in the juvenile justice system (Henggeler et al. 2002, 2009). This approach for working with adolescents with antisocial behaviors and their families is based on newer approaches in the field of family therapy, which are more attuned to the process of client engagement and the therapeutic alliance, emphasizing the family’s strengths, eliciting client goals, remaining aware and sensitive to the family’s and community’s culture and values, and focusing on the impact of larger systems on the youth’s behaviors (Henggeler et al. 2009). Based on the premise that adolescent antisocial behavior relates significantly to interactions with four systems (intrafamily, school, peer, and community systems), multisystemic therapy (MST) provides intensive, in-home ser vices addressed to family concerns and focused on negotiating interactions with the key systems maintaining the problem (ibid.). Research on MST has accumulated evidence that delinquency is reduced for several years after intervention (Henggeler et al. 1997, 2009). Critics suggest, however, that the MST intervention, however powerful with the microenvironment, still encounters families struggling to survive in hostile neighborhood and community environments (Littell 2006).

Common Factors in Family Systemic Interventions The approaches described in the preceding text have implemented similar principles. They posit that many family problems, including adolescent behavioral problems and child protection concerns are best understood in a larger systemic context. Families in these circumstances should be joined around issues of common concern, building on strengths and resources identified by the family. Ser vices need to be delivered in a manner convenient to the family and include prompt access to emergency ser vices.

Work with Involuntary Families Engagement Critical to each of the preceding approaches is the manner in which they engage family members. Each approach attempts to join families in areas of common concern. The complicated piece of engagement with families is that the practitioner not only needs to engage with the family as a group, but that he or she needs to engage with each family member as well. Some family members are unlikely to see problems in the same way that other family members do. For example, in MST, adolescents often see the problem as “getting off probation” or “get Mom off my back” (Henggeler et al. 2002). Engaging adolescents around these concerns makes it more likely that they will become at least nonvoluntary. Proponents of the approach, however, candidly note that some adolescents will find the agreement of other family members around curbing their behavior to mean, at least in the short term, losing many things they value and gaining little (ibid.). For example, there may be consensus among other family members around curbing contact with certain peers, attending school, and avoiding drug usage. Each of these goals may represent a loss of freedom for the adolescent, at least in the short term; the loss of multiple freedoms like this may elicit or increase reactance.

Overview of Adaptation for Work with Involuntary Families Earlier practitioners who worked with involuntary families had to choose among three alternatives: approaching involuntary families within a voluntary family therapy format; rejecting family treatment perspectives in involuntary settings and roles; or blending family therapy perspectives with involuntary work on a case-by-case basis. The family-centered alternatives in child welfare and juvenile justice have provided a fourth alternative that includes family treatment perspectives within a larger ecosystemic perspective in which the family is one of several systems. This alternative includes work with individual family members and on environmental problems, and includes settings and roles in which family therapy is not the ser vice offered. Guidance for specific steps in the engagement phase with involuntary families are presented here since many approaches suggest that negotiation should take place, yet fail to show how to negotiate or persuade family members to engage in contact. Interventions beyond the engagement process are described more briefly because it is assumed that the primary issue with involuntary families is achieving at least semivoluntary status. When semivoluntary status is achieved, a variety of voluntary approaches may be consulted for further guidelines. Primary assumptions underlying work with involuntary families include the following:

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Practice Strategies for Work with Involuntary Clients 1. A relevant systems perspective encompasses not only the practitioner and family but also the forces that impel the family into contact with the practitioner. It is useful in most initial contacts between families and helping practitioners to assume that one or more family members have been impelled into contact at least in part by mandated, formal, and informal pressures. Such a perspective would include exploration of the pressures felt by Christine and Mrs. King in initiating contact. 2. The practitioner or agency may become a source of formal pressure when attempts are made to redefine or reframe voluntary requests to focus on family issues. It is useful to recognize that when the family-based ser vice practitioner made an offer for ser vice that differed from the request made by Mrs. King, formal nonvoluntary pressures were being exerted. Further, if the practitioner works on a hidden agenda to effect change in problems that family members have not chosen to work on, the practitioner may be creating additional pressures for families. 3. Role conflicts can occur between family wishes and practitioner responsibilities to outside constituencies. For example, practitioner responsibilities to make recommendations on such issues as child placement can create role conflict. In the aforementioned example, family-based ser vices are often offered as part of an agency policy of preventing unnecessary out-of-home placement. This policy can be compatible with family wishes or contrary to them. With these assumptions as a basis, guidelines are provided for initial work with involuntary families, including (1) initiating contact, (2) pursuit of informed consent, and (3) contracting. 1. Initiating contact. Guidelines for initiating contact vary according to whether the family is ostensibly self-referred or referred by others. Contact with families who are not self-referred begins with step A while contact with selfreferred families begins with step B (figure 10.1). Step A. If the family is not self-referred, family members are entitled to an account of the circumstances that have led to that contact. Transparency is important. For example, any requirements or information from the referral source about suggested issues should be shared to avoid the practitioner working off a hidden agenda. Second, client options, rights, and choices in response to this referral should be clarified. Hence, family members need to be made aware of their choices and the potential consequences of such choices. Family members should have an opportunity to share their views of the circumstances that led to contact. When this step is completed, the practitioner can proceed to step B with families who are not selfreferred. For example, in the following exchange, a family-centered

Work with Involuntary Families Figure 10.1 Initiating contact in a potentially nonvoluntary situation Initiating contact

When not self-referred * share requirements, options * solicit views of why family

When family is self-referred * solicit views including those of potential “target” person

thinks referral occurred

Pursuit of informed consent * assess strength of external pressure * make persuasive case about costs and benefits

* clarify free choices and explore options to continuing contact

* facilitate a tentative decision about continuing contact

ser vice team follows up on the initial contact made at the beginning of the chapter.* practitioner: I am glad that you both were willing to meet with us today. I understand that you met with Karen last week to talk about some of the concerns that you were having about how things were going here in the home. Betty and I are a home-based ser vice team and we came here today to talk to you more about your situation and the choices that you have as you and Christine decide whether you want to continue with this. I understand that you had some reservations about whether you thought this was the best thing for you to do. You talked with Karen about having explored things on your own. You’ve gone to a number of other counselors, and you haven’t felt as though things have lasted, so you have some reservations. I would think, Christine, you may have some reservations about how this might work for you as well. * A videotape of the interview in which this dialogue takes place, entitled Contracting for Home-Based Services, is available from Alexander Street at https://alexanderstreet.com/. See appendix for details.

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Practice Strategies for Work with Involuntary Clients Step B. If the family is self-referred, the practitioner begins by soliciting the views of family members about what they see as concerns and eliciting their views about what they would like to see accomplished. Practitioners should be sensitive to suggestions of pressured contact in their presentation of concerns. If the request includes a desire that a family member be “fixed,” this step includes asking that “target” person to state their view of concerns. This may also take the form of separate interviews with adolescents or children if they are unwilling or unable to share those concerns with the family. 2. Pursuit of informed consent. On hearing the circumstances that have led family members into contact, the practitioner can attempt to enhance voluntarism by pursuing informed consent. This involves several steps: (a) assessing the strength of pressures and requirements; (b) making a persuasive case about the benefits and costs of continuing with the practitioner; (c) exploring options to continuing contact; and (d) facilitating a tentative decision about whether to continue. a. Assessing the strength of external pressures. If the above steps have uncovered pressures experienced by one or more family members, then the scope of those pressures can be assessed. For example, if contact is court ordered, then the specific requirements of that order for the family and practitioner should be clarified, including the consequences of noncompliance with court orders; full informed consent should be included in the discussion (Regehr and Antle 1997). Similarly, any nonnegotiable agency policies should be shared. For example, in the case of a family preservation program, the ground rules of working within a framework of time-limited contact toward the goal of preserving the family system would be described. In the case of an attachmentbased family treatment program for adolescent suicidal ideation, the theoretical assumptions and beliefs of that program are shared. As a requirement of that program, parents will need to actively participate actively, meeting individually with the clinician to complete work focused on learning “emotionally focused parenting skills” (Diamond et  al. 2010; Diamond, Siqueland, and Diamond 2003). When there is informal family pressure on a reluctant individual, coerced participation by the practitioner is unethical (Regehr and Antle 1997). It is also likely to increase reactance in the family members feeling pressured. The practitioner can, however, strongly encourage a family member to attend at least one session to discover what contact may offer. The practitioner can also explore the reasons contributing to that person’s reluctance. Finally, the practitioner should clarify the extent of involvement expected. Will it involve individual sessions, such as in attachment based family therapy to treat adolescents with suicidal ideation (Diamond et al., 2003, 2010) or might it just involve participation as an observer so that all family members are present.

Work with Involuntary Families b. Making a persuasive case about the benefits and costs of continuing with the practitioner. Families often feel ambivalent about ser vices. Families seeking residential placement for adolescents with behavioral challenges want problem relief and often see placement as the only alternative. Yet they often feel pain, guilt, and a sense of failure in pursuing this alternative. Family-based ser vices can be presented as an alternative option (Henggeler et al. 2002). Family members can be assisted in making an informed decision by knowing about the costs and benefits of the ser vice that the practitioner can offer (Regehr and Ante 1997). Arguments are more likely to be persuasive when they relate to values, attitudes, or goals that family members already hold. For example, in the case of family-based ser vices, connection of the ser vice offer to the problem expressed by the family should enhance its acceptance. Since out-of-home placement was a solution to a problem seen by Mrs. King, the practitioners can share Mrs. King’s concern with the problem without agreeing with her solution. They can empathize with the family duress that led to the request for help and offer to provide help with those problems. Other potential benefits of the ser vice can also be explained. For example, in the case of family-based ser vices, it can be explained that such ser vices are provided in the home at times agreeable to the families, without financial cost, that practitioners are available on a twenty-four-hour emergency basis, and that relief is often provided in a relatively brief time period. Potential costs and drawbacks of work with the family option should also be explored. For example, nonnegotiable policies of the agency or ser vice would be reviewed here, including sharing circumstances in which confidentiality would be violated, such as in mandated reporting of suspected abuse or neglect (Regehr and Antle 1997). Similarly, policies in some settings that require work with all members of a family should be explained and possible referral to settings with less restrictive policies considered. Practitioners are advised not to oversell the family option that they represent. For example, family suspicions of the effectiveness of family-based services in resolving all their problems are well founded and their disappointment at not receiving immediate relief from all concerns they raise should be acknowledged. The time-limited nature of that work should also be explained. Later in the session with Mrs. King and Christine, the practitioner comments in support of realistic expectations: practitioner: There wouldn’t be tremendous changes overnight. We would be working on making some changes, such that Christine might do some things differently, and you would also do some things differently. You would notice some little changes, at first. Our experience is that over time those changes can build up, so that the situation that brought you to the point a week ago where you thought you really couldn’t stay together with Christine wouldn’t be there anymore. On the other hand, I don’t think it’s

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Practice Strategies for Work with Involuntary Clients realistic to expect that all of the concerns that you and Christine have about each other are going to be cleaned up if we were going to work together ten weeks. c. Exploring options to continuing contact. Alternatives to family contact should be explored. In the case of legally mandated contact, families can be advised that they may return to court to attempt a change in the order. In nonvoluntary cases, other options, including not working with the practitioner, should be explored. Such options might include dealing with the problems on their own and exploring other forms of help. In the initial session between Karen and Mrs.  King, alternatives to home-based ser vices were explored. karen: I want to make sure that you are clear that you do not have to accept our ser vice. You can look at other possibilities. While foster placement by the county is not now an option, you could choose to explore private placement. If you feel as if you might do a better job working on these issues on your own, you would also be free to choose to do that. You could call parental stress lines for assistance. You might also get some respite help from a friend or relative. d. Facilitating a tentative decision about whether or not to continue family contact. A power struggle and adversary relationship often occurs at this point, as the practitioner increases pressure in response to family opposition. However, increasing efforts at persuasion can backfire on the practitioner and increase family resistance to ser vices. Reviewing options as described and facilitating a decision about whether to continue with contact demonstrates respect for the family process and does not proceed without their approval. Sometimes family members need time to make this decision. Family commitment to explore continuation even on a trial basis should be respected and seen as at least slightly increasing voluntarism. The option to pursue other directions should also be respected, however. For example, later in the followup session with Mrs. King and Christine, the practitioner asks the family for direction in considering their decision. practitioner: We are at a point now where you need to consider whether you want to continue working with us or go in another direction. We’ve identified some issues each of you have individually and then together. If we agreed to go ahead, then we would probably pick a specific issue to start with and see if we can get something going on that right away. I don’t know if it would be worthwhile for either of us to go much further in discussing home-based ser vices until you decide whether you want to give this a try or you want to go another direction.

Work with Involuntary Families 3. Contracting. Should the family be willing to pursue further contact at this time, the development of a contract can be explored. In the case of emergencies, such as a lack of basic necessities for food, shelter, or safety, the practitioner would proceed to help the family acquire needed resources before pursuing more formal contracting. The contract should include any nonnegotiable requirements such as provisions about confidentiality and sharing information, problems to be worked on, goals set, time limit, and methods to be used. Such contracting should enhance voluntarism and prevent focus on hidden agendas. a. Nonnegotiable requirements. Provisions for confidentiality and sharing of information should be included with all families. More specific requirements related to legal issues and requirements of the ser vice provision should also be clarified. For example, in the case of work with families who are involved with child protective ser vices, the limitations of confidentiality should be explicitly reviewed and clarified (Regehr and Antle 1997). Also, in family-based service, if ser vice is delivered under the overall premise of avoiding unnecessary out-of-home placement, that condition is shared in contracting, as well as any other legal requirements. For example: practitioner: We need to be clear that the ser vice together needs to take place within a goal of keeping Christine from having an unnecessary outof-home placement. In addition, there are laws about attending school and truancy that will influence what we do. b. Explore agreed-upon problems. Having set parameters of requirements and nonnegotiable conditions, the practitioner can proceed to pursue semivoluntary or voluntary status by assisting family members in identifying problems that family members now agree exist. This method is advised even in instances in which practitioners feel that reframing the problem or moving to another problem that the family has not expressed will be useful. The process should first follow original family conceptions of the problem in pursuit of problems that all family members now agree exist. Such original conceptions often locate the source and solution of the problem in the behavior of one person or a system outside the family. For example, parents tend to see the child as being at fault and feel blamed by other counselors, courts, or probation officers. On one level it is possible to join families on some concerns similar to the “get rid of the pressure” contracting strategy. Similarly, families who had expressed no other goals often agree to the goal of getting the court out of their lives (Rosenberg 2000). When family members locate the blame in the behavior of one person, the practitioner may accept that this is their view while ensuring that all family members can state their views. For example, when Mrs. King and Christine were asked for their views of problems, Mrs. King included that Christine was

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Practice Strategies for Work with Involuntary Clients truant and did not obey curfew; she had a “nasty attitude”; she had “bad friends;” and she did not take care of her younger brother or do other chores. Christine responded that her mother yelled and tried to control her too much, did not respect her friends, and did not pay her for taking care of her younger brother. Mrs. King and Christine did not readily frame issues as family problems and blamed each other for problems that existed. The practitioners might look here for problems that both Mrs. King and Christine agree now exist. For example, both mention problems with her friends and with taking care of her brother. Hence, a first attempt at stating these problems in a more useful, nonblaming way would be to ask whether they would agree that “disagreement on Christine’s friends and her responsibilities in taking care of her younger brother” were concerns both shared. Reframing is used to recast problems in an interactional form or to define the problem in a slightly different way (Reid 1985). Reframing is useful in constructing workable realities that can shift attitudes and make change possible (Robbins et al. 1996). Practitioners sometimes reframe by identifying patterns of interaction or other problems that the family has not considered. They may also attempt to cast problems in a more favorable light. For example, de Jong and Berg (2001) describe a client who is frustrated that her child is in a foster care placement. Berg and the client reframe the client’s problem together, going from “foster care placement” to “the child protection worker not understanding this mother’s commitment to her children” (de Jong and Berg 2001:367). This shifts the narrative and offers up new solutions to the problem. Schlossberg and Kagan (1988) describe a case example in which parents describe their child as “horrible, terrible.” The practitioner recognizes the family’s efforts and suggests that they have become exhausted by working so hard. In the following exchange, the practitioner working with Mrs. King and Christine attempts to reframe issues expressed by them as a lack of trust. practitioner: I’m wondering if trust and not knowing what to believe is an issue with both of you. You don’t know when you can trust Christine, and you’re feeling that your mother doesn’t trust you about your friends. Is the lack of trust between you something you are concerned about? One danger that practitioners need to be aware of in reframing by casting difficulties at a higher level of abstraction is that it may not capture what the family sees. They may reject the reframing or agree only superficially. Consequently, the practitioner should phrase the reframe tentatively to determine whether it is relevant to family members. c. Explore reciprocal or individual problems. Some families do not accept such reframing and persist with noninteractional views. This is particularly frequent in instances in which adolescents have a history of law violations, and blaming of the adolescent may have been reinforced by corrections systems.

Work with Involuntary Families It is sometimes possible in such instances to pursue reciprocal or quid pro quo exchanges. In the above instance, Mrs. King considered trust to be a lesser issue than obedience to house rules and school attendance. Meanwhile, Christine continued to be concerned about freedom to see her friends and respect for them. An exchange was established in which Christine could earn time with her friends in the home and noninterference with them if she would increase her school attendance to three times in the next week. Some problems relate primarily to one individual. However, these individual concerns may have a major impact on the concerns of the family and the system as a whole. For example, Bob, a stepparent, did not feel respected by his stepson who had returned home recently from foster care. Aggravating the problem was the fact that Bob had lost his job and hence was around the house more. Bob now felt more called upon to take a disciplinary role that had previously been played by the mother. Instead of dismissing the problem of employment, session time could be taken to assist Bob in making plans to seek employment and supporting his efforts. This chapter has suggested that nonvoluntary work with families occurs more frequently than is usually thought to be the case. While family therapy perspectives and treatment methods can be useful in work with involuntary clients, we have suggested that greater attention to the role of pressures impelling family members into contact is needed to enhance effectiveness and ethical contact. Many families are approached with family therapy concerns that do not fit their request and they are not persuaded that their concerns will be met through reframing. Problems can occur if alternative choices are not emphasized at the beginning of contact and when theories of underlying family dynamics lead the practitioner to focus on issues that have not been agreed upon with family members. Evaluation of family outcomes becomes a critical issue when the practitioner is attempting to achieve goals other than those that have been agreed upon. Some suggest that the practitioner has an ethical responsibility to place high priority on the assessment of desired change as seen by family members. There is a range of opinion about the importance of such change. Some see resolution of the family-defined problem as the sole criterion for assessing outcome; others see it as the most important, while others consider such resolution as one criterion among many. This may depend on the level of voluntariness of the services. For example, for services mandated by child protective services, an evaluation usually includes the client’s compliance with treatment mandates as well as the actual behavioral changes (Reich 2005; Smith 2008). Work on hidden agendas may lead to confusion in outcomes and lacks the transparency required in collaborative work with clients. While practitioners and families engaged in voluntary family treatment can perhaps afford less specificity in goals, vague goals in involuntary contact are likely to be costly to the families.

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Practice Strategies for Work with Involuntary Clients This chapter has made beginning steps in constructing an involuntary perspective for work with families by expanding the systems perspective to include the pressures that impel family members into contact and the practitioner or setting pressures that occur after contact is initiated. Practice guidelines have been suggested that are designed to assist in more informed choices in continuing family contact and enhancing voluntarism. Guidelines have not been provided for contact after the engagement phase, since many voluntary approaches can be useful at this point with originally nonvoluntary families. The guidelines do not resolve continuing issues in the potential conflict between attention to second-order change goals such as assisting a family in becoming less enmeshed or more individualized and commitment to the goals that the family explicitly agrees to. Should such commitment to second-order goals conflict with agreedupon goals, family opposition may be an expected by-product. At worst, families may be illegally and unethically forced to work on problems that are neither their concern nor legally mandated. Practitioner insistence on goals that are not legally required, setting requirements, or family concerns is unethical and likely to be ineffective. There is unlikely to be motivational congruence in such situations and insistence on practitioner-defined goals that exceed appropriate limits to self-determination and restricted use of paternalism is unethical, as discussed in earlier chapters. While practitioners working with voluntary families can be somewhat sure that those families will raise objections or withdraw from contact if their own identified goals are not addressed, practitioners working with nonvoluntary and mandated families have no such assurance. While specific examples have been provided for settings such as familybased ser vice, more specific adaptations are needed for other potentially nonvoluntary settings such as discharge planning. The next chapter will continue adaptations of the involuntary perspective for work with groups.

Discussion Questions 1. How often do you find that meeting with families entails negotiating different viewpoints? Are identified clients entitled to their viewpoint? 2. Family ser vices frequently entail a parent bringing in a child or adolescent to be “fixed.” That child or adolescent may be treated as an involuntary target of change unless there are systematic, open efforts to include their viewpoint. What practices have you seen to acknowledge and integrate work from the viewpoint of the persons brought by others to be “fixed”? 3. How extensively do you consider alternatives with individuals and families including rejecting ser vices?

Work with Involuntary Families 4. Common factors in family approaches to work with families in nonvoluntary situations have included increasing accessibility of ser vices and coordinating with hard or concrete ser vices. Are these part of your ser vice delivery plan?

References Allen, R. I., and C. G. Petr. 1996. “ Toward Developing Standards and Mea surements for Family- Centered Practice in Family Support Programs.” In Redefining Family Support: Innovations in Public-Private Partnerships, eds. G. H. S. Singer, L. E. Powers, and A. L. Olson, 57–85. Baltimore, MD: Brookes Publishing. Alternative Response in Minnesota. 2006. “American Humane.” Protecting Children 7 (1): 1. Altman, J. C. 2008. “Engaging Families in Child Welfare Ser vices: Worker versus Client Perspectives.” Child Welfare 87 (3): 41–61. Anderson, C., and S. Stewart. 1985. Mastering Resistance: A Practical Guide to Family Therapy. New York: Guilford. Asscher, J. J., S. Dijkstra, G. J. J. Stams, M. Deković, and H. E. Creemers. 2014. “Family Group Conferencing in Youth Care: Characteristics of the Decision Making Model, Implementation and Effectiveness of the Family Group (FG) Plans.” BioMed Central Public Health 14: 1–9. Berg, I. K., and S. Kelly. 2000. Building Solutions in Child Protective Services. New York: W. W. Norton. Burford, G., and J. Hudson. 2001. Family Group Conferencing. New York: Aldine de Gruyter. Children’s Bureau (undated). Family- Centered Practice. Retrieved from https://www .childwelfare.gov/topics/famcentered /. Cowger, C. D. 1994. “Assessing Client Strengths: Clinical Assessment for Client Empowerment.” Social Work 39 (3): 262–268. De Jong, P., and I. K. Berg. 2001. “Co-constructing Cooperation with Mandated Clients.” Social Work 46 (4): 361–374. de Shazer, S. 1982. Patterns of Brief Family Therapy: An Ecosystemic Approach. New York: Guilford Press. de Shazer, S. 1984. “Post-Mortem: Mark Twain Did Die in 1910.” Family Process 23 (1): 20–21. de Shazer, S. 1991. Putting Difference to Work. New York: W. W. Norton. Diamond, G., L. Siqueland, and G. M. Diamond. 2003. “Attachment-Based Family Therapy for Depressed Adolescents: Programmatic Treatment Development.” Clinical Child and Family Psychology Review 6 (2): 107–127. Diamond, G. S. 2005. “Attachment-Based Family Therapy for Depressed and Anxious Adolescents.” In Handbook of Clinical Family Therapy, ed. J. L. Lebow, 17–41. Hoboken, NJ: Jon Wiley and Sons. Diamond, G. S., M. B. Wintersteen, G. K. Brown, G. M. Diamond, R. Gallop, K. Shelef, and S. Levy. 2010. “Attachment-Based Family Therapy for Adolescents with Suicidal Ideation: A Randomized Controlled Trial.” Journal of the American Academy of Child and Adolescent Psychiatry 49 (2): 122–131. Dumbrill, G. C. 2006. “Parental Experience of Child Protection Intervention: A Qualitative Study.” Child Abuse and Neglect 30 (1): 27–37. Forrester, D., and J. Harwin. 2011. Parents Who Misuse Drugs and Alcohol: Effective Interventions in Social Work and Child Protection. Chichester, UK: Wiley-Blackwell.

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Practice Strategies for Work with Involuntary Clients Forrester, D., D. Westlake, and G. Glynn. 2012. “Parental Resistance and Social Worker Skills: Towards a Theory of Motivational Social Work.” Child and Family Social Work 17 (2): 118–129. Frankel, H. 1988. “Family- Centered, Home-Based Ser vices in Child Protection: A Review of the Research.” Social Service Review 62 (1): 137–157. Gibson, M. 2014. “Shame and Guilt in Child Protection Social Work: New Interpretations and Opportunities for Practice.” Child and Family Social Work 20 (3): 333–343. Girvin, H. 2004. “Beyond ‘Stages of Change’: Using Readiness for Change and CaregiverReported Problems to Identify Meaningful Subgroups in a Child Welfare Sample.” Children and Youth Services Review 26(10): 897–917. Gopalan, G., L. Goldstein, K. Klingenstein, C. Sicher, C. Blake, and M. M. McKay. 2010. “Engaging Families into Child Mental Health Treatment: Updates and Special Considerations.” Journal of the Canadian Academy of Child and Adolescent Psychiatry 19 (3): 182–196. Henggeler, S., G. Melton, M. Brondino, D. Scherer, and J. Hanley. 1997. “Multisystemic Therapy with Violent and Chronic Juvenile Offenders and Their Families: The Role of Treatment Fidelity in Successful Dissemination.” Journal of Consulting and Clinical Psychology 65 (5): 821–833. Henggeler, S. W., S. K. Schoenwald, C. M. Borduin, M. D. Rowland, and P. B. Cunningham. 2009. Multisystemic Therapy for Antisocial Behavior in Children and Adolescents. 2nd ed. New York: Guilford Press. Henggeler, S., S. Schoenwald, M. Rowland, and P. Cunningham. 2002. Serious Emotional Disturbances in Children and Adolescents: Multi-systemic Therapy. New York: Guilford Press. Horigan, V. E., L. Suarez-Morales, M. S. Robbins, M. Zarate, C. C. Mayorga, V. B. Mitrani, and J. Szapocznik. 2005. “Brief Strategic Family Therapy for Adolescents with Behavior Problems.” In Handbook of Clinical Family Therapy, ed. J. L. Lebow, 73–102. Hoboken, NJ: Wiley. Ingoldsby, E. M. 2010. “Review of Interventions to Improve Family Engagement and Retention in Parent and Child Mental Health Programs.” Journal of Child and Family Studies 19 (5): 629–645. Kemp, S. P., M. O. Marcenko, S. J. Lyons, and J. M. Kruzich. 2014. “Strength-Based Practice and Parental Engagement in Child Welfare Ser vices: An Empirical Examination.” Children and Youth Services Review 47(1): 27–35. Kinney, J., D. A. Haapala, and C. Booth. 1991. Keeping Families Together: The Home-Builders Model. New York: Aldine-de Gruyter. Lebow, J. L. 2005. “Family Therapy at the Beginning of the Twenty-First Century.” In Handbook of Clinical Family Therapy, ed. J. L. Lebow, 1–16. Hoboken, NJ: Wiley. Lietz, C. A. 2011. “Theoretical Adherence to Family Centered Practice: Are Strengths-Based Principles Illustrated in Families’ Descriptions of Child Welfare Ser vices?” Children and Youth Services Review 33(6): 888–893. Littell, J., and H. Girvin. 2004. “Ready or Not: Uses of the Stages of Change Model in Child Welfare.” Child Welfare 83 (4), 341–365. Littell, J., and H. Girvin. 2006. “Correlates of Problem Recognition and Intentions to Change Among Caregivers of Abused and Neglected Children.” Child Abuse and Neglect 30 (12): 1381–1399. Littell, J., and J. Scheurman. 2002. “What Works Best for Whom? A Closer Look at Intensive Family Preservation Ser vices.” Children and Youth Services Review 24 (9): 673–699. Littell, J. H. 2006. “The Case for Multisystemic Therapy: Evidence or Orthodoxy?” Children and Youth Services Review 28 (4): 458–472.Littell, J., and H. Girvin. 2002. “Stages of Change: A Critique.” Behavior Modification 26 (2), 223–273.

Work with Involuntary Families Lloyd, H., and R. Dallos. 2008. “First Session Solution-Focused Brief Therapy with Families Who Have a Child with Severe Intellectual Disabilities: Mothers’ Experiences and Views.” Journal of Family Therapy 30 (1): 5–28. Marsh, P., and G. Crow. 1998. Family Group Conferences in Child Welfare. Oxford, UK: Blackwell Science. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Preparing People for Change. New York: Guilford Press. Mirick, R. 2012. “Reactance and the Child Welfare Client: Interpreting Child Welfare Parents’ Resistance to Ser vices Through the Lens of Reactance Theory.” Families in Society: The Journal of Contemporary Social Services 93 (3): 165–172. Nock, M. K., and C. Ferriter. 2005. “Parent Management of Attendance and Adherence in Child and Adolescent Therapy: A Conceptual and Empirical Review.” Clinical Child and Family Psychology Review 8 (2): 149–166. Oliver, C., and G. Charles. 2015). “Enacting Firm, Fair, and Friendly Practice: A Model for Strengths-Based Child Protection Relationships.” British Journal of Social Work 46 (4): 1009–1026. Popple, P., and F. Vecchiolla. 2007. Child Welfare Social Work: An Introduction. Boston: Pearson. Regehr, C., and B. Antle. 1997. “Coercive Influences: Informed Consent in Court-Mandated Social Work Practice.” Social Work 42 (3): 300–306. Reich, J. A. 2005. Fixing Families: Parents, Power, and the Child Welfare System. New York: Taylor and Francis. Reid, W. 1985. Family Problem Solving. New York: Columbia University Press. Rempel, M., and C. D. Destefano. 2002. “Predictors of Engagement in Court Mandated Treatment: Findings at the Brooklyn Treatment Court, 1996–2000.” Journal of Offender Rehabilitation 33 (4): 87–124. Robbins, M. S., J. F. Alexander, R. M. Newell, and C. W. Turner. 1996. “The Immediate Effect of Reframing on Client Attitude in Family Therapy.” Journal of Family Psychology 10 (1): 28–34. Rosenberg, B. 2000. “Mandated Clients and Solution-Focused Therapy: ‘It’s Not My Miracle.’ ” Journal of Systemic Therapies 19 (1): 90. Saleeby, D. 1992. The Strengths Perspective for Social Work Practice. London: Longman Publishing. Saleeby, D. 2004. “The Power of Place.” Families in Society 85 (1): 7–16. Santiago, C. D., A. K. Fuller, J. M. Lennon, and S. H. Katoaka. 2016. “Parent Perspectives from Participating in a Family Component of CBITS: Acceptability of a Culturally Informed School-Based Program.” Psychological Trauma: Theory, Research, Practice, and Policy 8 (3): 325–333. Santisteban, D. A., L. Suarez-Morales, M. S. Robbins, and J. Szapocznik. 2006. “Brief Strategic Family Therapy: Lessons Learned in Efficacy Research and Challenges to Blending Research and Practice.” Family Process 45 (2): 259–271. Scheurman, J., T. L. Rzepnicki, and J. Littell. 1994. Putting Families First: An Experiment in Family Preservation. New York: Aldine de Gruyter. Schlosberg, S., and R. Kagan. 1988. “Practice Strategies for Engaging Chronic Multi-problem Families.” Social Casework 69 (1): 3–9. Smith, B. D. 2008. “Child Welfare Ser vice Plan Compliance: Perceptions of Parents and Caseworkers.” Families in Society 89 (4): 521–532. Snell-Johns, J., J. L. Mendez, and B. H. Smith. 2004. “Evidence-Based Solutions for Overcoming Access Barriers, Decreasing Attrition, and Promoting Change with Underserved Families.” Journal of Family Psychology 18 (1): 19–35.

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Practice Strategies for Work with Involuntary Clients Snyder, C., and S. Anderson. 2009. “An Examination of Mandated versus Voluntary Referral as a Determinant of Clinical Outcome.” Journal of Marital and Family Therapy 35 (3): 278–292. Sotero, L., S. Major, V. Escudero, and A. P. Relvas. 2016. “The Therapeutic Alliance with Involuntary Families: How Does It Work?” Journal of Family Therapy 38 (1), 36–58. Sykes, J. 2011. “Negotiating Stigma: Understanding Mothers’ Responses to Accusations of Child Neglect.” Children and Youth Services Review 33 (3), 448–456. Thompson, S. J., K. Bender, L. C. Windsor, and P. M. Flynn. 2009. “Keeping Families Engaged: The Effects of Home-Based Family Therapy Enhanced with Experiential Activities.” Social Work Research 33 (2): 121. Trepper, T. S., Y. Dolan, E. E. McCollum, and T. Nelson. 2006. “Steve de Shazer and the Future of Solution Focused Therapy.” Journal of Marital and Family Therapy 32 (2): 133–139. Tuck, V. 2013. “Resistant Parents and Child Protection: Knowledge Base, Pointers for Practice and Implications for Policy.” Child Abuse Review 22 (1): 5–19. Turnell, A., and S. Edwards. 1999. Signs of Safety: A Solution and Safety Oriented Approach to Child Protection. New York: W. W. Norton. Waites, C., M. Macgowan, J. Pennell, I. Carlton-LeNay, and M. Weil. 2004. “Increasing the Cultural Responsiveness of Family Group Conferencing.” Social Work 49 (2): 29. Wells, K. C. 2005. “Family therapy for ADHD.” In Handbook of Clinical Family Therapy, ed. J. L. Lebow, 42–71. Hoboken, NJ: Wiley. Yatchmenoff, D. 2005. “Mea suring Client Engagement from the Client’s Perspective.” Research on Social Work Practice 15 (2): 84–96.

Chapter 11

Work with Involuntary Groups

Michael Chovanec

A dozen women offenders file into the meeting room of the halfway house where they live. The program director has contracted with group leaders from an outside agency to lead a group. They describe the purpose of the group as helping the women deal with issues of abuse and violence in their lives and emphasize that this is to be their group. As the leaders have led many such groups with women who were eager to attend, they are dismayed to discover the women sitting in baleful silence. After a while, the women interrupt the presentation to say, “This is a bunch of bull. Why do we have to be here? Can we smoke? What I care about is getting a job, going back to school, not talking about this violence bull.” Finally, after several attempts to get the group away from these “distractions” and back to its purpose, the women sink back into a bored, detached silence, gazing out the window, checking their cell phones, sending text messages, and commenting that this had better be over soon because they have places to go. These women are participating in an involuntary group in which members feel external pressure to participate. Involuntary groups are often attended by persons with problems such as abuse and neglect, domestic violence, chemical dependency, sexual offenses, delinquency, and youth gangs (Ritner 2004; Milgram and Rubin 1992; Yu and Watkins 1996; Buttell and Pike 2003; Cameron and Telfer 2004; Levinson and Macgowan 2004). It is often assumed that grouping together clients with the same situations and problems will provide a ripe arena for modifying behaviors and attitudes. And yet such

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Practice Strategies for Work with Involuntary Clients groups are often equally ripe for learning antisocial behaviors, include high dropout rates, and persist with seemingly endless conflict or sullen, passive aggressive behaviors. There are two kinds of involuntary groups. Mandated groups include legal external pressure, such as occurs with imprisoned sex offenders. Nonvoluntary groups are distinguished by nonlegal external pressure from family, friends, agencies, and referral sources. These pressures often create a feeling of coerced or constrained choice and many individuals choose attendance as a lesser evil. For example, Berliner (1987) notes that an individual in a group for drivers convicted of driving while intoxicated (DWI) might agree that, “You are here because you would rather try this than go to jail.” Similar nonvoluntary group transactions can occur between students and instructors in required courses and between agency staff and trainers brought in as “hired guns” to modify practitioner attitudes, beliefs, and behaviors. The degree of voluntarism also varies within groups. For example, the women offenders group described earlier might include some women who consider talking about abuse to be beneficial while others react to the group discussion as an unnecessary imposition. On the other hand, some ostensibly voluntary groups for teaching parenting skills often include both highly voluntary clients and others who attend “because my child welfare worker said it would be a good idea.” Such groups often include so-called hard-to-reach members who attend irregularly or participate minimally. Such “hard-toreach” members may not agree with the purpose of the group, doubt its effectiveness, and view attendance as the lesser of two evils (Breton 1985). This chapter presents guidelines for legal, ethical, and effective practice with involuntary groups. We begin by considering the decision to form an involuntary group in light of the formidable challenges expected in such groups. Application of these guidelines is designed to enhance commitment to both nonnegotiable goals and voluntary group concerns. Guidelines are provided for pregroup planning and beginning involuntary groups. While specific guidelines are not provided for postcontracting intervention with involuntary groups, four frequent phases of such work are identified. This guidance is designed to facilitate movement through stages of group development and fostering individual growth and change.1

1 This chapter draws extensively from R. Rooney and M. Chovanec, “Involuntary Groups,” in Handbook of Social Work with Groups, eds. C. D. Garvin, L. M. Gutierrez, and M. J. Galinsky (New York: Guilford Press, 2017), 237–254.

Work with Involuntary Groups

Introduction to Involuntary Groups Clients labeled hard-to-reach, resistant, and unmotivated are often referred to groups “for their own good” with the notion that they can learn new behaviors with and from one another. At the beginning of such groups, such potential members often share a reluctance or ambivalence about receiving help (Behroozi 1992). Men in particular, who are socialized to be stoic and express few emotions, often find themselves pressed to share embarrassing aspects of their private lives in a public arena with strangers (Whatules 2000). The ideal client in an involuntary group enters the group acknowledging responsibility for problems and ready to pursue change. More frequently, prospective group members are pessimistic about the possibility of change or deny a need for it (Behroozi 1992). Garvin defines “social control groups” as characterized by a lack of consensus on goals between members and the agency such that participation is often resisted for a long time or a common purpose is never reached (Garvin 1981). Mandated groups, as noted previously, are social control groups. Despite the lack of legal mandates, nonvoluntary groups too often begin and end as social control groups. Participants often react to the purpose of involuntary groups as mala prohibita, or wrongs due to law or statute rather than wrongs in themselves (Smith 1985). For example, men with domestic violence problems rarely enter groups thinking that violence is unjustified but rather acknowledging that it is illegal. They are rarely motivated to stop the abuse itself but rather to placate the court or their partners. These men are characterized as tending to externalize and blame others, to believe little can be done to change them, to doubt the severity of the problem, and to doubt the efficacy of ser vices (Brekke 1989). Similarly, members of substance abuse treatment groups often begin by expressing open or passive hostility, by externalizing their alcohol and drug use, and by feeling that they can handle problems on their own (Milgram and Rubin 1992). Hence, a challenge of involuntary groups is to assist members in coming to recognize problems such as violent behavior or alcohol and drug abuse as mala in se, or bad in itself (Smith 1985). Many involuntary groups never advance beyond a mala prohibita motivation and persist in a power and control phase marked by continual vying for control. A coercive symmetry sometimes referred to as the “confrontation– denial cycle” occurs with members whose behavior is described as resistant, denying the need to change while irritated leaders alternately resort to threats, cajoling, shaming, confrontation, and preaching in efforts to encourage participation (Murphy and Baxter 1997). The challenge for involuntary group leaders is to both meet the societal and institutional purpose of the group while assisting participants in addressing their own concerns in socially acceptable ways (Behroozi 1992).

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Practice Strategies for Work with Involuntary Clients Involuntary groups have advantages for work with involuntary clients as well as potential disadvantages and dangers. Potential Advantages of Involuntary Groups The following are seven potential advantages of the group modality for ethical and effective work with involuntary clients. 1. The group can be a source of support. Involuntary clients pressured to join involuntary groups frequently feel isolated, ashamed, and embarrassed by that pressure. The group setting can be less threatening than individual contact for many and support can be experienced by meeting others who share a similar situation. For example, many DWI clients share multiple crises such as loss of a driver’s license, pressures to enter alcoholism treatment, legal involvement, attorney and treatment fees, increased insurance premiums, as well as family and social problems. The common mandated condition can create a useful crisis that can be reframed as a challenge in place of the original perception that it is a threat or loss (Panepinto et al. 1982). 2. The group can provide an opportunity for in vivo learning. New skills, knowledge, and attitudes can be learned through instruction and practice and vicariously through observing the problem solving of others. A learning atmosphere can be stimulated that promotes both acceptance and risk taking. As members consider plans for change, they can be helped to reality test those plans in the group before trying them outside. 3. In addition to being helped, members can learn to be helpers. Mutual aid can be a powerful process within groups (Gitterman 2004). Involuntary group members can move into a helping role in which they provide support, challenge, and modeling for other members. These leadership qualities can be supported by facilitators to enhance change efforts within the group (Chovanec 2009). Group members can become more aware of their strengths and growth as well as pursue improvement in their individual problems. 4. Peers and successful former members can provide role models. Since attitudes and beliefs are more likely to be changed when the person attempting influence is considered likable, trustworthy, and expert, peers can often exert a more powerful influence than professional leaders. For this reason, many involuntary groups are “seeded” with successful former members or others further along in the change process (Garvin 1981). 5. Involuntary group members who have harmed others can meet with victims. Since involuntary group members who have acted to harm others are often unable to relate to harm caused, live presentations by victims can create empathy and acceptance of responsibility for harm. For example, presentations by victims of domestic violence can make denial of harm more difficult (van Wormer and Bednar 2002).

Work with Involuntary Groups 6. Group members can provide empathic, effective confrontation to stimulate dissonance. Groups can provide empathic confrontation when behaviors and attitudes persist that conflict with laws, policies, or client goals (Reid 1986). For example, when men with domestic violence problems continue to encounter circumstances in which they are tempted to use violence, peers can help them explore alternative ways for dealing with such situations (see chapter 12 in this volume). 7. Groups can be an efficient, cost-effective way to reduce waiting lists. The larger staff/participant ratio in groups allows settings to serve a larger population and hence reduce waiting lists. Indeed, orientation groups are sometimes helpful for those involuntary clients with domestic violence problems who are waiting to be served (Brekke 1989). Many involuntary groups never reach the goal of providing ethical, effective help that meets both societal and individual needs. In fact, groups can be noxious as well as beneficial (Schopler and Galinsky 1981). Most of the aforementioned advantages can be reversed to describe six dangers of involuntary groups. 1. Involuntary groups often proceed with a completely imposed, unshared agenda. Too often, involuntary groups proceed with an externally imposed agenda in which compliance is maintained by fear of punishment rather than by positive attraction to benefits of the group. Common goals and group process are often ignored in pursuit of individual change. Mixed messages are communicated through suggestions that “this is your group,” as in the women offenders group at the beginning of the chapter, while in fact the agenda is not open for negotiation. When group purpose, methods, and rules are entirely predetermined by the agency and the leaders, many va rieties of overt and covert oppositional behav ior are a predictable result. 2. Oppositional behavior is often labeled resistance. Evasive behaviors and challenging leaders’ direction often occur in involuntary groups. Oppositional behavior is often interpreted as pathological resistance without examining such behavior in the context of group interaction (Hurley 1984). For example, vocal opponents of the group’s direction may in fact be potential group leaders who are attempting to help make the group worthwhile by focusing it on personally meaningful goals. In this way, their oppositional behavior may be more useful to the group than passive, compliant behavior that may not reflect a commitment to change in the group. 3. Peer modeling is often negative. While group members often learn from peers, such learning may be contrary to the goals of the group leaders. Group cohesiveness may develop the form “us against the leaders” in which the very kinds of antisocial behavior that the group is designed to reduce

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Practice Strategies for Work with Involuntary Clients may be reinforced. Members might actually learn from peers how to cope with involuntary groups in manipulative, deceptive ways. 4. Frustrated group leaders sometimes practice coercive persuasion. Faced with so-called resistive behavior, preaching and shaming may be used more frequently than focusing on positive attractions of the group. In their eagerness to help, group leaders can violate the dignity of individual members, demand participation, and resort to a form of coercive persuasion or brainwashing (Cushman 1986). Involuntary group methods that assault individual identity, provoke shame, demand pure and rigid adherence to an absolute standard, and include endless public confessions are comparable to brainwashing. Lifton (1961) uses the term “thought reform” for coercive persuasion and identifies eight characteristics: (a) the person is placed in a disorienting situation; (b) a clear simple answer or goal is provided; (c) guilt about past transgressions is induced; (d) new beliefs and behaviors are modeled and rewarded; (e) the individual is exposed to others who have accepted new beliefs; (f) the individual has little opportunity for private thoughts and sharing of doubts with other group members at the same point; (g) the individual learns first to behave in an approved way (when he or she is rewarded for this, then the behaviors become ritualized); and (h) it is believed that the separation between private beliefs and public beliefs breaks down through repeated confessions. The conditions that best prepare one for thought reform have been called dependency, debilitation, and dread (Schein, Schneier, and Barker 1961). Hence, if involuntary group members are highly dependent on the leaders and institution, deprived of adequate exercise and food, and maintained in a highly punitive environment, the conditions for thought control exist. With perhaps exceptions for access to exercise and food, similarity between the characteristics of thought reform and the characteristics of treatment groups designed to influence behaviors labeled as deviant are striking. Thoughts, attitudes, and beliefs that are neither illegal nor related to a clientdefined goal are sometimes assaulted by group members or leaders. For example, an overweight member of an incarcerated sexual abusers group was verbally assaulted for not caring enough about himself to reduce his weight. While behaviors and attitudes related to sexual abuse are appropriate for such groups, weight problems are not an appropriate subject for coercive intervention if they do not endanger self or others, or are not a voluntary concern of the individual. Attack on attitudes, beliefs, and thoughts may be illegal under laws to protect mentation, or the right to one’s own thoughts (Alexander 1989). Hence, a major legal and ethical issue in involuntary groups is determining the boundary between what is “fair game” for the group and what issues are matters of privacy and personal choice. 5. Some clients do not learn well in groups and may spoil it for others. Group composition is often a key variable in the success of groups. Yet many clients

Work with Involuntary Groups are sent to groups “for their own good,” whether they learn well in groups or not. As a result, those persons may not learn and also make the experience more difficult for others. 6. Groups may be operated primarily for budgetary reasons. Staff in institutions may be unable to consider appropriate group composition because staffing limitations require that residents be in groups for most of their time. Hence, while groups can be an efficient, effective means for ser vice delivery, they are often required even when they may not be effective because they keep staffing costs down. At worst, group methods are used as a form of “cheap warehousing.”

Pregroup Planning Given the preceding discussion of the benefits and potential drawbacks of involuntary clients, the following discussion considers the decision of whether or not to form an involuntary group. Second, we consider how to prepare individuals for membership in such a group. Next, the concepts of stages of group development as applied to involuntary groups are presented. Finally, we follow with an integration of the earlier presented material on the stages of individual change to stages of group development. Should an Involuntary Group Be Formed? Following the advantages and disadvantages described in the preceding text, an agency and practitioner considering forming a group should first determine whether the group would be beneficial. A group that is unlikely to progress toward treatment goals but rather become a hotbed for learning and practicing antisocial behavior should not be formed. Hence, there should be genuine, tangible benefits available to members from participation. Second, leaders are needed who can model a supportive, empathic, respectful attitude and reinforce prosocial modeling through empathic, respectful confrontation (Trotter 2015). Seeding the group with successful graduates can increase this possibility. It is recommended that the group have a clear, predictable structure that can be explained to prospective members. Some have suggested that lack of structure in a group generates tension that causes members to express or expose defenses that can be useful to treatment (Empey and Ericson 1972). Others note that members of unstructured groups are often blamed for this tension and, if chemicals or violence have been used in the past to cope with anxiety, such tension can inadvertently reinforce inappropriate behavior (van Wormer 1987). Prospective members want to know: “Why am I here? Are

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Practice Strategies for Work with Involuntary Clients others here for the same purpose? What can I expect of the leaders and the group? What is expected of me?” (Shields 1986). Shulman (1999) suggests a “tuning in” process by which facilitators anticipate the major concerns prospective members will have. The more specific the offer of ser vice and tangible goals and the clearer the boundaries, the less the energy will be expended on testing the boundaries, and searching out hidden agendas. Ambiguity creates anxiety that in turn intensifies defensive behavior. Similarly, hard-to-reach clients are motivated to maintain control, minimize risk, and avoid failing (Breton 1985). The rule of least contest can be used to address these motivations. Specifically, the practitioner can permit groups to start on their own turf, work with an intermediary person already trusted by group members, respect the values of the group, and give members an opportunity to state their own goals (ibid.). Pregroup planning of involuntary groups raises special ethical issues and responsibilities for practitioners. Compulsory attendance in a group is like compulsory education: students can be compelled to attend but not to learn (Corey et al. 2004). If there are special limitations on informed consent and confidentiality for members of involuntary groups, then group leaders are responsible to fully inform potential members about requirements and rights. They are entitled to know about the nature and goals of the group, required procedures, and their rights and responsibilities (ibid.). Potential members need to know about the potential impact of behavior in the group on decisions that occur outside the group such as judicial recommendations or recommendations about program termination. Hence, leaders should emphasize how group member behaviors can affect their ability to reach their goals. Consequently, a challenge with involuntary groups is to provide both clear structure about nonnegotiable conditions of ser vice and clear opportunities for sharing in developing the processes of the group in negotiable areas. Opposition to threats to valued freedoms can be usefully reframed as expected reactance (Brehm and Brehm 1981). Providing structure can reduce reactance by (1) clarifying boundaries through description of specific nonnegotiable requirements; (2) clarifying available freedoms and choices, even though constrained; and (3) clarifying areas open for negotiation. Prospective group members are entitled to information about the goals of the group, basic rules, qualifications of the leaders, techniques to be employed, and their rights. Such information can be disseminated through preparation of written descriptions of the group, meeting with prospective members individually, or through informational group sessions. For example, if the women offenders described at the beginning of the chapter had received a flyer describing the group and had been invited to an informational session in which required purposes and negotiable possibilities for the group had been discussed, the initial level of opposition expressed might have been reduced (figure 11.1).

Work with Involuntary Groups Meeting with Individual Prospective Members in Pregroup Orientation 1. Clarify nonnegotiables, focusing on specific requirements. Reactance is likely to be high if members perceive that they will be powerless in the group. Unnecessary reactance can be reduced by specifying basic ground rules of group participation and consequences for failure to follow those rules. When clients may be in a mandated status, their requirements, choices, and alternatives regarding participation in this group need to be clarified. If membership is required, basic member expectations regarding attendance and participation need to be clear. In addition, requirements of leaders to report attendance and assess participation should also be clear. Prospective members of nonvoluntary groups always have the right to choose not to participate in the group. If they choose to participate, they will need to be aware of the ground rules for group membership. For example, prospective members of a parenting group may need to agree to discuss at least one problem in parenting with which they are concerned.

Figure 11.1

Pregroup preparation

Pregroup preparation 1. Clarify nonnegotiables focusing on specific requirements 2. Clarify rights and choices. Reactance is likely to be reduced if members are clear about their rights and can make at least constrained choices. The most basic right or choice is whether the prospective member can choose to be in the group or not. For example, unnecessary reactance among many of the woman offenders might have been reduced if they could have chosen to participate in the abuse group or a group devoted to another issue. If membership in the group is not a choice, then members need to know their rights and choices within the group. For example, in some mandated groups, members are permitted a limited number of excused absences. They can make a constrained choice for how and when they take those absences. Members also need to know their rights and choices about participation in group activities. Can group members participate in the selection of agenda items? Can they participate in the selection of the order for presentation of any required items? Can they pick a problem or goal they want to work on? In some cases, members can choose whether or not to participate in particular group activities or can choose the time for such participation (Corey et al. 2004). 3. Expect oppositional behavior. Membership in an involuntary group often represents a stigmatized status that members re-

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Practice Strategies for Work with Involuntary Clients spond to with denial, shame, guilt, anger, and embarrassment. If motivations to avoid stigma and risks of failing in order to maintain a sense of personal control are to be expected, then opposition to external direction can be reframed as reactance to threatened freedoms (Brehm and Brehm 1981). Group leaders can empathize with this feeling of pressure and reinforce available choices, opportunities for learning skills, and knowledge consistent with at least some of the group members’ current motivations. 4. Identify current motivations and attempt to link to them. For involuntary group members to move from a mala prohibita (bad because illegal) to a mala in se (bad in itself) motivation, they will need opportunities to identify their own goals. Too often, those individually expressed goals are rejected by group leaders as inappropriate. For example, when clients in residential settings say that they want to “get out of here,” this motivation is often rejected as inadequate. While group leaders might wish that members begin with mala in se motivations, beginning with current mala prohibita motivation is better than beginning with none. Linkage with current values and goals can enhance the possibility of at least semivoluntary motivation. For example, recognizing that men about to enter domestic violence groups are unlikely to want to be there and wish to get out of the court system is one way of acknowledging mala prohibita motivation. 5. Identify positive skills and knowledge that can be learned as an alternative to illegal or disapproved behavior. The involuntary group is likely to be more successful if members can expect to have some of their own concerns met. Such skills and knowledge are more likely to be accepted if they will probably be rewarded such that members can see progress in a time-limited period. Leaders can prepare by “tuning in” to the concerns of the population (Shulman 1999). For example, awareness of adolescent desires to be autonomous and avoid stigma can assist in linking with expectable motivations (Shields 1986). Similarly, leaders of domestic violence groups can be aware of motivations to avoid loss of control (Milgram and Rubin 1992). The group can be described as a place where men can choose to learn manly ways to deal with disputes without resorting to violence. In fact, the positive focus for the group can be reinforced with a name such as “alternatives to aggression.”

Work with Involuntary Groups 6. Identify possible role models to “seed” in the group. As involuntary group members are more likely to be influenced by peers than by group leaders, finding role models is recommended. Facilitators across three domestic abuse programs report identifying potential group leaders, asking them for their input and suggestions in dealing with more resistant men in group (Chovanec 2009). Former members who have completed the group successfully or are further along in the intervention process might assist in recruitment for and operation of the group. For example, Rooney (1977) found that group enrollment and attendance for groups of potential high school dropouts increased when “junior leaders” were recruited to assist in running groups.

Stages of Group Change for Involuntary Groups Stages of change were originally posed as applying to most kinds of groups (Bennis and Shepard 1956; Garland, Jones, and Kolodny 1965). These applications have tended to assume that clients are voluntary. The pregroup orientation is not included in those voluntary models. Potential members of involuntary groups make critical decisions about whether to join the group and how to engage in the group process prior to the first session.2 Involuntary groups include a pregroup planning phase, in which potential leaders and organizations decide whether and how to form groups. The leaders try to enhance choices, however constrained, and to stimulate self-motivation for participation rather than relying exclusively on threats of punishment or promises of reward. Potential members are familiarized with rules, nonnegotiable policies, and choices available in the group. Most stage models assume that in the beginning stage of group development, new members are anxious about what they do not know and issues of trust and distrust are prominent (Kurland and Salmon 1998). Major tasks in the beginning stage include orientation to the group, clarification of group purpose and norms, and linking commonalities between group members to build cohesion. Trust is even more of an issue in the beginning stage of involuntary groups, since potential members often do not see themselves as being like others nor that their difficulties are like those of others in the group (Berman-Rossi and Kelly 1998). Thus avoidance behaviors are more likely to be emphasized by group members. For example, in domestic abuse groups, 2 This section is drawn largely from R. Rooney and M. Chovanec, “Involuntary Groups,” in Handbook of Social Work with Groups, eds. C. D. Garvin, L. M. Gutierrez, and M. J. Galinsky (New York: Guilford, 2017), 237–254.

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Practice Strategies for Work with Involuntary Clients men often present themselves in a wary, noncommittal fashion. Providing an opening statement that anticipates and addresses some of the initial concerns that potential members typically present is useful in reducing these avoidant behaviors and engaging participants in the group process. It is also important when clarifying norms that group leaders make explicit which norms are negotiable and which are not as a way of reducing reactance. In addition, group members often express anger and frustration in the early development stage of involuntary groups. Reactance theory (Brehm and Brehm 1981) suggests that those who feel coerced into joining the group are more likely to express their frustration and anger toward the group leader. Group leaders are tested early and need to respond to the men’s complaints in an empathic and respectful way without condoning their problem behaviors. Articulating group members’ anger and frustration early on can stop opposition from continuing or being driven underground by threats of retribution and allows members to become engaged in the group process. When the group leader can respond to anger respectfully rather than cutting off or avoiding the issue, he or she can model a way of dealing with anger without putting others down. Many involuntary (and voluntary as well) groups never seem to progress beyond this beginning stage. Consequently, many techniques focus on ways to enhance cohesion and identification with the group. Caplan (2008), for example, through his groupwork change model provides an array of interventions that build group cohesion. There is some empirical support for the notion that individual growth is enhanced through participation in a cohesive group (Levinson and Macgowan 2004). Many involuntary groups never appear to reach the middle stage of group development (Kurland and Salmon 1998). At this stage, the group leader’s role is less central group members support one another. Group members should be familiar with the group process by this point and be able to assess how they are similar and different from other members. The power of the group leader in an involuntary group may diminish in this stage, but it does not disappear. In the ending stage, group leaders help members to describe changes made and connect with supports outside the group (Kurland and Salmon 1998). How ending is experienced depends on whether the group is closed or open ended. In open-ended groups, the ending process is less intense since members may leave at different times. There are typically completion requirements that determine when a group member ends participation, adding more structure to the ending process. Integrating Stages of Individual Change with Stages of Group Change The beginning stage is critical with involuntary groups. Dropout or minimal participation is a frequent problem since many group members lack belief in

Work with Involuntary Groups the utility of the group or their view of the problem does not match the focus of the group (Eckhardt, Babcock, and Homack 2004). The transtheoretical model of change and motivational interviewing (MI) are helpful in addressing these issues since motivation is considered transactional rather than a character trait (Prochaska, Norcross, and Di Clemente 1994; Miller and Rollnick 2002). While developed for voluntary clients with self-identified health issues, several aspects of the approach are useful in work with involuntary clients on other problems. MI has been applied to involuntary clients with a variety of problems such as sexual offending (Mann and Rollnick 1996) and domestic violence (Taft et al. 2001), as well as in work with offenders who are on probation (Harper and Hardy 2000). Rather than viewing beginning involuntary group members as unmotivated, the MI perspective would view them as precontemplators, who do not see a need for change, or as contemplators, who have not yet decided to take action. From this perspective, many involuntary groups fail because they presume that members join a group in the action stage, when they are ready to begin to make changes to address their own acknowledged concerns. The precontemplation phase sounds like mala prohibita motivation in that the problem focus of the group is not acknowledged as valid in its own right but is accepted because of its consequences. Thus, it would be expected that most involuntary clients would begin work in the group desiring to fulfill obligations and avoid punishing consequences rather than seeking a change for their own benefit. For example, substance abuse treatment groups often assume that members are ready to change at the point they begin a group (Lincourt, Kuettel, and Bombardier 2002). Since legally mandated members are often likely to feel coerced and are unable to identify a problem or develop a treatment goal, Lincourt et al. (2002) report adding six sessions at the beginning of the group to enhance motivation. In the first session, members were encouraged to share pros and cons of beginning to deal with substance use. In the second session, they were introduced to the idea of decisional balance through reviewing what had tipped the balance toward their taking action with other behaviors such as smoking. In the third session, members were introduced to the concept of stages of change and asked to identify their current stage. In the fourth session, they completed a drinking profile with an assessor and were asked to present the results to the group. In the fifth session, members would brainstorm options for dealing with their situation and the pros and cons of each choice. Finally, in the sixth session, they would once again rate their stage of change. The additional sessions were effective in stimulating greater attendance among legally mandated members as well as completing treatment and reducing dependence on substances (ibid.). These techniques are incorporated below in the guidelines for increasing group participation. (Integration of individual and group change is discussed in detail in chapters 15 and 17.)

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Beginning Involuntary Groups Involuntary groups often start, end, or persist indefinitely in power struggles between leaders and participants. Such participant efforts to regain control are to be expected in involuntary groups. While leaders of voluntary groups can share agenda setting on most issues with the group, many issues in involuntary groups may not be subject to negotiation. Yet even mandated groups often include at least constrained choices such that activities to pursue in the group can be selected from limited alternatives. Too often, involuntary groups struggle over nonnegotiable requirements and never explore the negotiable. The goal for the beginning session is to establish a basis for collaborative work that is at least semivoluntary, and includes both a framework of nonnegotiable expectations and choices that individuals and the group as a whole may make. This goal is pursued through negotiation of a contract that is the convergence of agency-mandated purposes and rules and goals expressed by participants. Seven steps in the initial session are suggested: (1) arrange the meeting room; (2) make an introductory statement that clarifies nonnegotiable issues and rights and negotiable issues; (3) initiate discussion of pros and cons of deciding to change; (4) solicit member goals and attempt to link to group goals; (5) negotiate some group process rules; (6) use tactful, experiential confrontation; and (7) clarify expectations and choices for the next session. 1. Arrange the meeting room. Involuntary group members want to know what to expect from the group and what is expected of them. They gather answers to some of these questions through pregroup individual sessions and handouts. They probe for further answers both from what is said in the group and through nonverbal messages conveyed by leaders, including the physical arrangements of the group setting. If member participation is to be reinforced and status hierarchies diminished, then leaders should consider arranging chairs in a circle and not separating themselves from the group. In addition, providing name tags and ways to identify the number of sessions attended (for open-ended groups) can help group members connect and identify the “veterans.” Refreshments might also be made available. Posters welcoming participants and handouts with the agenda can also clarify structure and choices. 2. Make an introductory statement that begins to establish realistic expectations. Leaders can begin to establish realistic expectations by: (a) welcoming the group; (b) searching for common concerns; (c) clarifying circumstances of the referral; (d) clarifying nonnegotiable expectations of leaders and members; (e) clarifying rights, freedoms, choices, and areas for negotiation; and (f) empathizing with pressure experienced. Leaders can suggest common concerns in a matter-of-fact, nonjudgmental tone and empathize with feelings of pressure experienced by some without supporting the behavior that may have

Work with Involuntary Groups led to the referral. For example, many members may be expected to be ambivalent about group membership. They may have conflicted wants that include both attraction to the group and desires to avoid it. To address such conflicted wants in a group of persons who are together because they drove while intoxicated, that statement can be • No one wishes to be here (commonality). • We all would like to stay out of trouble, but we may not wish to stop drinking (conflicted wants). • You are here because you decided you would rather try this than go to jail (choices). (Berliner 1987) The latter statement implies that people are responsible for what happens to them and that choices can be made between undesirable alternatives (ibid.). “No one wants to be here” is an area of commonality and identifies wishing to stay out of trouble but not wishing to stop drinking. The statement notes the commonality but does not judge it. In addition to stating in advance what the commonalities might be, the group leader can ask members to introduce themselves including describing why they have come to this group. The leader can then note the similarities that emerge from those introductions. For example, they will often include an observation that other persons or events pressured the client to come to the group. The leader can note the similarity that no one chose to join the group freely, which can be difficult. Still, all members are similar in choosing to participate rather than accept other consequences. In addition to identifying common concerns and emphasizing choices, leaders can describe circumstances of the referral and expectations of the group and the leaders. Shields (1986) reports an introduction made by the leader of a group with drug-dependent adolescents in high schools. The group leader identifies drug use leading to hassles with parents and teachers as a common concern, notes that members will not be judged and will have to make their own choices about drug use, and begins to identify expectations of the leader and of members. This is what I know: all of you are in trouble here in school because of drugs. The principal has spoken to all of your parents and has told them that you are all one step from being expelled (the students all agree) (commonality). Now the principal asked me to meet you (circumstances of referral). I’ve been thinking about what I can do to help. I think your drug use, whether a little or a lot, has gotten you into trouble with your families and here in school (nonjudgmental description of commonality). Now, I know I can’t stop you from getting high, and I’m not going to preach about drugs (emphasizes choices and nonjudgmental attitude). You’ve heard all that. I know you make your own decisions about

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Practice Strategies for Work with Involuntary Clients getting high (emphasizes choices), since all of you are facing similar hassles— like probation here in school, feeling everybody is watching  you, hassles with your parents, decisions about drugs (areas of commonality)—I think you can help each other work these things out, and I can help you do that (what leader can do). You’ve all told me you want to stay in school (commonality), and I’d like to help you do that, but it will mean work—looking hard at how you make decisions about getting high in school, how you handle the restrictions of probation and problems that arise with teachers here at school (what members can do). Now, I think we can work these things out together—I can help you work together on these issues here in group. I can help you talk to teachers and maybe parents or I can even talk to them with you (what leader can do), but you have to be willing to really share and work together here on the hassles you’re facing if group is going to help (what members can do). How about it? Can we do it? (emphasizes choices). (Shields 1986:69) The introduction is also a time to describe beliefs and philosophies of the program. For example, many domestic abuse programs believe that the abuser is responsible for his or her own violence, is not provoked to use violence, chooses violence as a way of coping, that abuse rarely stops spontaneously, and that abuse is learned behavior (Purdy and Nickle 1981). While involuntary group members cannot realistically be expected to accept these beliefs as their own at the beginning of the group, they must be aware of the program’s rationale. Some mandated groups contain many nonnegotiable rules. Even in such groups, constrained choices can be emphasized. For example, such groups often entail attendance requirements while permitting as many as two absences. Members can be encouraged to use their choice of absences judiciously as only two are permitted. Similarly, members may be required to select a personal goal to work on. They may select one from an approved list such as “improve employment skills, improve communication skills, improve health and nutrition.” Group leaders sometimes become involved in defending the fairness of the nonnegotiable rules. It is important to keep these rules to the minimum necessary and be prepared to offer a rationale for them. Leaders can reduce the arguing and clarification by sharing a written list of nonnegotiable expectations with prospective members before the first session. The leaders can recognize member discomfort or disagreement with the rules while affirming that members have a choice about whether or not to join the group. If they choose to join the group, they are implicitly choosing to comply with the rules of the group. Leaders should move as soon as possible to identifying rights, free choices, constrained choices, and areas for negotiation. Alternative ways to meet group goals are clarified next.

Work with Involuntary Groups Nonvoluntary groups include more emphasis on choices to participate than mandated groups. Empathy with feelings of pressure experienced by nonvoluntary members in other wise voluntary groups can be expressed. For example, in a parenting skills group, including some who joined the group voluntarily and others who came through pressure from their child welfare worker, the leader assures any members feeling pressure to attend that such pressure is external to the group. A reframing to identify what the prospective member would like to receive from the group rather than a focus on the referral source’s agenda is suggested. Some of you have come to this group because you think that it can help you with some parenting issues you are concerned about. Others may be here because someone suggested that you come and you felt as if you had to take their advice (identifies areas of commonality). It can be difficult when you feel as if you don’t have a choice (empathizes with feelings of pressure). I want to make it clear to any of you who feel as if you don’t have a choice that we are not requiring that you be here. You can decide not to come to the group and go back and talk it over with the person who referred you. You can also decide to remain and see if the group meets some of your own concerns. If you are unsure, I would suggest that you avoid making a decision until today’s session ends. You might want to think about what you could get out of this group for yourself, not for the person who sent you (emphasizes choices). 3. Initiate discussion of pros and cons of deciding to change. Members can be assumed to vary in their readiness to engage in change. Rather than punish members for being in the precontemplation or contemplation stage, acceptance of the likelihood that members may still be undecided to change is recommended. Members can be encouraged to make lists of the reasons why they may not now see a need to make a change. Then members make additional lists of reasons that would incline them to choose to make a change. Group leaders can emphasize that no one can make members choose to make a change, but the group can assist members in gathering the information they need to decide whether or not to change (Lincourt, Kuettel, and Bombardier 2002). 4. Solicit member goals and attempt to link to group goals. Self-attributed changes in behaviors and attitudes tend to last longer than changes produced primarily via reward or punishment. For members to self-attribute change and become at least semivoluntary, their own goals need to be explored. Duncan (2010) offers a collection of client feedback tools in a Partners for Change Management Outcome System (PCOMS) that help facilitators assist clients in articulating goals and support client voice. As considered previously, many members can be expected to be in the precontemplation or contemplation

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Practice Strategies for Work with Involuntary Clients stage, so their expression of goals is likely to be tentative. It should be expected that many of their goals at this point will be of the mala prohibita sort. Leaders can accept some of these motivations while beginning to encourage members to explore additional goals of their own. For example, members of an adolescent drug use group expressed motivations such as wanting to end involvement with the criminal justice system, to be released from the facility, or fear that further drug use would lead to incarceration, while other members suggested, probably quite candidly, that they wanted to continue to use drugs and avoid getting caught (Smith 1985)! The leaders can attempt to link individually expressed goals of the former kind with the mandated goals of the group. They can also identify common themes as group goals. For example, the leaders of the drug alternatives group could suggest that by learning about the dangers of illegal drug use and alternatives to it, members could also learn ways to avoid further involvement with the criminal justice system. Additional goals may be shared by members but be unrelated to the group mandate. For example, one such common goal in drug abuse groups for adolescents could be dealing with feeling stigmatized by others (Shields 1986). As members express goals, leaders can support those goals or parts of them and, in some cases, reach for goals slightly beyond the mala prohibita level. For example, “it sounds as if most of you want to get out of this group successfully and to finish school. If you can learn some skills here that might help in school and in relations with your parents, all the better.” 5. Negotiate some process rules of the group. If some rules for the group are nonnegotiable, as in the attendance policy stated for this group, it is important to state these first before the floor is opened to discuss other groupgenerated rules. Involuntary groups often have unexplored possibilities to share power in the process of the group. For example, within an overall nonnegotiable framework of exploring issues in drug education, group members can identify the topics of most interest to them (Smith 1985). Knowing their preferences can then influence the order of presentation. Agreements can be negotiated about expectations for member participation and group decision making. For example, rules about times for breaks, when and where members might smoke, and bringing in food might be negotiated in the group. 6. Use tactful experiential confrontation. Guidelines were suggested in chapter 4 about the use of confrontation with individuals that are also relevant for work with groups (Reid 1986). Confrontation is appropriate when behavior or attitudes are expressed that are illegal, dangerous, violate group rules, or are inconsistent with the person’s own goals. Inconsistency with a member’s own expressed goal is most likely to be effective, since dissonance may not be stimulated if the person does not consider the behavior or attitude in question to be mala in se. Since clients are more likely to be persuaded by persons they

Work with Involuntary Groups like, trust, and feel to be expert, leaders are unlikely to be sources of powerful influence in early group sessions if they are not yet seen by members as possessing these attributes. Confrontation in groups is often initiated by group members and may lack the characteristics of specificity and empathy identified in chapter 4. On the other hand, other members may be more likely to be seen as similar and hence more powerful sources of influence. Therefore, confrontation in groups can be a powerful source of influence. It can also be a source of abuse when the member cannot choose not to receive it, when empathy is not expressed, and when choices are not available. Group leaders can shape, take the edge off of confrontation, or in fact sharpen it to make the point clear. They can also model how to confront in a nonjudgmental fashion. 7. Clarify expectations for the next session. Expectations of any tasks to be completed outside of the session should be reviewed before the session ends. Where possible, members should select such tasks from several possibilities, or should be encouraged to generate their own tasks. For example, the members of the prostitution group might have been asked to think of topics they would like to have discussed in the group. They might also examine the alternative programs for individual goals such as pursuing further education, acquiring job skills, getting a driver’s license, or bringing in their own alternative ideas for an individual plan. In chemical dependency groups, members may be asked to read specified chapters of a text and bring in questions. Such initial tasks should be specific and highly likely to succeed such that positive momentum might be generated.

Techniques for Enhancing Attendance, Participation, and Cohesion For involuntary clients to benefit from group membership, they need to attend sessions, participate in activities, and experience some cohesion with other group members. Cohesive groups are more likely to have engaged members (Levinson and Macgowan 2004). Members have to come to see a need for change and develop an alliance with group leaders (Taft et al. 2004). Research on sexual abuse treatment in groups suggests that engagement is related to group progress, which in turn reduces recidivism (Hanson et al. 2002; Levinson and Macgowan 2004). Successful groups with sexual offenders with children are cohesive, promote responsibility, and foster a positive rather than confrontative style (ibid.). Members who make progress are more likely to be engaged and less likely to deny responsibility (Hanson and Bussiere 1998). Members are more likely to value the group if their attendance and participation is valued. Since attending to dropout potential in domestic violence groups is critical, sending a handwritten letter or making a phone call inviting

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Practice Strategies for Work with Involuntary Clients the member to return have been shown in one study to reduce dropout from 30  percent to 15  percent and increase attendance by 10  percent (Taft et  al. 2001). Such respectful attention to attendance is recommended. Asking members to self-assess reasons for considering to change or not to change early on supports ownership of the decision to change. Subsequent sessions can introduce the concept of decisional balance, and examining what moved members to change around other problems they have identified such as smoking or weight loss can convey the idea that they acted to make positive changes in the past (Lincourt, Kuettel, and Bombardier 2002). Dissonance can be aroused by keeping a visual record of inconsistencies between goals and behaviors as a way of influencing the decisional balance (Draycott and Dabbs 1998). The PCOMS collection of client feedback tools has been found to build therapeutic alliance between facilitator and group members, retain clients in treatment, and improve outcomes in involuntary groups (Chovanec 2016). These client feedback tools include a “scoreboard” that allows group members to compare their self-reported distress scores across weeks. This provides an opportunity for group members to discuss changes they notice within themselves over time. Skills for enhancing member participation in involuntary groups are critical. Thomas and Caplan (1999) describe several techniques for enhancing participation. At one level, the leader is advised to pay attention to process or themes underlying the surface of the conversation. For example, the leader might say “it sounds as if many of us are raising some issues about how much they want to disclose in this group, how safe is it going to be for me to trust.” In addition, the leader should make explicitly empathic statements that indicate understanding of what the member is trying to convey. For example, if a member notes early on that he hesitates to share his views because he is quite sure that others will not agree, the leader would want to assure him that he would be listened to even if not all would agree with him. Linking interventions are those in which the concerns of one participant are connected to those of another (Thomas and Caplan, 1999). For example, “Frank, when I hear you talk about wanting to be a good father for your sons, I am reminded of what George said last week about wanting to be a good role model.” Finally, inclusion techniques are used to encourage a member to increase his or her participation by offering activities within the group to provide an opportunity for all members to participate without focusing on specific members. For example, a facilitator may choose to get input on how the group is being experienced through a group checkout. “Before we leave tonight I would like to give you all an opportunity to let me know what you will take away from this group session that you think will be useful for you” (Thomas and Caplan 1999).

Work with Involuntary Groups Solution-focused methods have also been successfully used to engage groups of domestic violence male offenders (Lehmann and Simmons 2009). Group leaders seek to explore exceptions, when the problem did not occur, and build on the exception. For example, the leader might explore instances in which the client had resolved disputes without resorting to verbal threats or violence. This allows for facilitators to focus on group members’ strengths rather than on their deficits. In addition, safety for themselves and their family can be assessed using scale questions. In this way attention can be placed on how to reduce the risk of abuse in the future rather than only focusing on group members taking responsibility for their past abusive behavior.

Postcontracting Work with Involuntary Groups Once a working contract is established that meets both nonnegotiable purposes and individual goals, many forms of continued work are possible. Too often, involuntary groups never reach this stage. Activities after the contracting phase become much more specific to the type of group and problems addressed. However, some general differences occur between open-ended and closed groups. For example, open-ended groups continue to add members and are ongoing, while other groups have closed membership and may last for a specific time-limited period. Open-ended groups offer members the opportunity to move through stages in the group from initiate to role model and are easier to staff, since the same group is used for persons at different stages. However, open-ended groups often have difficulty in maintaining a sense of forward progress, since attention must continually be given to orienting new members. Schopler and Galinsky (2005) recommend managing when and how often new members are added to the group. They suggest movement through the stages of group development occur for cohorts of group members that enter the group at the same time. Longer-term members, however, can often assist in this orientation process by describing their experience in the group and sharing group norms. Closed, topic-oriented groups have the advantage of grouping persons according to where they are in a predictable sequence of change processes. For example, some writers propose that different group purposes are needed for the changing needs of alcoholics at early, middle, and ongoing support stages of the recovery process (Cohen and Sinner 1981). Whether a single group or a sequence of groups is planned, a series of four phases is often found. Involuntary groups begin with an orientation phase in which information about the problem area is shared, followed by a skill-learning phase in which alternative behavioral skills are learned and practiced. Groups

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Practice Strategies for Work with Involuntary Clients then often move to an examination of attitudes and beliefs, followed by attention to preparation for experiences after the group ends. Orientation Phase After the initial meeting, many involuntary groups continue with an orientation phase that is aimed at providing information and assisting members in making decisions about how they will use the group experience. For example, a study of rankings of therapeutic factors by male participants in groups for men who batter found that issues related to self-understanding and understanding of the problem were prominent (Roy et al. 2005). Thus, an emphasis on education early in the group helped the participants feel that they were not alone in dealing with the problem (Roy et al. 2005). Education is noted by group facilitators as an important intervention in engaging abusive men in the change process (Chovanec 2012). In addition, participants in these groups report that “learning things” is key to their ability to change (Chovanec 2014). The orientation phase works best when members are presented with information in a factual, nonblaming fashion, assisted in self-assessment of problem behaviors, and encouraged to make proactive choices. Cognitive dissonance may be stimulated by the provision of information that indicates dangers to meeting the member’s own goals (Draycott and Dabbs 1998). 1. Presentation of problem behavior in factual, nonblaming ways. As involuntary groups usually begin with greater concern for the mala prohibita goals, the orientation phase often includes a presentation of problem behavior in a matter-of-fact, nonjudgmental way. Hence, in DWI and alcoholism treatment groups, tapes and films examining the consequences of drunken driving or physical consequences of drug abuse are often shared at this point. Experts are also engaged to provide information. For example, Smith reports using credible, outside experts to describe effects of chemical use with chemically dependent adolescents. The experts discussed problem drug use in two-sided arguments (see chapter 4) and did not pressure the adolescents to change beliefs or behavior (Smith 1985). At this point, members are not pressed to take personal responsibility for having “a problem,” but rather are asked to be open to hearing information about the consequences of such behaviors. 2. Facilitate decisions about dealing with problem behavior. Building on the decisional balance exercise described above, members can be encouraged to make decisions about whether or not to attempt change for their own reasons, not just because of outside pressures (van Wormer 1987). Contact with persons who have successfully completed the group often assists in this decision-making process (Citron 1978; Panepinto et al. 1982). In open-ended groups, “veterans” can be useful in assisting those earlier in the change process in their decisions about change (Chovanec 2009).

Work with Involuntary Groups Decision making is often facilitated by asking members to complete a self-assessment of their own problem behavior. For example, Smith reports that adolescent drug users were helped to construct a behavioral definition of dangerous drug usage followed by completing an individual assessment of their own danger using the group-constructed definition (Smith 1985). To facilitate such self-assessment, members of alcoholism treatment groups are often asked to complete a written self-assessment of dangerous drug usage. Citron recommends that these questions be asked in a matter- of-fact, nonjudgmental fashion, avoiding value-laden questions such as “Are you powerless over alcohol?” (Citron 1978). Involuntary clients might be expected to respond more to factual questions about behavior and consequences than to take on self-blame for the problem, especially when they are unaware of other alternatives for meeting needs.

Skills Learning Change in orientation from mala prohita to mala in se motivation is more likely to occur if members become aware of alternative ways to meet their own goals. Hence, instruction in developing alternative behavioral, affective, and cognitive responses to problem situations often follows the orientation phase. For example, skills groups for domestic violence often include instruction in relaxation methods, substitution of positive self-messages for negative self-talk, and practice of alternative behavioral responses such as taking time-outs and making assertive requests (Saunders 1984). Teaching men to observe their own cues that indicate a potentially violent or anger-provoking situation is particularly important. When such situations occur, men are taught to record both positive and negative self-talk and to generate behavioral alternatives (see chapter 12). Similarly, in alcoholism treatment, assertiveness training groups can focus on alternative ways of dealing with situations that have led to drinking in the past (Brody 1982). In the S.O.B.E.R. program, members are taught to slow down, relax, analyze the behavioral exchange, and recognize the methods they use to deal with situations that in the past have led to alcohol use (Brody 1982).

Examining Attitudes and Beliefs It is often the hope in involuntary groups that members will change not only behaviors but also the beliefs and attitudes that support those behaviors. Members of involuntary groups may be more likely to consider change in attitudes and beliefs if completion of the two previous phases has stimulated dissonance and alternative means of reaching goals have been learned. Domestic violence groups often address attitudes and beliefs at this stage by presenting

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Practice Strategies for Work with Involuntary Clients violence as learned behavior frequently reinforced by society. Men who batter are seen in part as victims of domestic violence through their lack of skills, fear of intimacy, and dependence on women (Purdy and Nickle 1981). They are seen as the products of a society that often teaches men to be unaware of their feelings, to have an action orientation, and to see less-than-perfect performance as failure. Such normalizing and nonblaming attention to attitudes and beliefs may assist in the modification of values. However, the process is not smooth and many members continue to express values or carry out behavior that is contrary to group purposes. Some members leave the group during this phase. Group leaders eager to change a person’s attitudes and behavior at this point are susceptible to a member’s use of abusive confrontation that violates individual dignity, or a member’s right not to participate and to withdraw within him- or herself (Bratter, Bratter, and Helmsberg 1986). Bratter et al. suggest that unless the individual retains the right to self-determination in choosing whether and how to change behavior and attitudes, group leaders can become tyrants. When denial persists, Purdy and Nickle (1981) suggest asking direct factual questions about time and information gaps in reports of violence and asking about discrepancies in reports. Emphasis on choices and consequences of behavior and attitudes that are obstacles to members’ own goals, followed by empathy, are more likely to be successful forms of confrontation than assaults on attitudes and behavior (Roffers and Waldo 1983). In particular, confrontation around values and attitudes that the member does not have are unlikely to be successful. Without such self-attribution, members are likely to change overt behavior and attitudes only under the pressure of threatened punishment or tangible rewards. Evidence that such self-attribution is difficult to attain is suggested in domestic violence treatment research reports that men completing the program were more likely to reduce physical violence while maintaining or increasing psychological violence (Tolman and Bhosley 1987). This finding suggests that while physical violence remained mala prohibita, psychological violence did not become mala in se.

Preparation for Post-Group If involuntary groups are to assist members in maintaining changes after the group ends, generalization to other settings and linkage with other resources must be facilitated. For example, role plays of situations in which peers attempt to influence a member to engage in renewed problem behavior can be helpful in preparing for difficulties. Planning for possible setbacks and regression in which a crisis plan, including means of maintaining an ongoing support plan, is developed can be beneficial. In addition, some members may move on to

Work with Involuntary Groups join ongoing support groups or assist in running new groups. Support for choices should be especially encouraged since self-attributed change is more likely to persist in the absence of the kinds of rewards and punishments that were available in the group.

Summary This chapter has suggested that involuntary groups can be ethical and effective sources of influence that meet both societal needs and individual goals. Dangers of abuse of group leader power have also been described. A major issue is the determination of whether the specific purposes of a mandated or nonvoluntary group are legal and ethical. Questions to ask when an involuntary group’s purpose are to be supported include: What role can individuals play in meeting their own goals? How can they participate in structuring the group? If structure is so rigid that neither leaders nor members can modify it, member efforts to regain some control can be expected, or, if they are unsuccessful, mute, passive acceptance. Are members required to participate who do not benefit and inhibit the benefit that others might obtain? The chapter has also suggested that attitudes and beliefs may be more subject to change in groups through the influence of peers than is normally possible in work with individuals. While that influence can be ethical and effective, the danger of abusive confrontation in the group was also described. Remembering that confrontation is more appropriate as a persuasion method than as a method of punishment, questions should be asked about its use in the group. What choice does a member have in receiving confrontation? Corey et al. (1979) suggest that members should be free to decline participation and that groups are “not appropriate for endless interrogation . . . beating into submission. How is confrontation related to the members’ own goals? To what extent is confrontation used as a means of venting frustration over progress perceived to be too slow by the leaders?” (144).

Discussion Questions 1. This chapter has emphasized joining and linking methods designed to make the involuntary group a safe, cohesive place to try out new behaviors and attitudes. To what extent have you seen such methods used with involuntary groups? 2. Should groups have open membership with members joining and leaving at different times? What are some of the ways the benefits of the group can be maximized?

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Practice Strategies for Work with Involuntary Clients 3. This chapter has suggested that members of oppressed groups may feel disproportionately singled out by a majority society for involuntary treatment. How can group leaders acknowledge disproportionality and also support member choices? 4. Confrontation with peers can be a powerful source of attitudinal influence. How can members be assisted to deliver and receive such confrontation in useful ways? 5. Some involuntary groups seem to persist in an unresolved power and control stage. What methods can leaders use to assist groups in addressing their growth as a group?

References Alexander, R. Jr. 1989. “The Right to Treatment in Mental and Correctional institutions.” Social Work 34 (2): 109–112. Behroozi, C. S. 1992. “A Model for Social Work with Involuntary Applicants in Groups. Social Work with Groups 15 (2/3): 223–238. Bennis, W., and H. Shepard. 1956. “A Theory of Group Development.” Human Relations 9: 415–437. Berliner, A. K. 1987. “Group Counseling with Alcoholic Offenders: Analysis and Typology of DWI Probationers.” Social Work with Groups 10 (1): 17–31. Berman-Rossi, T., and T. Kelly. 1998. “Advancing Stages of Group Development Theory.” Paper presented at the annual program meeting of the Council on Social Work Education, Orlando, Florida, March. Bratter, T., E. Bratter, and J. Helmsberg. 1986. “Uses and Abuses of Power and Authority in American Self-Help Residential Communities: A Perversion or a Necessity?” In Therapeutic Communities for Addiction: Readings in Theory, Research and Practice, eds. G. DeLeon and J. T. Ziegenfus, Jr., 191–208. Springfield, IL: Charles C. Thomas. Brehm, S., and J. Brehm. 1981. Psychological Reactance: A Theory of Freedom and Control. New York: Academic Press. Brekke, J. 1989. “The Use of Orientation Groups to Engage Hard to Reach Clients: Model, Method and Evaluation.” Social Work with Groups 12 (2): 75–88. Breton, M. 1985. “Reaching and Engaging People: Issues and Practice Principles.” Social Work with Groups 8 (3): 7–21. Brody, A. 1982. “S.O.B.E.R. A Stress Management Program for Recovering Alcoholics.” Social Work with Groups 5: 15–23. Buttell, F., and C. Pike. 2003. “Investigating the Differential Effectiveness of a Batterer Treatment Program on Outcomes for African American and Caucasian Batterers.” Research on Social Work Practice 13 (6): 675–692. Cameron, H., and J. Telfer. 2004. “Cognitive-Behavioural Group Work: Its Application to Specific Offender Groups.” Howard Journal 43 (1): 47–64. Caplan, T. 2008. NEEDS-ABC: A Needs Acquisition and Behaviour Change Model for Group Work and Other Psychotherapies. London: Whiting & Birch. Chovanec, M. G. 2009. “Facilitating Change in Group Work with Abusive Men: Examining Stages of Change.” Social Work with Groups, 32 (1/2): 125–142.

Work with Involuntary Groups Chovanec, M. G. 2014. “The Power of Learning and Men’s Stories in Engaging Abusive Men in the Change Process: Qualitative Study Across Programs.” Social Work with Groups 37 (4): 331–347. Chovanec, M. G. 2016. “Increasing Client Voice within Involuntary Groups.” Social Work with Groups. doi:10.1080/01609513.2016.1201451. Citron, P. 1978. “Group Work with Alcoholic Poly-Drug Involved Adolescents with Deviant Behavior Syndrome.” Social Work with Groups 1 (1): 39–52. Cohen, M., and A. Sinner. 1981. “A Group Curriculum for Outpatient Alcoholism Treatment.” Social Work with Groups 5: 5–13. Corey, G., M. S. Corey, and P. J. Callanan. 1979. Professional and Ethical Issues in Counseling and Psychotherapy. Monterey, CA: Brooks- Cole. Corey, G., M. S. Corey, P. J. Callahan, and J. M. Russell. 2004. Group Techniques. 3rd ed. Pacific Grove, CA: Brooks/Cole. Cushman, P. 1986. “The Self-Besieged: Recruitment, Indoctrination Processes in Restrictive Groups.” Journal for the Theory of Social Behavior 16 (1): 1–32. Draycott, S., and A. Dabbs. 1998. “Cognitive Dissonance 2: A Theoretical Grounding of Motivational Interviewing. British Journal of Clinical Psychology 37: 355–364. Duncan, B. L. 2010. “Just the Facts, Ma’am: A No-Nonsense Guide to Becoming a Better Therapist.” In On Becoming a Better Therapist, 3–32. Washington, DC: American Psychological Association Press. Eckhardt, C., J. Babcock, and S. Homack. 2004. “Partner Assaultive Men and the Stages and Processes of Change.” Journal of Family Violence 19 (2): 81–93. Empey, L. T., and M. L. Ericson. 1972. The Provo Experiment. Lexington, MA: Lexington Books. Garland, J. A., H. E. Jones, and R. L. Kolodny. 1965. “A Model for Stages of Development in Social Work Groups.” In Explorations in Social Group Work, ed. S. Bernstein, 17–71. Boston: Boston University School of Social Work. Garvin, C. D. 1981. Contemporary Group Work. Englewood Cliffs, NJ: Prentice-Hall. Gitterman, A. 2004. “The Mutual Aid Model.” In Handbook of Social Work with Groups, eds. C. Garvin, L. Gutierrez, and M. Galinsky, 93–110. New York: Guilford Press. Hanson, R. K., and M. T. Bussiere. 1998. “Predicting Relapse: A Meta-Analysis of Sexual Offender Recidivist Studies.” Journal of Consulting and Clinical Psychology 66 (2): 343–362. Hanson, R. K., A. Gordon, A. Harris, J. Marques, W. Murphy, V. Quense, et al. 2002. “First Report of the Collaborative Outcome Data Project on the Effectiveness of Treatment for Sex Offenders.” Sexual Abuse: A Journal of Research and Treatment 11: 49–67. Harper, R., and S. Hardy. 2000. “An Evaluation of Motivational Interviewing as a Method of Interviewing with Clients in a Probation Setting.” British Journal of Social Work 30: 393–400. Hurley, D. J. 1984. “Resistance and Work in Adolescent Groups.” Social Work with Groups 1: 71–81. Kurland, R., and R. Salmon. 1998. Teaching a Methods Course in Social Work with Groups. Alexandria, VA: Council on Social Work Education. Lehman, P., and C. A. Simmons, eds. 2009. Strength-Based Batterer Intervention: A New Paradigm in Ending Family Violence. New York: Springer. Levinson, J., and M. Macgowan. 2004. “Engagement, Denial and Treatment Progress among Sex Offenders in Group Therapy. Sexual Abuse 16 (1): 49–63. Lifton, R. T. 1961. Thought Reform and the Psychology of Totalism: A Study of Brainwashing in China. New York: W. W. Norton.

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Practice Strategies for Work with Involuntary Clients Lincourt, O., T. J. Kuettel, and C. H. Bombardier. 2002. “Motivational Interviewing in a Group Setting with Mandated Clients: A Pilot Study.” Addictive Behaviors 27: 381–398. Mann, R. E., and S. Rollnick. 1996. “Motivational Interviewing with a Sex Offender Who Believed He Was Innocent.” Behavioral and Clinical Psychotherapy 24: 127–134. Milgram, D., and J. Rubin. 1992. “Resisting Resistance: Involuntary Substance Abuse Group Therapy.” Social Work with Groups 15 (1): 95–110. Miller, W. R., and S. Rollnick. 2002. Motivational Interviewing: Preparing People for Change. New York: Guilford. Murphy, C., and V. Baxter. 1997. “Motivating Batterers to Change in the Treatment Context.” Journal of Interpersonal Violence 12 (4): 607–619. Panepinto, W. C., J. A. Garrett, W. R. Williford, and J. A. Prieke. 1982. “A Short-Term Group Treatment Model for Problem Drinking Drivers.” Social Work with Groups 5: 33–40. Prochaska, J., J. Norcross, and C. C. DiClemente. 1994. Changing for Good. New York: Avon Books. Purdy, F., and N. Nickle. 1981. “Practice Principles for Working with Groups of Men Who Batter.” Social Work with Groups 4 (3/4): 111–122. Reid, K. 1986. “The Use of Confrontation in Group Treatment: Attack or Challenge?” Clinical Social Work Journal 14: 224–237. Rittner, B. 2004. “Group Work in Child Welfare.” In Handbook of Social Work with Groups, eds. C. Garvin, L. Gutierrez, and M. Galinsky, 245–258. New York: Guilford Press. Roffers, T., and M. Waldo. 1983. “Empathy and Confrontation Related to Group Counseling Outcomes. Journal for Specialists in Group Work 8 (3): 106–113. Rooney, R. H. 1977. “Adolescent Groups in Public Schools.” In Task- Centered Practice, eds. W. J. Reid and L. Epstein, 168–182. New York: Columbia University Press. Rooney, R., and M. Chovanec. 2017. “Involuntary Groups.” In Handbook of Social Work with Groups, eds. C. D. Garvin, L. M. Gutierrez, and M. J. Galinsky, 237–254. New York: Guilford Press. Roy, V., D. Turcotte, L. Montminny, and J. Lindsay. 2005. “Therapeutic Factors at the Beginning of the Intervention Process in Groups for Men Who Batter.” Small Group Research 36 (1): 106–133. Saunders, D. 1984. “Husbands Who Batter.” Social Casework 65 (June): 347–353. Schein, E. H., I. Schneier, and C. H. Barker. 1961. Coercive Persuasion: A Socio-Psychological Analysis of American Civilian Prisoners by the Chinese Communists. New York: W. W. Norton. Schopler, J. H., and M. Galinsky. 1981. “When Groups Go Wrong.” Social Work 26: 424–429. Schopler, J. H., and M. J. Galinsky. 2005. “Meeting Practice Needs: Conceptualizing the OpenEnded Group.” Social Work with Groups 28 (3/4): 49–68. Shields, S. A. 1986. “Busted and Branded: Group Work with Substance Abusing Adolescents in Schools.” Social Work with Groups 9: 61–81. Shulman, L. 1999. The Skills of Helping Individuals and Groups. 4th  ed. Itasca, IL: F. E. Peacock. Smith, T. E. 1985. “Group Work with Adolescent Drug Abusers.” Social Work with Groups 8 (1): 55–63. Taft, C. T., C. M. Murphy, J. D. Elliott, and T. M. Morrel. 2001. “Attendance Enhancing Procedures in Group Counseling for Domestic Abusers.” Journal of Counseling Psychology 48 (1): 51–60. Taft, C. T., C. M. Murphy, P. H. Musser, and N. Remington. 2004. “Personality, Interpersonal and Motivational Predictors of the Working Alliance in Group Cognitive Behavioral

Work with Involuntary Groups Therapy for Partner Violent Men.” Journal of Counseling and Clinical Psychology 72 (2): 349–354. Thomas, H., and T. Caplan. 1999. “Spinning the Group Process Wheel: Effective Facilitation Techniques for Motivating Involuntary Client Groups.” Social Work with Groups 2 (4): 3–21. Tolman, R. M., and G. Bhosley. 1987. “A Comparison of Two Types of Pregroup Preparation for Men Who Batter.” Journal of Social Service Research 13: 33–44. Trotter, C. 2015. Working with Involuntary Clients: A Guide to Practice. 3rd ed. London: Sage. van Wormer, K. 1987. “Group Work with Alcoholics in Recovery: A Phase Approach.” Social Work with Groups 10 (3): 81–98. van Wormer, K., and S. G. Bednar. 2002. “Working with Male Batterers: A RestorativeStrengths Perspective.” Families in Society 83 (5/6): 557–565. Whatules, L. J. 2000. “Communication as an Aid to Resocialization: A Case Study of a Men’s Anger Group.” Small Group Research 31 (4): 424–446. Yu, M. M., and T. Watkins. 1996. “Group Counseling with DUI Offenders: A Model Using Client Anger to Enhance Group Cohesion and Movement.” Alcoholism Treatment Quarterly 14 (3): 47–57.

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Part III

Practice Applications with Involuntary Problems and Settings

Part 3 examines work with involuntary clients in several practice settings to address a variety of issues. Chapter 12 presents work with domestic violence perpetrators as involuntary clients. Chapter 13 examines behavioral health care as an arena for involuntary contacts. Chapter 14 presents work with persons with dementia from a strength-oriented perspective. Chapter 15 presents substance abuse treatment as an arena for involuntary work. Chapter 16 describes work with unmotivated clients. Chapter 17 describes screening, brief intervention, and referral for treatment for students for alcohol issues and depression Chapter 18 examines involuntary work in public schools and chapter 19 applies the involuntary perspective to child welfare. The involuntary perspective in corrections settings is examined in Chapter 20. Chapter 21 presents applications of the involuntary perspective to the role of supervisors and managers in public social ser vices. Finally, Chapter 22 explores the nonvoluntary practitioner and the system.

Chapter 12

Work with Men in Domestic Abuse Treatment

Michael Chovanec

The purpose of this chapter is to introduce innovations in domestic abuse treatment that better engage men in the treatment process in an effort to reduce attrition and improve treatment effectiveness. First the extent of the problem is introduced, followed by a description of the link between domestic abuse treatment and involuntary clients. Treatment effectiveness and influencing factors, including methodological flaws, the attrition problem, and the use of the confrontational model, are described, followed by a discussion of innovative applications from various theories and models, including reactance theory, the Caplan and Thomas Group process model, the stages of change model combined with motivational interviewing, solution-focused treatment, and the Partners for Change Outcome Management System (PCOMS) to domestic abuse treatment. Finally, future treatment and research implications of these innovations are examined.

Introduction to the Problem of Domestic Abuse Domestic abuse is a social problem that impacts women and their families and the community. At least eight million women of all races and classes are battered by intimate partners each year and current patterns predict that between 20  percent and 50  percent of women will be victims of domestic abuse at some point in their lives (Roberts 1998). The National Institute of Justice found that domestic violence costs $67 billion per year in property

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Practice Applications with Involuntary Problems and Settings damage, medical costs, mental health care, police and fire ser vices, victim services, and lost worker productivity (Miller, Cohen, and Wiersema 1996). Group work has traditionally been the treatment of choice to address this significant social problem (Healey, Smith, and O’Sullivan 1999) and is recommended by the majority of state standards (Austin and Dankwort 1999). There are more than 1,500 batterer intervention programs nationwide that provide education and assist men in ending their abusive behaviors (Adams 2003). Group programs range from process oriented (Jennings 1987, 1990; Caplan and Thomas 1995, 2002, 2004; Caplan 2008; Stosny 1995; Dutton 2007) to the more structured approach that integrates cognitive behavioral, social learning, communication, and feminist theories (Edleson and Tolman 1992; Russell 1995; Babcock and Taillade 2000). The Duluth model, based on the psychoeducational program developed in Duluth, Minnesota (Pence and Paymar 1993; Pence and Shepard 1999), is probably the most widely applied in domestic abuse programs. The model defines abuse broadly to include emotional and economic abuse and the use of intimidation, coercion, and threats. The basic assumption is that men abuse women primarily to maintain power and control. The facilitator role includes holding men accountable for their abuse; keeping the group discussion on issues of violence, abuse, and control; and challenging, not colluding with, with men’s abusive belief system. While this confrontational model has been the treatment of choice for addressing domestic violence, some have challenged its effectiveness in addressing domestic violence. Approximately 60  percent to 80  percent of program completers end their violent behavior and fewer reduce their threats and verbal abuse (Gondolf 1997a, 2004). However, the methodology used to assess effectiveness has been questioned. In addition, high dropout rates of between 22 percent and 78 percent (Jewell and Wormith 2010) not only cloud the effectiveness issue but also create safety concerns for women whose partners are in domestic abuse treatment. Women often remain with partners who enroll in domestic abuse programs and expect them to complete the program and stop the abuse (Gondolf 1988). Yet, dropouts are more likely to reoffend than program graduates, putting their partners in dangerous potentially abusive situations (Palmer, Brown, and Barrera 1992; Gondolf 1997b; Sartin, Hanson and Huss 2006; Bennet et al. 2007).

Groups and Involuntary/Nonvoluntary Participation Group facilitators have the daunting task of working with this population of men, who at least initially are to some degree involuntary. Rooney (2009) breaks down involuntary clients into those who are formally mandated into programs through court orders and nonvoluntary clients who are pressured into attending. Men referred to domestic abuse treatment fit both categories.

Work with Men in Domestic Abuse Treatment Court-ordered programs for domestic abuse have multiplied since the early 1980s (Ganley 1987; Gondolf 1991). In 1997, 136,000 men were arrested on charges of domestic violence with 86 percent ordered into counseling (Hagen 1998). This trend continues today as a majority of men referred to domestic abuse treatment are court ordered (Jewel and Wormith 2010). Other men are nonvoluntary clients. These men are not formally courtordered; however, they are pressured to attend either by a partner threatening divorce, significant others pleading with them to get help, or professionals who influence their ability to access their families. In a qualitative study of men who had completed treatment, 90 percent had requested help only after their partners had left or had threatened to leave (Gondolf 1985). Thus, even if the potential client is not court-ordered, they encounter a variety of pressures to stop their abusive behaviors. The visibility of involuntary status with domestic abuse clients varies depending on whether men are mandated or nonvoluntary. Men who are formally mandated into a program are visible to the practitioner and agency. Nonvoluntary men are less visible, with sources of pressure to attend remaining unknown unless men are specifically asked about their pressures in the intake process. Involuntary status is fluid, as the client’s perception of coercion changes over time. Court-ordered men whose involuntary status is most visible are more likely to be labeled as resistant to change, yet individual changes occur from the time of arrest to the start of a domestic abuse program. For example, court or jail experience can increase men’s’ motivation to change. O’Hare (1996) found that in a sample of court-ordered mental health clients, 28 percent were already making efforts to change their behavior. This is important information for group facilitators who can easily ignore these individuals if they have a static view of involuntary status. Identifying men who have progressed further in the change process are valuable resources, both for group facilitators who can support changes made and for other group members in the program who are struggling with the change process.

Effectiveness of Domestic Abuse Treatment While outcome studies suggest high numbers of treatment completers ending physical abuse, methodological flaws and treatment attrition challenge the validity of these findings. Three published reviews calculated effect size for twenty-seven studies and found mixed results (Davis and Taylor 1999; Babcock, Green, and Robie 2004; Feder and Wilson 2005). Effect size identifies the extent to which treatment impacts the client’s presenting problem. Only Davis and Taylor reported a moderate effect size ranging from 0.108 to 0.946. This compares to effect sizes for treatment of depression from 0.65 to 2.15 (Asay

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Practice Applications with Involuntary Problems and Settings and Lambert 1999). What is unique about the domestic abuse setting is that even a small effect change results in a significant impact on women’s safety. Babcock et al. (2004) suggest that even a 5 percent reduction in violence results in approximately 42,000 women per year no longer being battered, taking into account all reported cases of domestic abuse in the United States. Outcome measures have included reduction in the conflict tactics scale as completed by participants, their partners, or both; posttreatment contact with police; and court records of posttreatment convictions. While studies selected for effect size analysis had quasi-experimental designs, including matched control groups and random assignment, methodological flaws continue to be a challenge. The use of victim reports rather than police records to measure recidivism impacts the treatment effect. For example, Feder and Wilson (2005) used victim reports in the calculation, which brought the effect size nearly zero. Murphy and Ting (2010) suggest that using only police reports to identify recidivism might not accurately capture the treatment effect. In addition, most studies report low numbers at follow-up for men and their partners, which can further cloud the actual treatment effect. There is also a lack of consistency across studies in regard to how treatment is defined, length of follow–ups, and even how treatment completion is defined. Attrition, as mentioned earlier, is a major factor impacting the effectiveness of domestic abuse treatment. In a meta-analysis of thirty studies, Jewell and Wormith (2010) reported attrition rates between 22 and 78 percent. High rates of attrition, with dropouts left out of the outcome analysis, can seriously inflate treatment success. Many studies examining attrition in domestic abuse treatment have focused on demographic variables, violence-related factors, and intrapersonal variables like alcohol and drug problem (Jewel and Wormith 2010). Men who have not been court-ordered, are unemployed, younger, less educated, or have lower incomes are more likely to drop out of treatment. Drug and alcohol problems and criminal history also increase the likelihood of dropout. Jewel and Wormith (2010) and others suggest that the lack of life stability greatly impacts the likelihood of dropout and program efforts to stabilize men’s life situations are recommended, such as job ser vices and transportation (Cadsky et al. 1996; Roy, Chateauvert, and Richard 2013). While these variables identify strong risk factors, they are limited in their usefulness in treatment.

Engagement in Domestic Abuse Treatment There are a growing number of studies that have begun to examine motivational factors and the process of change from both men’s and facilitators’ perspectives. These qualitative studies have generated a number of important themes that help us to understand the change process in domestic abuse treat-

Work with Men in Domestic Abuse Treatment ment. Men identify the importance of their own personal motivation for change and their willingness to take responsibility for their abuse (Chovanec 2012; Roy et al. 2013; Silvergleid and Mankowski 2006). Men report the importance of facilitators providing both support and challenge, as well as validation of their experiences (Silvergleid and Mankowski 2006; Chovanec 2009). Listening to other men’s stories and the support they received from other men in the group were also identified as very important in stimulating change in behavior (Chovanec 2012; Silvergleid and Mankowski 2006; Wangsgaard 2001). In addition, men report being motivated to learn new ideas and that learning was an important part of their change process (Chovanec 2012, 2014; Brownlee and Chielovic 2004). This fits the treatment context, as most programs have a psychoeducational component. It also suggests that education can be a way to engage the men without singling them out or shaming them for past abusive actions. Finally, for domestic abuse programs that use an openended group format, facilitators have identified the importance of identifying and supporting group leadership by the “veteran” group members (Silvergleid and Mankowski 2006; Chovanec 2009). These veterans can provide modeling and challenge newer members who are more resistant to change. Tetley, Jinks, Huband and Howells (2011) in their systematic review of forty-seven studies identifying forty measures of treatment engagement, articulated key indicators of engagement. While none of the studies had applied an engagement measure to men in domestic abuse treatment, an engagement instrument can have important utility within the field. Tetley et  al. (2011) identified six dimensions of treatment engagement, including attendance; completion of treatment within an expected time frame; completion of between-session tasks; expected contributions to the treatment sessions (i.e. self-disclosure, group activities; a working alliance with the group facilitator); and support and helpful behavior toward other group members. The group engagement measure (GEM) developed by Macgowen (1997) was identified as the measure that included the most indicators of treatment engagement. The GEM assesses seven dimensions of group engagement, including attendance, contributing, relating to facilitate with group members, and contracting and working on their own and others’ problems. The measure has been used with sex offenders (Levenson and Macgowan 2004), in chemical dependency (Macgowen 2006), and more recently in domestic abuse treatment (Chovanec 2012, 2016). In mea suring engagement over two points in time, the change in scores produced a moderate treatment effect (0.81) (Chovanec 2016). The GEM was completed by facilitators who worked with the men in the program so the change in scores reflects a change in facilitator perceptions. This was despite the fact that most men were court-ordered into the program. The GEM has been used as a clinical tool with group members in substance abuse treatment to dialog with facilitators about the engagement process (Macgowen 2006). In the same study, the subscale score that measured “working

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Practice Applications with Involuntary Problems and Settings on own problem” was found to be associated with program completion (t = 2.061, p = 0.043). This makes clinical sense, since men entering treatment typically are focused externally, on their partner or on the court system, and move to an internal focus as they begin taking responsibility for their past abuse. These findings suggest the GEM has potential utility in domestic abuse treatment. Holdsworth et al. (2014) also point to the lack of clarity in how engagement is articulated in the corrections literature. From their systematic review of forty-six studies they propose a theoretical framework to help focus future research and provide a guide for practitioners who want to examine engagement in domestic abuse treatment. They suggest three groupings of variables that more thoroughly articulate the engagement process in a correctional group that includes domestic abuse treatment. Determinant variables are present as men enter treatment and include client motivation, program responsivity, facilitator and peer support, and the out-of-group environment. Process variables include men’s attendance and group participation, including selfdisclosure and out-of-session tasks. Engagement and outcome variables include treatment completers or dropouts, treatment satisfaction, and behavioral change. In their review, Holdsworth et al. (2014) identify men’s participation in group, such as self-disclosure and tasks completed in between sessions as possibly more accurately reflecting engagement in behavioral change than attendance or treatment completion. Given the safety issue for the partners of men who drop out of treatment, ways to better engage men in the treatment process needs to be a key part of the discussion on best practices in domestic abuse treatment.

Standard Confrontational Approaches Impact Attrition Historically, due to safety concerns of the victims, batterer programs focused primarily on stopping physical abuse with little attention to the change process. The Duluth model focuses on confronting men’s rationalizations and challenges them to acknowledge responsibility for their abusive behavior (Pence and Paymar 1993). While the goal of helping batterers to accept responsibility for their abusive behavior is common in most treatment programs, the means to accomplishing this goal is controversial. While the effects of confrontation used in domestic abuse groups have not been researched, adverse effects can be found in other settings. Confrontational approaches were introduced in the chemical dependency field in the 1970s and 1980s (Thomas and Yoshioka 1989). Research in chemical dependency treatment supports the use of empathic rather than confrontational interventions for successful outcomes (Miller 1985; Miller and Rollnick 2012). Lambert and Bergin (1994) found that clients most at risk of deterioration within group

Work with Men in Domestic Abuse Treatment treatment were those with low self-esteem and impaired self-concepts. High-risk clients fit the description of many batterers (Hamberger and Hastings 1991; Dutton and Starzomski 1993; Jewell and Wormith 2010). Personality disorders and men with history of severe child abuse are common in this population (Hamberger and Hastings 1989; Faulkner et al. 1991; DeHart et al. 1999; Hamberger, Lohr, and Gottlieb 2000; Dutton 2007). Using a confrontational approach without acknowledging clients’ readiness for change limits engaging men in the treatment process. Murphy and Baxter (1997) question how well this confrontational approach supports the goals of safety and justice for battered women since research suggests increased risk for partners whose men drop out of treatment. The confrontational approach also calls into question what facilitators are modeling for abusive men when using confrontation to change behavior. With increased resistance to confrontations, the issues of power and control are more likely to be present between therapist and client (Mankowski, Haaken and Silvergleid 2002). This mirrors the dynamics many men have grown up with who enter domestic abuse treatment and contradicts the goal of moving men from inequality in power and control to more equality in relationships (Pence and Paymar 1993).

Evidence for Best Practices In recent years there has been a call for guidelines for empirically based treatment in clinical practice (Howard and Jenson 1999; Howard, Edmond, and Vaughn 2005). In domestic abuse, guidelines for best practices are in demand as states develop standards for treatment (Austin and Dankwort 1999). In the domestic abuse treatment literature, there is no empirical evidence to support greater effectiveness of one modality over another (Tolman and Bennett 1990; Saunders 1996; Davis and Taylor 1999; Gondolf 2000; Babcock, Green, and Robie 2004; Feder and Wilson 2005). However, variations in format appear to have some effect on treatment effectiveness. Groups offering more structure within a didactic format are more effective than didactic and discussion and self-help groups (Edleson and Syers 1989; Gondolf 1999). Also, short- and long-term treatments produce similar reductions in assault (Edleson and Syers 1989; Gondolf 1999).

Innovations in Domestic Abuse Treatment Practice innovations have evolved in an effort to reduce attrition and better engage abusive men in the change process. These innovations include: reactance theory; the stages of change model combined with motivational interviewing;

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Practice Applications with Involuntary Problems and Settings Thomas and Caplan’s group process model; the solution-focused treatment model for abusive men; and the Partners for Change Outcome Management System (PCOMS). These theories, feedback tools, and practice models have yet to be fully examined as to their impact on attrition and reducing abuse. While more research is needed, practice wisdom and some preliminary studies suggest these innovations deserve attention as potential best practices. Reactance theory applied to domestic abuse treatment suggests that men who are court-ordered or pressured from others to attend have lost the freedom to leave treatment without negative consequences. The theory suggests that these men demonstrate high levels of reactance or motivational arousal that is presented through an array of predictable behaviors, such as hostility toward a group leader or passive participation (Brehm and Brehm 1981). Chovanec (1995) confirms the assumption of high levels of reactance in men entering a domestic abuse program. A variety of interventions have been suggested to either reduce or increase reactance with individuals (Rooney 1992; Norcross, Beutler, and Clarkin 1998) and more recently with groups (Rooney and Chovanec 2017). For example, acknowledging pressures men experience and providing choices in programming help to reduce reactance upon entering a program. Assessing reactance early in the treatment process has been found to be useful in engaging general practice clients early on in the treatment process and increasing the chances for successful outcomes (Prochaska, Norcross, and DiClemente 1994; Beutler and Berren 1995; Beutler et al. 1996; Groth-Marnat 1997). This is also the case in working with child welfare clients (Mirick 2012). However, little attention has been given in examining reactance in the domestic abuse setting. The Thomas and Caplan (1999) group process model is included as an innovation since its emphasis is on process rather than on psychoeducational programming and it provides a variety of strategies for engaging men in the change process, potentially reducing the risk of dropout. Others in the field have also advocated for greater focus on relationships and process in domestic abuse treatment (Stosny 1995; Stefanakis 2008). Group techniques are categorized into process, inclusion, and linking interventions. The group facilitator uses process interventions to identify the emotional message behind the client’s statement and reflects the client’s world view. Common emotional themes found in domestic abuse clients’ stories include betrayal, abandonment, and powerlessness. Linking interventions are used to connect clients’ individual issues with others in the group and allow the group leader to make generalized statements about the group itself. Inclusion interventions encourage uninvolved group members to join the group discussion and include didactic and projective exercises that allow group members to voice their opinions without being singled out. These interventions have been explored as to how they can be used to help facilitators stay in the moment in uncomfortable exchanges with clients to further growth and avoid a confrontational impasse (Caplan

Work with Men in Domestic Abuse Treatment and Thomas 2002). Caplan (2008) further refines the model to help group workers build group cohesion and avoid power struggles. The stages of change model is another promising framework for addressing the attrition problem (Prochaska, Norcross, and DiClemente 1994; Norcross, Beutler, and Clarkin 1998; Prochaska 1999). It examines the process of change men go through as they enter domestic abuse treatment. The model suggests men move through five stages of change: precontemplation (limited recognition of their abuse); contemplation (acknowledge abuse but no behavioral change); preparation (small efforts toward change); action (active efforts to change); and maintenance (efforts to maintain changes made). The model has been applied to domestic abuse treatment with some success to assess men’s readiness for change and predict treatment completion (Murphy and Maiuro 2008; Alexander and Morris 2008; Scott 2004). Motivational interviewing is a practice model evolving out of the chemical dependency field to better engage involuntary clients entering treatment (Miller and Rollnick 2012). Resistance is reframed as ambivalence and is explored with the client. For example, clients are asked to identify negative and positive consequences of changing their behavior. Client self-motivating statements toward change are identified and supported. If not elicited by the client, the worker initiates these statements through self-reflective questions. The model has been used to better engage men in the early stages of domestic abuse treatment. In a systematic review of criminal offender treatments that include a few domestic abuse programs, McMurran (2009) found the application improved retention in treatment, enhanced motivation for change, and reduced offending. The model has been combined with stages of change as a treatment alternative to more traditional treatment such as the Duluth model (Pence and Paymar 1993). Murphy and Maiuro (2009) provide a collection of research and practice applications for work with perpetrators and victims of intimate partner violence, and examine the benefits and challenges of applying this model to domestic abuse treatment.

Specific Application of Innovations for Domestic Abuse Treatment The remainder of this chapter offers suggestions for applying these innovations to domestic abuse treatment throughout the stages of group development while examining men’s anticipated stages of change. Table 12.1 links interventions to group stages and to stages of change and provides a useful guide as we proceed through the treatment process. The Kurland and Salmon (1998) model of group development is also used because it includes a pregroup planning stage, which is a crucial element in domestic abuse treatment when examining ways to better engage men in treatment.

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Interventions and Stages of Change and Development

Adapted from R. H. Rooney and M. Chovanec (2017), p. 245.

7. Utilize criteria for group completion a. Plan for maintenance; prepare for lapse via role-play.

5. Support in planning actions; preparation for action, i.e., role-play, buddy systems. 6. Gather feedback on change attempts.

4. Deciding to make a change a. Assist in assessing costs and benefits of change. b. Provide information about choices c. Provide videos that dramatize consequences of not changing.

1. Decide on the nonnegotiable and negotiable elements of the program. 2. Pregroup orientation a. Initial orientation of group b. Anticipate resistance and reframe as ambivalence c. Clarify and validate choices 3. Emphasize joining and inclusion a. Provide opening statement addressing client’s initial concerns/fears. b. Clarify nonnegotiables. c. Support positive choices made to date. d. Provide emotional support. e. Explore ambivalence. f. Identify self-motivating statements g. Stimulate nonthreatening attention to issues. h. Use inclusive group exercises to pull in disengaged members. i. Support self-evaluation regarding possible problem. j. Review formal testing to provide information on potential problem. k. Use videos that dramatize impact of abuse. l. Continue to clarify nonnegotiables. m. Continue to clarify choices.

Interventions

Table 12.1

Ending

Middle

Beginning

Pregroup planning

Group Stage

Maintenance

Preparation Action

Contemplation

Precontemplation

Anticipated Level of Individual Motivation for Change

Work with Men in Domestic Abuse Treatment Pregroup Planning Pregroup planning is important in developing a program that responds effectively to men who are initially resistant to treatment and anticipates the varying degrees of readiness for change that men present. Reactance theory suggests that increasing choices and clarifying negotiable and nonnegotiable rules reduces reactance (Brehm and Brehm 1981; Wright, Greenberg, and Brehm 2004). It is important to identify in the program where choices can be offered and to clarify negotiable and nonnegotiable elements. For example, courtreferred men can be encouraged early in the intake process to check out other programs with regard to cost and time available before committing to one program. Men who are required to complete various tasks/exercises required for completion of the program (i.e., control plan, empathy exercise) may be given choices in terms of when they complete them. Applying the stages of change model to domestic abuse treatment suggests that men will be at varying stages of change when entering the program. While a majority of men can be anticipated to be in the precontemplation stage (i.e., they do not see a problem), a number of men may not (O’Hare 1996). Facilitators need to ask early on about the client’s perception of the problem, motivation to change, and the pressures to change. In addition, programs should set up a routine of gathering feedback from the men about their experience with the engagement process. The group engagement measure (GEM) assessment can be filled out by the men and reviewed with the facilitator as a way of strengthening engagement over time (Macgowen 2006). The PCOMS group session rating scale can also be used to examine the therapeutic alliance and provide a useful exchange between men and facilitators (Duncan and Miller 2007). Another important element of pregroup planning is the development of a prepared opening statement that is presented to men in either a first group or an orientation meeting with one or more men. Originally developed to anticipate client concerns and fears in contracting with voluntary groups (Schwartz 1976; Shulman 1999), the opening statement allows the facilitator to join with the potential group members by anticipating some of the major questions and concerns men bring with them as they enter the program. The statement can also be used to reduce reactance and support men’s preliminary efforts toward change. The following is an example of an opening statement one could use for men entering a domestic abuse program: Welcome to the program. I know many of you may feel you have been forced to come here. Many men who are in similar situations never make it to orientation. I support your choice in attending the program. (Validate choices made.) You may be anticipating that we will try to force you to change. The reality is that no one can make you change. (Comment on change process.) All we ask is that you listen to what we have

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Practice Applications with Involuntary Problems and Settings to say and take the bits and pieces of the program that make sense to you and that can help you avoid future problems and/or contact with the court system. You may also be fearing that you will be judged as guilty, or worse, shamed for the incident that brings you in. Many of you have already gone through the court system. We are not here to judge you as guilty or innocent for the charges you bring with you. Our focus is on helping you learn from whatever incident brings you in. Our task is to create a safe environment for men to examine their actions and learn from their mistakes. I will not tolerate physical or verbal abuse within group sessions. Those men who are abusive within the group will be asked to leave. In regard to confidentiality, we ask that all men keep confidential what is said within group. I cannot force group members to do this but expect men will do this in respect for others within group. (Clarify nonnegotiable group rules.) The exception to confidentiality for me as the facilitator is that if you tell me that you are in danger of hurting yourself or others I need to by law, report that information to other professionals or the authorities. Beginning Stage In anticipation of precontemplators, the focus is on exploring the change process of men entering treatment. Prochaska, DiClemente, and Norcross (1992) suggest the change process has both an experiential and behavior component. In the beginning of treatment, the focus is on the experiential, which includes men thinking about or reacting emotionally to abusive behavior they have been accused of using. Facilitators use reflective listening skills and encourage self-evaluation of the situation. The goal is to move men from not seeing a problem to considering they may have a problem and might want to address it. Negative consequences of using abusive behavior are explored, that is, court and jail experience and the impact the abusive incident had on significant others in their lives such as children or parents. Men are asked through the use of scale questions to self-evaluate the degree to which they feel responsible for the abusive incident. Including other group members in the discussion who may be further ahead in the change process is useful, as they often can identify with the men who do not see a problem and can offer ideas that helped them in the change process (i.e., talking to others, taking responsibility for self ). In addition, the use of inclusive group exercises, that is, check-in/out or pulling in disengaged group members in a nonthreatening way and asking for their input on group topics. The following is an example of work with a precontemplator in an early session. Joe is a twenty-seven-year-old who has been in and out of chemical dependency treatment. He reports that he was charged with fifth-degree

Work with Men in Domestic Abuse Treatment assault when he and his partner of several years got into an argument over an old boyfriend of hers who they had seen at a bar that night. Joe reports they were both drunk and the argument escalated to Joe shoving his partner, claiming he had no other choice. “I was trying to get her out of my face.” She promptly called police. Joe and his partner are no longer together. joe: I don’t know why I am here. She is the one that needs an anger program. Besides I am no longer with her and I have not drunk since this happened so this problem will never happen again. I don’t consider myself to have an anger problem. leader: Sounds like you are feeling forced into being here (Reflective skills). Given that you have come tonight tells me that at least part of you wants to figure out what happened to make sure it never happens again (Assuming ambivalence). A lot of men decide not to attend this group and go to jail instead so I support your choice (Validate choice to attend treatment). Even if you don’t reconnect with this partner you want to make sure this type of situation doesn’t happen (Possible client goal). Looking back on the incident, what part do you take responsibility for from 0  percent to 100 percent? (Encourage self-evaluation). Sounds like this argument caught you off guard and that things happened pretty quickly. joe: I take maybe 40  percent responsibility for what happened. I did shove her, but she forced me to do it. leader: Joe, it takes courage to take responsibility for your part in the past conflict. That 40 percent is what we will focus in on in this program since that is the part that you have control of. Who else in this group can identify with the strug gle to take responsibility for their part in past abuse? (Linking other men farther ahead in the change process.) Using the Duluth model, a group facilitator would work to avoid colluding with Joe, view his description of the problem as denial, and challenge his perception of the problem. In contrast, applying these innovations, the facilitator avoids challenging beliefs too early in the process and looks for change efforts to validate. The discussion of taking responsibility for abusive behav ior is brought up early and is seen on a continuum, with men taking more responsibility as they feel validated, separate from their abusive behaviors. Contemplators may also be present in the beginning of group as earlier research suggests (O’Hare 1996). The focus in domestic abuse treatment is on exploring the pros and cons of ending abusive behavior. Encouragement of self-evaluation continues gathering information on consequences of continuing abusive behav ior, like the effects of anger on one’s physical health or the impact of their children witnessing the abuse. Video that dramatizes the

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Practice Applications with Involuntary Problems and Settings impact of abuse on victims and their family members is also useful when men are in this stage (Stosny 1995). The goal is to help the client resolve their ambivalence about ending abusive behavior. Early on in the process, the facilitator should help men to articulate interpersonal and behavioral specific goals that are important to them (Lee, Uken, and Sebold 2012). Another alternative is using the Outcome Rating Scale (ORS) to assess their level of distress and develop tasks to reduce it (Miller and Duncan 2000). Other group members again can be extremely helpful, by providing information on the impact of abusive behavior and how they went about resolving their ambivalence toward the problem. The following is an example of work with a contemplator in an early session: joe: After a few sessions I have decided that I can’t do anything about that court order now so I might as well make the most out of it. I still think my ex-partner should have a group like this but I know I did shove her. I am realizing that I was a jerk at times. Things just started building up and when she got in my face and told me she didn’t love me anymore I couldn’t handle it. leader: It takes a lot of courage to look at oneself and take responsibility. What helped you do this? (Praising strengths.) joe: I don’t know, I just didn’t want to waste any more time; I just want to get it over with. leader: Sounds like you want to make sure this type of incident doesn’t happen again. Tell me more about how things started to build up. joe: Well like I said we were just talking and then things got a little out of hand and she got up in my face and was showing me up, saying she didn’t love me. leader: That must have been hard to hear. What things can you do to avoid this type of build up in the future? joe: I don’t know, maybe not respond right away when she mouths off at me. leader: So you have some choices about how you choose to respond to her. (Reinforcing choices.) Can you identify other things that might have set you off? joe: I had a bad day at work with my boss giving me a hard time. When I got home I started to get upset with the little things she said and before you know it we were screaming at each other. It happened so quickly. I’m not sure what I can do to avoid the pressure build up. All I know is that I don’t want to ever experience that again. leader: How many men can identify with Joe’s pattern of getting angry? [Many hands go up.] What have others done to deal with this pattern? Several other members now tell their stories of how they have gotten angry.

Work with Men in Domestic Abuse Treatment leader: The challenge is how to speak up [about concerns] without putting others down before things get out of hand. (Linking to other group members who have addressed this pattern of anger buildup.) Middle Stage In the middle group stage, with the earlier efforts of engaging men in the change process you will have men in the preparation and action stages of change. The stage fits well with a majority of teaching interventions identified in a traditional domestic abuse program. For example, the Duluth model identifies one of the roles of the facilitator as providing information on relationship skills and encouraging critical and reflective thinking (Pence and Paymar 1993). Teaching counter-conditioning and finding alternatives to abusive behavior is focused on in this stage, as well as offering reflective listening skills and messages to improve communication in relationships. Roleplaying and modeling behavior are useful in building men’s confidence to try out skills/ information learned in the group. Men’s efforts in completing between-session tasks should be explored and supported as it may be an indicator of behavioral change Holdsworth, et  al. (2014). Creating a group culture in which learning efforts are validated and men’s stories of change are focused on is recommended (Chovanec 2012, 2014; Silvergleid and Mankowski 2006). The goal of the facilitator is to support change efforts of the men and encourage selfevaluation and feedback from others to help refine their efforts to change. Daniels and Murphy (1997) encourage the use of “buddy” systems for social support as men try out various change efforts among their family and friends when they are in the action stage. Ending Stage In the ending group stage, most men are building confidence in changing their abusive behaviors and are ready to examine ways of maintaining their changes after group is completed. Identifying and supporting group leadership with veterans, particularly in open-ended groups, is impor tant (Silvergleid and Mankowski 2006; Chovanec 2009). On a program level, it is important that there are clear criteria for treatment completion, such as the number of tasks or sessions. This not only reduces reactance of men entering the program but also provides clear feedback to participants about their progress in the group. Clear criteria for program completion also is helpful to partners, families, and probation workers who are interested in the participant’s progress. Relapse is a particularly dangerous problem in domestic abuse treatment as it leads to reassault of partners. Useful relapse prevention strategies have been developed for domestic abuse treatment (Jennings 1990). Daniels and Murphy (1997) make a distinction in domestic abuse treatment between a

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Practice Applications with Involuntary Problems and Settings “lapse” that results in verbal and psychological abuse and a relapse that results in a reassault. They recommend focusing on lapses in men’s change efforts to reduce the risk of relapse. Men can be asked to identify situations that test their ability to be nonabusive. Once these situations are identified, men can brainstorm alternative strategies with the group to reduce their risk of becoming verbally or psychologically abusive. Requiring men while in the program to connect outside the group for a series of meetings to discuss ways to maintain their changes can also be helpful. The intent of the meetings is to increase the chance of men using former group members as support as they run into challenges once they have completed the program.

Summary This chapter has focused on the application of innovative models and theories to domestic abuse treatment. These innovations consist of program recommendations and interventions that facilitators can use to better engage men in the treatment process and to reduce the risk of future abusive behavior. While practice knowledge suggests these innovations can improve domestic abuse treatment, further research is needed to confirm this. Research on these innovations and their impact on attrition and treatment effectiveness will lead to more respectful and effective treatment of men and increased safety for women, children, and the community.

Discussion Questions 1. Reflect on your current domestic abuse group program. What elements of your program are negotiable/nonnegotiable with the group members? What elements in the program currently offer choices for the group members? What elements in the program could be modified to increase choices for group members? 2. What are the kinds of pressures you anticipate men having as they enter a treatment program for domestic abuse? 3. Reflect on a domestic abuse group program you will lead or are currently running. What are the important issues and questions you anticipate your group members will have in the first session? Include issues of authority (acceptance by the group leader) and intimacy (acceptance by the group members), and issues specific to your group. Write out an opening statement for the first session that addresses these concerns.

Work with Men in Domestic Abuse Treatment 4. Reflect on the stages of change (precontemplation, contemplation, preparation, action, and maintenance). Identify individual and group interventions that best fit each stage. 5. Reflect on the following process themes and how they might be presented in an involuntary group: marginalization, lack of respect, intimacy, avoidance of responsibility, incompetence, loss/grief, betrayal, abandonment, powerlessness. 6. Develop a collection of potential high-risk situations that could lead to relapse of the problem behavior your group focuses on. Have group members rate them on a one-to-five scale. Each member presents his or her most at-risk situation and uses the group to brainstorm strategies to address the situation.

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Practice Applications with Involuntary Problems and Settings Caplan, T. 2008. NEEDS-ABC: A Needs Acquisition and Behaviour Change Model for Group Work and Other Psychotherapies. London: Whiting and Birch. Caplan, T., and H. Thomas. 1995. “Safety and Comfort, Content and Process: Facilitating Open Group Work with Men Who Batter.” Social Work with Groups 18: 33–51. Caplan, T., and H. Thomas. 2002. “The Forgotten Moment: Therapeutic Resiliency and Its Promotion in Social Work with Groups.” Social Work with Groups 24 (2): 5–26. Caplan, T., and H. Thomas. 2004. “ ‘If We Are All in the Same Canoe, Why Are We Using Different Paddles?’ The Effective Use of Common Themes in Diverse Group Situations.” Social Work with Groups 27 (1): 53–73. Chovanec, M. G. 1995. “Attrition in the Treatment of Men Who Batter: A Closer Look at Men’s Decision-Making Process About Attending or Dropping Out of Treatment.” In Proceedings of the Eighth National Symposium on Doctoral Research and Social Work Practice, Ohio State University, November 3–4. Chovanec, M. G. 2009. “Facilitating Change in Group Work with Abusive Men: Examining Stages of Change.” Social Work with Groups 32 (1–2): 125–142. Chovanec, M. G. 2012. “Examining Engagement of Men in a Domestic Abuse Program from Three Perspectives: An Exploratory Multi-Method Study.” Social Work with Groups 35 (4): 362–378. Chovanec, M. G. 2014. “The Power of Learning and Men’s Stories in Engaging Abusive Men in the Change Process: Qualitative Study Across Programs.” Social Work with Groups 37 (4): 331–347. Chovanec, M. G. 2016. “Increasing Client Voice Within Involuntary Groups.” Social Work with Groups. doi:10.1080/01609513.2016.1201451. Daniels, J. W., and C. M. Murphy. 1997. “Stages and Processes of Change in Batterers’ Treatment.” Cognitive and Behavioral Practice 4 (1): 123–145. Davis, R. C., and B. G. Taylor. 1999. “Does Batterer Treatment Reduce Violence? A Synthesis of the Literature.” Women and Criminal Justice 10: 69–93. DeHart, D. D., R. J. Kennerly, L. K. Burke, and D. R. Follingstad. 1999. “Predictors of Attrition in a Treatment Program for Battering Men.” Journal of Family Violence 14 (1): 19–34. Duncan, B. L., and S. Miller. 2007. The Group Session Rating Scale (GSRS). Retrieved from http://heartandsoulofchange.com. Dutton, D. G. 2007. The Abusive Personality: Violence and Control in Intimate Relationships. 2nd ed. New York: Guilford. Dutton, D. G., and A. J. Starzomski. 1993. “Borderline Personality in Perpetrators of Psychological and Physical Abuse.” Violence and Victims 8: 327–337. Edleson, J. L., and M. Syers. 1989. Domestic Abuse Project Research Update (No. 2). Minneapolis, MN: Domestic Abuse Project, Inc. Edleson, J. L., and R. M. Tolman. 1992. Intervention for Men Who Batter: An Ecological Approach. Newberry Park, CA: Sage. Faulkner, K. K., R. Cogan, M. Nolder, and G. Shooter. 1991. “Characteristics of Men and Women Completing Cognitive-Behavioral Spouse Abuse Treatment.” Journal of Family Violence 6 (3): 243–254. Feder, L., and D. B. Wilson. 2005. “A Meta-Analytic Review of Court Mandated Batterer Intervention Programs: Can Court Effect Abusers’ Behavior?” Journal of Experimental Criminology 1: 239–262. Ganley, A. 1987. “Perpetrators of Domestic Violence: An Overview of Counseling the CourtMandated Client.” In Domestic Violence on Trial, ed. D. Sonkin, 155–177. New York: Springer. Gondolf, E. W. 1985. “Fighting for Control: A Clinical Assessment of Men Who Batter.” Social Case-work 66 (January): 48–54.

Work with Men in Domestic Abuse Treatment Gondolf, E. W. 1988. “The Effects of Batterer Counseling on Shelter Outcome.” Journal of Interpersonal Violence 3 (3): 275–289. Gondolf, E. W. 1991. “A Victim-Based Assessment of Court-Mandated Counseling for Batterers.” Criminal Justice Review 16: 214–226. Gondolf, E. W. 1997a. “Batterer Programs: What We Know and Need to Know.” Journal of Interpersonal Violence 12 (1): 83–98. Gondolf, E. W. 1997b. “Patterns of Reassault in Batterers’ Programs.” Violence and Victims 12: 373–387. Gondolf, E. W. 1999. “A Comparison of Reassault Rates in Four Batterer Programs: Do Court Referral, Program Length, and Ser vices Matter?” Journal of Interpersonal Violence 14: 41–61. Gondolf, E. W. 2000. “A 30-Month Follow-up of Court-Referred Batterers in Four Cities.” International Journal of Offender Therapy and Comparative Criminology 44 (1): 111–128. Gondolf, E. W. 2004. “Evaluating Batterer Counseling Programs: A Difficult Task Showing Some Effects and Implications. Aggression and Violent Behavior 9: 605–631. Groth-Marnat, G. 1997. Handbook of Psychological Assessment. 3rd ed. New York: John Wiley. Hagen, M. A. 1998. “Bad Attitude.” National Review 50 (13): 38–39. Hamberger, L. K., and J. E. Hastings. 1989. “Counseling Male Spouse Abusers: Characteristics of Treatment Completers and Dropouts.” Violence and Victims 4: 275–286. Hamberger, L. K., and J. E. Hastings. 1991. “Personality Correlates of Men Who Batter and Nonviolent Men: Some Continuities and Discontinuities.” Journal of Family Violence 6: 131–147. Hamberger, L. K., J. M. Lohr, and M. Gottlieb. 2000. “Predictors of Treatment Dropout from Spouse Abuse Abatement Program.” Behavior Modification 24 (4): 528–552. Healey, K., C. Smith, and C. O’Sullivan. 1999. Batterer Intervention: Program Approaches and Criminal Justice Strategies. Collingdale, PA: DIANE Publishing. Holdsworth, E., E. Bowen, S. Brown, and D. Howat. 2014. “Offender Engagement in Group Programs and Associations with Offender Characteristics and Treatment Factors: A Review.” Aggression and Violent Behavior 19: 102–121. doi:10.1016/j.avb.2014.01.004. Howard, M. O., T. Edmond, and M. G. Vaughn. 2005. “Mental Health Practice Guidelines: Panacea or Pipedream?” In Mental Disorders in the Social Environment: Critical Perspectives, ed. S. Kirk, 270–292. New York: Columbia University Press. Howard, M. O., and J. M. Jenson. 1999. “Clinical Practice Guidelines: Should Social Work Develop Them?” Research on Social Work Practice 9 (3): 283–301. Jennings, J. L. 1987. “History and Issues in the Treatment of Battering Men: A Case for Unstructured Group Therapy.” Journal of Family Violence 2 (3): 193–213. Jennings, J. L. 1990. “Preventing Relapse versus “Stopping” Domestic Abuse Violence: Do We Expect Too Much Too Soon from Battering Men?” Journal of Family Violence 5 (1): 43–60. Jewell, L. M., and J. S. Wormith. 2010. “Variables Associated with Attrition from Domestic Violence Treatment Programs Targeting Male Batterers: A Meta-Analysis.” Criminal Justice and Behavior 37 (10): 1086–1113. Kurland, R., and R. Salmon. 1998. Teaching a Methods Course in Social Work with Groups. Alexandria, VA: Council on Social Work Education. Lambert, M. J., and A. E. Bergin. 1994. “The Effectiveness of Psychotherapy.” In Handbook of Psychotherapy and Behavior Change, 4th ed., eds. A. E. Bergin and S. I. Garfield, 143–189. New York: John Wiley. Lee, M. Y., A. Uken, and J. Sebold. 2012. “Solution-Focused Model with Court-Mandated Offenders.” In Solution-focused Brief Therapy, eds. C. Franklin, T. Trepper, W. Gingerich, and E. McCollum, 165–182. New York: Oxford University Press.

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Practice Applications with Involuntary Problems and Settings Levenson, J., and M. Macgowan. 2004. “Engagement, Denial and Treatment Progress Among Sex Offenders in Group Therapy.” Sexual Abuse 16 (1): 49–63. Macgowan, M. J. 1997. “A Mea sure of Engagement for Social Group Work: The Groupwork Engagement Mea sure (GEM).” Journal of Social Service Research 23 (2): 17–37. doi:10.1300/ J079v23n02_02. Macgowan, M. 2006. “Mea suring and Increasing Engagement in Substance Abuse Treatment Groups: Advancing Evidence-Based Group Work.” Journal of Groups in Addiction and Recovery 1 (2): 53–67. doi:10.1300/J384v01n02_05. Mankowski, E. S., J. Haaken, and C. S. Silvergleid. 2002. “Collateral Damage: An Analysis of the Achievements and Unintended Consequences of Batterer Intervention Programs and Discourse.” Journal of Family Violence 17: 167–184. McMurran, M. 2009. “Motivational Interviewing with Offenders: A Systematic Review.” Legal and Criminology Psychology 14: 83–100. Miller, S. D., and B. L. Duncan. 2000. “The Outcome Rating Scale (ORS).” http://heartand soulofchange.com. Miller, T., M. Cohen, and B. Wiersema. 1996. Victim Costs and Consequences: A New Look. Washington, DC: U.S. Department of Justice, National Institute of Justice. Miller, W. R. 1985. “Motivation for Treatment: A Review with Special Emphasis on Alcoholism.” Psychological Bulletin 98: 84–107. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Preparing People for Change. 3rd ed. New York: Guilford. Mirick, R. G. 2012. “Reactance and the Child Welfare Client: Interpreting Parents’ Re sistance to Ser vices through the Lens of Reactance Theory.” Families in Society 93 (3): 165–172. Murphy, C., and V. Baxter. 1997. “Motivating Batterers to Change in the Treatment Context.” Journal of Interpersonal Violence 12 (4): 607–619. Murphy, C. M., and R. D. Maiuro. 2008. “Understanding and Facilitating the Change Process in Perpetrators and Victims of Intimate Partner Violence: Summary and Commentary.” Violence and Victims 23 (4): 525–536. Murphy, C. M., and R. D. Maiuro. 2009. Motivational Interviewing and Stages of Change in Intimate Partner Violence. New York: Springer. Murphy, C. M., and L. A. Ting. 2010. “Interventions for Perpetrators of Intimate Partner Violence: A Review of Efficacy Research and Recent Trends.” Partner Abuse 1 (1): 26–44. Norcross, J. C., L. E. Beutler, and J. F. Clarkin. 1998. “Prescriptive Eclectic Psychotherapy.” In Paradigms of Clinical Social Work, vol. 2, ed. R. A. Dorfman, 289–314. New York: Brunner/ Mazel. O’Hare, T. 1996. “Court-Ordered versus Voluntary Clients: Problem Differences and Readiness for Change.” Social Work 41 (4): 417–422. Palmer, S. E., R. A. Brown, and M. E. Barrera. 1992. “Group Treatment Program for Abusive Husbands: Long-Term Evaluation.” American Journal of Orthopsychiatry 62 (2): 276–283. Pence, E., and M. Paymar. 1993. Education Groups for Men Who Batter: The Duluth Model. New York: Springer. Pence, E., and M. Shepard, eds. 1999. Coordinating Community Responses to Domestic Violence: Lessons Learned from Duluth and Beyond. Thousand Oaks, CA: Sage. Prochaska, J., C. C. DiClemente, and J. Norcross. 1992. “In Search of How People Change: Applications to Addictive Behaviors.” American Psychologist 47 (9): 1102. Prochaska, J., J. Norcross, and C. C. DiClemente. 1994. Changing for Good. New York: Avon Books.

Work with Men in Domestic Abuse Treatment Prochaska, J. O. 1999. “How Do People Change and How Can We Change to Help Many More People?” In The Heart and Soul of Change: What Works in Therapy, eds. M. Hubble, B. Duncan, and S. Miller, 227–255. Washington DC: American Psychological Association. Roberts, A. R. 1998. Battered Women and Their Families: Intervention Strategies and Treatment Approaches. 2nd ed. New York: Springer. Rooney, R. H. 1992. Strategies for Work with Involuntary Clients. New York: Columbia University Press. Rooney, R. H., ed. 2009. Strategies for Work with Involuntary Clients. 2nd Ed. New York: Columbia University Press. Rooney, R., and M. Chovanec. 2017. “Social Work with Involuntary Groups.” In Handbook of Social Work with Groups, eds. C. D. Garvin, L. M. Gutierrez, and M. J. Galinsky, 237–254. New York: Guilford. Roy, V., J. Chateauvert, and M- C. Richard. 2013. “An Ecological Examination of Factors Influencing Men’s Engagement in Intimate Partner Violence Groups.” Journal of Interpersonal Violence 28 (9): 1798–1816. Russell, M. 1995. Confronting Abusive Beliefs: Group Treatment for Abusive Men. Thousand Oaks, CA: Sage. Sartin, R. M., D. J. Hansen, and M. T. Huss. 2006. “Domestic Violence Treatment Response and Recidivism: A Review and Implications for the Study of Family Violence.” Aggression and Violent Behavior 11: 425–440. http://dx.doi.org /10.1016/j.avb.2005.12.002. Saunders, D. 1996. “Feminist-Cognitive-Behavioral and Process-Psychodynamic Treatments for Men Who Batter: Interaction of Abuser Traits and Treatment Models.” Violence and Victims 11: 393–414. Schwartz, W. 1976. “Between Client and System: The Mediating Function.” In Theories of Social Work with Groups, eds. R. R. Roberts and H. Northen, 186–188. New York: Columbia University Press. Scott, K. 2004. “Stage of Change as a Predictor of Attrition Among Men in a Batterer Treatment Program.” Journal of Family Violence 19 (1): 37–47. Shulman, L. 1999. The Skills of Helping Individuals and Groups. 4th  ed. Itasca, IL: F. E. Peacock. Silvergleid, C. S. and E. S. Mankowski. 2006. “How Batterer Intervention Programs Work: Participant and Facilitator Accounts of Processes of Change.” Journal of Interpersonal Violence 21: 139–159. Stefanakis, H. 2008. “Caring and Compassion with Working with Offenders of Crime and Violence.” Violence and Victims 23 (5): 652–661. Stosny, S. 1995. Treating Attachment Abuse: A Compassion Approach. New York: Springer. Tetley, A., Jinks, M., Huband, N., and Howells, K. 2011. “A Systematic Review of Therapeutic Engagement in Psychosocial and Psychological Treatment.” Journal of Clinical Psychology 67 (9): 927–941. doi:10.1002/jclp.20811. Thomas, E., and M. Yoshioka. 1989. “Spouse Interventive Confrontation in Unilateral Family Therapy for Alcohol Abuse.” Social Casework 70: 340–347. Thomas, H., and T. Caplan. 1999. “Spinning the Group Process Wheel: Effective Facilitation Techniques for Motivating Involuntary Client Groups.” Social Work with Groups 2 (4):3–21. Tolman, R., and L. Bennett. 1990. “A Review of Quantitative Research on Men Who Batter.” Journal of Interpersonal Violence 5: 87–118. Wangsgaard, S. M. 2001. “The Participants’ Perspectives: Factors of Batterer Group Treatment That Facilitate Change. Dissertation Abstracts International 61 (11B): 6153. Wright, R. A., J. Greenberg, and S. S. Brehm. 2004. Motivational Analysis of Social Behavior. Hillsdale, NJ: Lawrence Erlbaum.

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Chapter 13

Integrated Care and Health Disparities Critical Patient-Provider Considerations

Tamara S. Davis and Adriane Peck

Integrated care (IC) is an umbrella term used to identify systematic approaches that bring together physical health and mental health care in ways that address barriers to care (Thielke, Vannoy, and Unutzer 2007; Valentijn et al. 2013). Key barriers include cultural norms and stigma around the use of mental health ser vices, poverty and a lack of adequate insurance, access to care in a fragmented ser vice system, and language when English is not one’s first language. Other barriers include transportation, scheduling conflicts, lack of motivation, and resistance (i.e., attitudes toward behavioral health care and patient stage of change), and a perception that behavioral health services are not effective and the patient can handle the issue alone (Mojtabai et al. 2011). The term “integrated care” refers to models of care that are co-located, collaborative, or integrated (Peek 2013) and that coordinate services across multiple levels. This is in contrast to “integrative” medicine, which refers to mind, body, spirit, and incorporates complementary and alternative forms of medicine such as meditation and mindfulness (Shiver and Cantiello 2016). Integrating behavioral health ser vices into primary care settings, particularly in public community health centers, is arguably the fastest growing approach to integration, largely brought about by health care reform. Well-documented disparities in health and mental health among diverse populations of the United States greatly contribute to recent efforts to integrate behavioral health ser vices into community primary care settings. Policy makers and researchers alike contend that integrated, effective, and efficient

Integrated Care and Health Disparities health care systems can serve to address inequities in accessing quality care (Dall 2011; Adams and Corrigan 2003; Sharfstein 2011). Initiatives underway to integrate behavioral health ser vices into primary care practice nationwide were accelerated by the Affordable Care Act (ACA). Aligning with interests of social work, the ACA recognizes and aims to address social determinants contributing to people’s health status, such as poverty, fragmentation of services, and the lack of health insurance, by increasing access to holistic care (Kocher, Emanuel, and DeParle 2010; Miller, Talen, and Patel 2013; Shim et al. 2012). Perhaps less central to the discussion is that even with increased access, cultural norms regarding the use of health care, especially behavioral health care, impacts individual decisions to seek available ser vices (National Center for Health Statistics 2012; National Research Council 2001). For example, immigrant communities and persons diagnosed with serious mental illness are more likely to encounter social related barriers to care (O’Day et  al. 2005; Satcher, Pamies, and Woelfl 2006) and may be less likely to present in a primary care health setting. In contrast, domestic persons of color often seek ser vices for mental health concerns from their primary care physicians. Seemingly absent from burgeoning integrated care discourse is a critical examination of the notion that not all patients want to discuss or receive treatment for behavioral health concerns. While typical patients receiving ser vices in community health settings are not under court mandate to obtain care, incorporating behavioral health into standard primary care practice raises questions around the involuntary nature of integrated care from both patient and provider perspectives and whether the benefits of integrated care are assumed to outweigh any such concerns. Providers and patients alike are asked to deliver and receive care in a different way and may “resist” participating in these new models of health care. Successfully implementing integrated care requires behavioral health clinicians to learn effective strategies to empower both patients and providers to confidently assume responsibility for their respective roles in patient-centered medical homes.

Integrated Care and Health Disparities Low income, aging, uninsured, rural, ethnic, racial, and LGBTQ populations are disproportionately affected by disparities in access to quality health and mental health ser vices (U.S. Agency for Healthcare Research and Quality 2013; Smedley, Stith, and Nelson 2003; U.S. Department of Health and Human Ser vices [USDHHS] 2001; Wang et al. 2005). As such, ethnic and racial minorities experience longer delays and lower rates of receiving mental health care (Miranda et  al. 2008; Wang et  al. 2005). Ser vices received, regardless of care setting, often are not evidence-based or culturally

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Practice Applications with Involuntary Problems and Settings and linguistically relevant, and are wrought with mistrust, discriminatory practices, fragmentation, and low consumer and family engagement (USDHHS 2001). Many who study the roots of disparities in mental health point to the pervasive societal stigma around mental illness (USDHHS 2003; USDHHS 1999, 2001). Among the general population, 60 percent of adults and 80 percent of children and youth who need specialty mental health care never get to a conventional specialty mental health agency for treatment (Wang et al. 2005; American Academy of Child and Adolescent Psychiatry [AACAP] 2009). Stigma as a barrier to behavioral health care is greatest for populations of color (Conner et al. 2010; Vega, Rodriguez, and Ang 2009). Cultural beliefs around mental illness and seeking ser vices inhibit people from going to conventional behavioral health agencies. The Affordable Care Act’s support of collaborative health care and emphases on prevention and wellness suggest integrated care in patient-centered medical homes can help to reduce the impact of societal stigma on seeking behavioral health services (Shim et al. 2012). Patient-centered medical homes are models of primary care that provide accessible, high quality comprehensive and coordinated care to meet physical and mental health needs in partnership with patients (https://pcmh.ahrq.gov/page/defining-pcmh). The very act of deliberately attending to both the mind and body at the same primary care appointment offers patients an opportunity to share information they may not share with the primary care provider. Historically, racial and ethnic minorities first utilize primary care to address their mental health care needs (Snowden and Pingatore 2002; Vega et  al. 1999). Hence, racial and ethnic minorities are projected to be among the greatest beneficiaries of integrated care practices. What follows, then, is the potential for integrated care, particularly in community health centers, to help reduce health disparities (Grantmakers In Health 2013; Shiver and Cantiello 2016). The next section explores involuntary challenges experienced by patients and providers respectively followed by strategic responses. Ideas shared are based on both the literature and the authors’ experience working with a multisite community health center to integrate professional social workers and students to provide behavioral health care. The final section explores patient experiences of integrated care and critical considerations for moving the field forward.

Involuntary Considerations in Community Health Involuntary Patient Challenges in Integrated Care Settings The intrinsic nature of the system of primary care health centers with integrated behavioral health ser vices implies a certain level of patient willingness

Integrated Care and Health Disparities to receive care. Unlike some community mental health agencies and psychiatric hospitals, patients are not legally mandated to participate in or receive treatment in community health primary care centers. This does not mean, however, that patients do not experience pressures from other sources to seek medical attention, pursue care within specific health care systems, report certain symptoms or maintain loyalty to specific providers. Patient Challenge: Pressures to Seek Medical Care Patients experiencing mental health concerns may be influenced by family members or friends, or they might need primary care for employment, school, or some other obligation to obtain care. Patients may also seek care due to medical issues and symptoms they are no longer willing or able to tolerate. In all of these scenarios, patients may hold various levels of opposition to seeking and receiving medical care, which adds an involuntary element to their status as a patient from the onset. Patients opposed to receiving care even at a traditional primary care setting may experience greater reluctance if choosing to go to a center with integrated care where they will be assessed, treated, and evaluated by several types of care providers, such as a behavioral health clinician, dietician, and pharmacist. From a professional’s standpoint, integrating behavioral health and primary care via separate specialty providers located within the same facility principally seems like a positive and improved approach when the focus is on overall patient outcomes, particularly for patients with comorbid physical health and mental health conditions. However, from the patient’s perspective, the integrated care model may not always be appreciated or well received. Although in our experience patients are never forced (and are not “intentionally” pressured) to complete behavioral health screenings, they still may be less than ready or willing to answer these types of questions on screening tools. Patients can be taken off guard because they are not expecting this specific line of questioning. When patients screen positive they may be unprepared for the implications of their results, as they could be indicative of substantive mental health concerns and ultimately result in a mental health diagnosis. While the argument could be made that most patients are not fully prepared to receive any type of adverse medical diagnosis, the stigma that surrounds mental illness and the fact that it may not be the patient’s chief complaint contribute to a perception of involuntariness of participating in integrated care treatment models. When patients seek medical care due to pressures from others, the addition of a behavioral health screening as a routine part of a patient appointment can increase this perception.

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Practice Applications with Involuntary Problems and Settings Patient Challenge: Lack of Provider Options Contributing to a perception of involuntary patient participation in integrated care is the lack of choice many community health center patients have regarding which health system or providers they are able to use. Patients may face many barriers that decrease their ability to access quality health care, such as finances, insurance coverage, immigration status, transportation, and language barriers (Kocher, Emmanuel, and DeParle 2010; Miller, Talen, and Patel 2013). For patients with few health care options, they may be pressured to seek care in a location that utilizes an integrated care model, even if this is not the patient’s preference. In other instances, patients may have choices in health centers, but little if any choice in the specific provider they see at the health center. In these cases, patient care is subject to the approach of the medical provider.

Patient Challenge: Pressure to Report Symptoms When patients are screened for behavioral health symptoms as part of physical health appointments, they may feel pressured to report various symptoms before they would have chosen to report them, if at all, or had they waited to visit a specialty mental health agency. While an implied level of readiness for change is assumed when patients voluntarily seek help directly from a mental health agency, this is not necessarily the case in a primary care setting. Thus, when behavioral health clinicians engage with patients during medical appointments, patients may sense more internal involuntariness than members on both sides of the treatment team are aware of or acknowledge.

Patient Challenge: Loyalty and Lack of Empowerment Patients with established care within a health system can feel a sense of loyalty to their primary care providers. Thus, patients may feel pressured to comply with provider suggestions, which may be more likely to include behavioral health interventions in an integrated care setting than in a traditional primary care setting. If patients screen positive for behavioral health issues but are not yet at the stage of change (Prochaska, DiClemente, and Norcross 1992; Prochaska et al., 1994) to accept treatment, patients may experience increased pressures, stress, and overall resistance to participate in any aspect of their health care. When patients do not feel empowered enough to voice their opinions it can lead to increased treatment resistance, decreased compliance with physician recommendations, and, potentially, overall withdrawal from care. In contrast, where patients hold high trust in their primary care provider patient resistance to receiving behavioral health ser vices may lessen and compliance may increase.

Integrated Care and Health Disparities The challenges leading to resistance from both sides of the treatment relationship certainly impact the overall goals of positive health outcomes, wellness, and satisfaction with high quality health care that all relevant parties share. Through research, observation, and reflection, trial and error, and general experience, we have identified strategies to address these challenges and improve the overall provision of health care in an integrated care setting.

Involuntary Provider Challenges in Integrated Care Settings Involuntary aspects exist on both sides of the treatment relationship in any setting. Resistance originating from health-care providers in primary care settings with integrated behavioral health ser vices is a crucial factor to address in overcoming involuntariness in the treatment relationship. First, true behavioral health integration is a new concept for many health systems and requires changes in how clinicians practice. Change can be difficult for providers accustomed to practicing in certain ways. Health-care systems employ medical providers with a plethora of diverse practice experiences, cultures, specialties, and styles. Consequently, provider resistance could be tied to new practice requirements they must implement relative to integrated care. Second, healthcare systems approach integrated care implementation in various ways. How staff are trained on new procedures matters. Without training, ancillary staff may feel a lack of investment and resist the transition to integrated care. In the following section we discuss specific challenges of integrating behavioral health ser vices as observed by behavioral health clinicians and medical providers in the primary health care settings in which we work.

Provider Challenge: Patients’ Presenting Issues Medical providers are trained to address patients’ chief presenting problems and often do not have time to consider multiple secondary patient concerns. In primary care settings chief articulated concerns generally relate to physical health rather than mental health, resulting in prioritizing treatment of physical health issues. Although patients may not always volunteer mental health concerns, a lack of consistency exists among medical providers regarding their assessment of mental health issues, especially when patients identify physical health issues as their chief complaints (Donaldson et al. 1996). Some providers express resistance to routine screening for mental health symptoms due to various factors that impact their ability to address these types of issues. Even when behavioral health issues are a patient’s articulated presenting issue, medical providers are not always comfortable managing mental health symptoms and frequently default to referring the patient for specialty behavioral health

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Practice Applications with Involuntary Problems and Settings care outside of the primary care setting. The external referral-based method can be detrimental to patients, as it increases chances of patients getting lost in bifurcated systems of physical and mental health care. Prioritizing physical health issues without mental health screenings, as well as using traditional referral-based approaches to address identified behavioral health concerns, may stem from provider resistance and can lead to increased barriers to receiving quality behavioral health care for patients.

Provider Challenge: Logistics Health-care providers operate under the auspices of the health system for which they are employed and are therefore subject to the scheduling, space, workflow, billing, productivity requirements, and ancillary staffing preferences of the agency. Providers often maintain full schedules and specific expectations for productivity and efficiency, limiting their ability to address numerous patient concerns in a single encounter (Gask 2005). These factors contribute to medical providers prioritizing chief physical complaints (often more obvious) over subtler mental health concerns. In integrated care settings, mental health ser vices are rendered by behavioral health clinicians in the same space (exam rooms) in which medical providers operate. The inclusion of an additional clinical ser vice lengthens the time for exam room turnover and general workflow, which can negatively impact physician scheduling and productivity requirements tied to billing and payment. These significant logistical challenges are central to understanding medical provider resistance to integrated models of care.

Provider Challenge: Stigma of Mental Illness and Provider Attitudes Unfortunately, mental illness remains highly stigmatized in society, and health care providers are not impervious to this trend (Smith and Cashwell 2010). People experience biases to different degrees, and preconceptions about mental illness permeate even the professions of those in the helping professions, such as physicians, nurses, medical assistants, and interpreters (Smith and Cashwell 2010). Behavioral health clinicians, often to a lesser extent, may also unknowingly harbor negative perceptions of people with mental illness. Negative biases toward mental illness can lead providers, consciously or unconsciously, to ignore the signs and symptoms of mental illness, make judgments about patients that affect quality of care, deny the significance of mental illness to a patient’s recovery, utilize ineffective techniques to address concerns, or resist treating the patient’s mental health condition at all. Health-care professional attitudes toward one another also contribute to the challenges of integrating care. Physicians retain ultimate authority in

Integrated Care and Health Disparities the medical model and as such are prioritized during a medical appointment in an integrated care setting. Behavioral health clinicians often must negotiate with the medical team to see patients. When physicians harbor negative feelings or attitudes toward behavioral health, and behavioral health clinicians by extension, the overall efficacy of the treatment team suffers (Gask 2005). Health- care providers may underutilize behavioral health ser vices or resist behavioral health clinician input into the patient’s care plan. Observed hierarchical clashes or hostile interprofessional interactions can result in ineffective and sometimes negative communications with patients. When health-care providers experience negative attitudes toward patients with behavioral health issues, patients are less likely to comply with medical recommendations and often experience worse outcomes than patients receiving care from less biased providers (Smith and Cashwell 2010). Provider Challenge: Training and Education In integrated care settings, primary care providers come with vastly different training, clinical experiences, and overall practice styles (Jenkins and Strathdee 2000). Training areas of significance to integrated care include behavioral health assessment (including crises), behavioral health symptoms and diagnoses, relationships between mental and physical health, importance of and evidence supporting integrated care and its implementation, and the scope of practice for various types of behavioral health providers. Although many primary care providers are willing to address and treat milder symptoms of mental illness, there are just as many who are unwilling or unable to do so (Gask 2005). Of particular concern are providers who lack knowledge and skills to adequately treat mental health conditions but attempt to do so with less information than is needed for effective care. Primary care providers are understandably concerned about risk management and liability. Asking patients about risk factors may significantly increase liability over not asking about, assessing for, or acknowledging potential risk factors. The lack of assessment, however, does not mean the patient is not challenged by mental health conditions, and ignoring related symptoms and risk factors can lead to worse overall patient outcomes (Smith and Cashwell 2010) and more expensive care in the long term. As integrated care increasingly becomes the expectation and not the exception, providers resistant to integrated care may soon be liable if they do not explore and address mental health concerns. Educating providers about mental health can increase their willingness to participate in integrated care treatment approaches as well as the degree to which they are willing to engage.

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Strategic Responses: Creating a Patient-Centered Environment Providing Excellent Customer Service Several strategies can help address the issue of patient-experienced pressures to seek medical care, including: excellent customer ser vice, patient choice of language, helpful explanation of ser vices and patient options, and operative engagement and communication styles by all health center staff. Every patient interaction matters, as the patient experience begins before the patient encounters the actual health-care providers. Patient-staff interactions influence patient perceptions of the agency, the providers, quality of care, satisfaction, trust in treatment recommendations, and willingness to return for care (Sofaer and Firminger 2005). These factors can ultimately influence health outcomes, as patients perceiving better engagement report better health outcomes (Gill 2013). All staff should be trained to provide excellent customer ser vice, including courteous interpersonal engagement; cultural awareness; respect; professionalism; knowledge and per formance of job; and overall positive regard toward patients, treating them as customers with choices concerning their health care. Patients expect health center staff to have a working knowledge of integrated care, such as the ser vices provided, how to access those ser vices, and what those ser vices may entail. The addition of various types of professionals to the typical primary care team means more moving parts within the health center. Team-based approaches are more seamless when interdisciplinary team members know and understand one another’s contributions to care. The following text box provides examples across typical patient interactions of the need for all team members to understand the role of behavioral health clinicians within a primary care setting.

Examples of Need to Understand Role of Behavioral Health Clinician Example 1 A patient navigation specialist receives a phone call regarding a patient experiencing a mental health crisis and should know that there are behavioral health clinicians on staff, where they are located, how to contact them, and which circumstances warrant contacting them.

Integrated Care and Health Disparities Example 2 Front desk personnel are often the first staff members to interact with patients during their appointments and may be the first to notice signs of emotional distress. If a patient escalates emotionally regarding a bill or wrong appointment time, for example, the front desk staff should be able to follow protocol to contact a behavioral health clinician within the health center to help deescalate. (Without behavioral health clinicians, some situations may escalate to the point of needing law enforcement.) Example 3 Medical assistants (MAs) check in with patients to get their vitals and details about presenting issues. Patients may reveal details that indicate potentially significant life stressors or symptoms of mental illness during this checkin period. MAs should be trained to recognize warning signs and know when to contact a behavioral health clinician for further assessment and intervention.

Practicing with Awareness to Patient Barriers Part of providing excellent health care is setting patients up for successful implementation of collaborative care plans. What is sometimes viewed by providers as patient resistance to treatment compliance may actually be related to barriers inhibiting a patient’s ability to comply. The care team can help patients progress toward treatment goals by assessing for, acknowledging, and addressing barriers that interfere with their ability to access, comply with, or follow through with various aspects of treatment recommendations. For

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Practice Applications with Involuntary Problems and Settings example, in a health-care system that practices patient-centered care, team members might assist patients with transportation options or offer easily accessible and reliable interpretation services. Patients may also need help accessing medications, and health systems often collaborate with pharmacies or drug companies to offer subsidized, discounted, or free medications to individuals in need. Awareness of potential patient barriers and options for resolution increase patients’ ability to successfully implement their care plans.

Less Restrictive and More Coordinated Appointment Policies Similar to awareness of patient barriers, separately noted due to its importance to reducing barriers and increasing access to care, is the tendency for medical practices to implement punitive attendance policies around appointments. For example, patients may be told they will not be seen under any circumstances if they are more than fifteen minutes late, or they might be discharged from the practice if they do not show up for several scheduled appointments. Such policies create tensions between patients and providers that can create negative perceptions of investment by both parties and may even unwittingly exacerbate a crisis for someone experiencing an episode related to a mental illness. While reasonable guidelines help protect the time of health-care employees, patient-centered agencies will ensure flexibility in their systems to respect the time of both members of the treatment relationship. Alternative practices might include rescheduling a late patient in an available same-day appointment, asking the provider if he or she has time to see the patient in between other appointments, or collaborating with the patient to reschedule for a more convenient time or date. A key benefit of an integrated care setting is the ability for patients to see multiple providers in one day. This aspect of care immediately increases patient access to behavioral health ser vices as specialty mental health settings typically do not offer same-day appointments. With mindful coordination of care, patients can attend to various needs in one visit and decrease overall need for resources (transportation, days/time off from work, money for copayments, etc.). This convenience can help reduce patient resistance to receiving behavioral health ser vices and increase overall patient participation in his or her health care.

Emphasis on Patient Advocacy Integrated systems of care encourage greater communication among providers to help ensure patient needs are met and to create realistic care plans. Patient case advocacy is a specific role the behavioral health clinician brings to the health setting (Jannson 2011). The combined perspectives of professionals

Integrated Care and Health Disparities practicing with cultural awareness can result in patient champions (i.e., patient advocates). For example, a patient may reveal to the front desk staff member that he lost his job last week and is a little down, but not perceive an opportunity to share this with the medical provider. The front desk staff may choose to advocate for the patient by reaching out to the behavioral health clinician and asking him or her to touch base with the patient regarding the job loss. Or, a discussion between the medical provider and behavioral health clinician may require them to work through opposing views to agree on care recommendations. In this example, the advocacy (generally by the behavioral health clinician) and collaboration may have occurred without the patient necessarily realizing the pressures or resistance that either provider experienced or the effort that went into the patient-centered care decision.

Creating an Informed Workforce Disparities in physical and mental health for diverse populations in the United States result from a complex mix of issues related to systemic policies and procedures, institutional and individual provider biases, and individual and cultural patient beliefs and behaviors. Serving diverse persons through a patient-centered integrated care approach requires a health-care system and its providers to grasp and understand the patient populations served and their pathways to care. This is of particular significance to community health centers whose patient populations include people with low incomes, immigrants and refugees, people of varying racial and ethnic groups, among others. Overcoming re sistance to provide integrated behavioral health care requires organizations and providers to make ser vices relevant to the people they serve. Steps toward this end require not only creating a welcoming and inclusive environment with resources required to meet patient needs but also a workforce prepared to provide culturally relevant ser vices. The promise of integrated care to reduce health and care disparities of diverse populations rests with health centers and health-care teams to equip themselves with knowledge and skills to effectively serve and engage diverse patients in their own health care.

Overcoming Stigma As noted previously, stigma around mental illness creates patient and provider resistance to behavioral health ser vices. Cultural groups experience stigma to different degrees, and such cultural beliefs transcend patient or provider status. Strategies to combat stigma include acknowledging the stigma and providing education on mental illness to both patients and providers. It is crucial in educational efforts to change the language used to describe mental illness

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Practice Applications with Involuntary Problems and Settings and those struggling with mental illness. Terms such as “crazy,” “lunatics,” or “nuts,” are derogatory and may be detrimental to the self-esteem of those affected (Putman 2008). Furthermore, providers should be encouraged to identify, acknowledge, and process through their personal biases so they can work to overcome attitudes that may impact patient care. Educational efforts should directly challenge the false beliefs some may hold and should discuss the mind-body connection, with an emphasis on the notion that mental health is physical health, and the concepts are not mutually exclusive.

Providing Training and Education Educating both patients and providers about integrated care is essential to its success. A crucial strategy for empowering patients to express concerns, advocate for their rights, and understand their options is to educate them about the health system’s policies and procedures regarding satisfaction with providers and ser vices and expectations around the various professionals involved in care. Behavioral health clinicians should routinely explain their role, reason for meeting with the patient, and plans for the encounter before proceeding with ser vices. When patients are not willing to engage with behavioral health clinicians, clinicians should ask permission to check in at subsequent appointments and explain how their requests will be honored. If the agency requires administration of screenings, the clinician should explain the patient’s right to refuse to answer the questions. When patients agree to engage with behavioral health clinicians, a jointly created care plan should be developed to satisfy both parties. Although patients may still demonstrate resistance to the presence and involvement of behavioral health in their primary care, education around rights and options can increase understanding of integrated care. Moreover, it can help to normalize the patient’s experience to learn that certain elements of behavioral health involvement are routine for all patients. To provide the highest quality of integrated care to patients, all employees of the health system should have a working knowledge of integrated care, how it is implemented in their agency, and relevant agency goals. Treatment team(s) should have an advanced understanding of integrated care, its purpose, the supporting research, and their respective role in the integration of ser vices. Treatment team members should also be familiar with the roles and scopes of practice of all other members of the collaborative care teams and be familiar with appropriate methods for referring and/or consulting with other professionals. For example, medical providers should know the process of referring patients for behavioral health ser vices in the event the clinician is not available to immediately see a patient and how and when to consult with behavioral health clinicians, including psychiatrists. Behavioral health clinicians

Integrated Care and Health Disparities should understand important medical issues patients may identify and know how and when to inform the medical provider. This mutual understanding contributes to the levels of respect, cooperation, and collaboration between the professions, leading to overall better patient care (Haig, Sutton, and Whittington 2006) and helps reduce provider resistance to an integrated model of care.

Utilizing Evidence-Informed and Best Practices Effective Screening Tools and Protocols A strategy to address the pressures patients may feel about discussing mental health symptoms is to standardize agency protocols regarding screening and assessment. Standardizing these processes can help agencies identify their goals for behavioral health ser vices, classify patient needs, and normalize screening processes. For example, the use of a screening tool that includes the Patient Health Questionnaire (PHQ)-4, National Institute on Drug Abuse (NIDA)-4, and a list of potential resource needs provides a snapshot of a patient’s status regarding several mental health symptoms, substance use, and need for case management. Utilizing a screening tool consistently allows providers to quickly gain insight into their patients’ symptoms, allows for data collection to measure health outcomes, and increases ser vice provision efficiency, all of which help reduce provider resistance to integrated care.

Excellent Clinical Skills When patients reveal mental health symptoms or concerns, clinicians should be prepared to provide follow-up questions to further assess the patient’s situation and respond accordingly. Integrated care behavioral health clinicians must assess for various risk factors quickly using all information available, including patient mental status, nonverbal cues, and information from the medical chart, other members of the care team, and directly from the patient (and sometimes family and friends). While assessing the situation, the clinician should simultaneously assess the patient’s stage of change and level of motivation for participating in various levels or types of treatment. This process inherently uncovers any patient resistance to receiving behavioral health services. Employing motivational interviewing skills can help engage the patient in creating a collaborative care plan, which could range from providing immediate psychoeducation to planning for a follow-up check-in phone call to the recommendation for involuntary commitment requiring involvement from law enforcement due to risk. Successful behavioral health clinicians practicing in integrated care settings possess excellent clinical skills to engage,

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Practice Applications with Involuntary Problems and Settings assess, and intervene with patients effectively and appropriately using the best practices available. Short-Term Intervention Models Using short-term models of treatment, patient-identified needs and presenting problems are the focus of care in integrated settings rather than treatment of a diagnosis. Thus, emphasis on the “short-term” nature of treatment extends across assessment, documentation, and care planning. Patient mental health needs in primary care are generally at a lower level of need than patients receiving long-term care at a specialty provider agency, and community health system payers require less intensive behavioral health assessment processes in order to treat a patient. As a result, behavioral health clinicians in primary care settings must quickly assess the most pressing issues and intervene accordingly without completing full diagnostic assessments or other lengthy paperwork. Emphasizing short-term care, clinicians use elements from each of an eclectic combination of brief evidence-based interventions, such as psychoeducation, solution-focused brief therapy, cognitive behavior therapy, and dialectical behavior therapy to address most patient mental health concerns. Since clinicians in integrated care settings focus on symptom-specific, shortterm treatment, their goal is to quickly assess presenting problems, identify the patient’s priorities for care, and intervene in the present time. This approach can increase treatment efficiency and minimize the time commitments required from patients (Jenkins and Strathdee 2000). The case example further illustrates setting differences.

Gloria: A Patient Case Vignette Gloria, a twenty-five-year-old female patient, is experiencing frequent panic attacks, insomnia, and various symptoms of anxiety that are exacerbated during busier times at work and school. She also struggles with seasonal allergies, which have worsened over the past few weeks. Traditional Care Model: Gloria makes an appointment with her primary care doctor to address her allergies, as she is most bothered by these symptoms at this time. During her appointment, Gloria mentions having trouble sleeping, which she and her provider both consider to be secondary to her allergies. Several months later, Gloria is still struggling with insomnia, has had more frequent panic attacks, and her anxiety overall has gotten worse. Though she is somewhat embarrassed, she calls the counseling center on campus and gets an appointment six weeks after calling them. Gloria participates in a thirty-minute phone

Integrated Care and Health Disparities screening, and is then told that her intake appointment will be at least ninety minutes long, followed by at least one more sixty-minute intake session with a clinician. During the first two appointments, which are two weeks apart, Gloria would learn about her options for care, such as counseling, group therapy, or medications. Integrated Care Model: Gloria schedules an appointment with her primary care provider to address her allergies. She obtains an appointment the next week. When she arrives at her appointment, she is instructed to complete a behavioral health screening tool while she is waiting to see her doctor. The screening asks about her anxiety, the panic attacks, and her insomnia. Gloria indicates that she has been struggling with all three symptoms. After Gloria is taken to the exam room, the medical assistant takes her vitals, reviews her screening, and informs her that the physician is running late, but asks her if another member of the care team, the behavioral health specialist, could come in and discuss her screening responses. Gloria agrees, and a social worker meets with her within minutes of her interaction with the medical assistant. The social worker questions the frequency, duration, intensity, severity, and potential triggers of Gloria’s mental health symptoms, and leads her through a deep breathing exercise on the spot. The social worker leaves the room when the physician enters, and returns with educational handouts on insomnia, anxiety, and panic attacks. The social worker reviews all of the information with Gloria, and collaborates with her on a few techniques to try at home. Gloria schedules to return for an allergy shot fifteen minutes before an appointment to see the social worker the following week to work on more techniques and discuss implementation of new skills from this week. Gloria leaves with a prescription for allergy medication, a plan to take routine allergy shots, understanding of her anxiety symptoms, panic attacks, and insomnia, and hope that she will find relief from all of her symptoms in the near future. Gloria also realizes the connection between her mental and physical health, since she was able to address her needs in both areas within a primary care setting.

Trauma-Informed Care Many patients in community health settings, especially in health systems that serve large numbers of refugees and individuals experiencing socioeconomic detriment, bring a history of trauma (Gillespie et  al. 2009). Since health center staff interact with patients before care providers, all employees should be trained in the basic tenets of trauma-informed care. According to the

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Practice Applications with Involuntary Problems and Settings Substance Abuse and Mental Health Ser vices Administration’s (Substance Abuse and Mental Health Ser vices Administration 2014) concept of a trauma-informed approach, a program, organization, or system that is trauma-informed: realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization. (9) Negative interactions with any employee of the health center could potentially retraumatize a patient. Hence, it is essential that all employees are trained in, aware of, and understand the importance of trauma-informed care. Depending on the staff role, some skills learned in good customer service trainings are transferable to a trauma-informed approach. Patients are less likely to resist care recommendations when they feel safe in their treatment environment. Motivational Interviewing The tenets of motivational interviewing are critical to developing strategies for increasing patient voluntariness in integrated care. First and foremost, behavioral health clinicians should be proficient in quickly assessing patient stage of change relative to given presenting issues. Clinicians can utilize any and all information available to them to make this assessment, including information from other staff member interactions, patient nonverbal cues, and patient responses to questions. Based upon the information received, clinicians can choose an engagement style and intervention technique. For example, if a patient demonstrates resistance to a behavioral health clinician’s questions and has an overall dismissive tone, the clinician might proceed with further relationship-building techniques or education regarding the clinician’s role in the health center. When patients are willing to identify and acknowledge mental health issues, clinicians might proceed with interventions to address patient concerns in the moment, such as guiding a deep breathing or relaxation exercise or providing psychoeducation. Motivational interviewing techniques can help honor the expertise across care providers and the patient’s expertise on his/her own life in identifying patient problems. Behavioral health clinicians and patients can collaboratively work through any patient ambivalence around the health recommendations made by the care team.

Integrated Care and Health Disparities Maximizing Efficiency One of the most effective strategies we have found to help patients and providers overcome resistance to integrated care is to maximize the efficiency of agency operations. A coordinated, adept workflow that allows all providers to meet productivity and billing standards and also maximize patients’ time is crucial for integrated care sustainability. Excellent communication between all parties, including administrators, staff, providers, and patients, consisting of frequent constructive feedback about policies and procedures, can improve the level of coordination and allow for necessary adjustments and adaptations. Of note, much of the communication between staff takes place via an electronic medical record, and it is important for members of treatment teams to be aware of provider communication preferences (e.g., direct debriefing vs. patient message vs. phone call, etc.). Clinical documentation should be concise and meet the standards needed for billing, with all staff aware of providers’ billing and productivity requirements. Treatment teams can make more informed decisions to help maximize efficiency if they understand pressures faced by providers.

Patient Perceptions of Integrated Care As professionals continue to define what it means to provide care in a collaborative and coordinated manner they may fail to consider how patients understand what it means to receive care in an integrated patient-centered medical home. Social work and medical ethics alike require informed consent be obtained from patients in advance of clinical treatment. Yet patients often remain unclear on the definition of integrated care (Walker et al. 2013). Practitioners must be cognizant of how people who speak primary languages other than English interpret the term. Walker and colleagues (2013) found among Spanish-speaking individuals that the term they used to represent integrated care had a completely different conceptual meaning to participants. With the relative newness of including behavioral health ser vices as part of primary care, informed consent processes should intentionally include an explanation of the types of care provided and how the care is delivered. We need to be certain the term “integrated care” is understood conceptually by the diverse patients receiving care. The “client-clinician” relationship is well documented as key to keeping people engaged in treatment and in achievement of positive patient outcomes. In psychiatric care this relationship also impacts patients’ sense of coercion and is tied to ser vice retention and negative patient outcomes (Newton-Howes and Mullen 2011; Stanhope, Marcus, and Solomon 2009). Patients at poorer levels of psychological functioning and who feel stigmatized, dehumanized,

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Practice Applications with Involuntary Problems and Settings and without a voice in treatment are most likely to perceive a sense of coercion in care received and experience long-term negative outcomes (NewtonHowes and Mullen 2011). In contrast, approaches viewed as persuasive may not evoke a sense of coercion (Stanhope et al. 2009), supporting motivational interviewing as an appropriate evidence-based practice for integrated care. Geller (2012) argues that some level of coercion in outpatient psychiatric care is sometimes necessary in a recovery-oriented paradigm. For example, involuntary ser vices benefit patients with severe mental illness who need care but who are not in a place to make a good self-determined decision. He compares the involuntariness of such ser vices to practices employed by entitlement programs, medicine, licenses, among other programs whereby patients receive the benefits under certain conditions. In these instances, consumer perceptions of involuntariness will vary. Geller (2012) contends that perhaps it is more appropriate to consider how to better use involuntary ser vices to enhance recovery and safety of patients than to try to eliminate any form of coercive treatment. All of these considerations highlight the importance of attending to how integrated care processes are explained and experienced by patients to minimize perceptions of coercion. This is especially critical in an environment driven by billing and payment systems that operate on specified minute increments and push health-care systems to maintain consistent workflows of brief appointments scheduled. Despite the challenges to implementing integrated care, recent studies indicate patients who understand the underlying concepts of integrated care support its implementation (Bridges et al. 2014; Walker et al. 2013). Moreover, Bridges and colleagues (2014) found Latino and non-Latino patients to comparably use and experience improved outcomes and satisfaction with integrated care, providing evidence of the positive impact of integrated care on health disparities. As the literature base around integrated care continues to develop researchers and practitioners alike must examine patient experience of integrated care as holistically as the care is intended to be provided.

Conclusion There is no one-size-fits-all model or handbook that spells out exactly how to implement the integration of primary and behavioral health care. However, research to date supports suggested strategies to successfully integrate care and improve the overall effectiveness of treatment teams. Focusing on resolving the issues that lead to resistance from both sides of the treatment relationship can result in increased voluntariness from all parties involved in the provision and acceptance of care, thereby improving overall patient health outcomes. Providers of health and behavioral health ser vices operate under multiple imperatives. The ACA is the most recent national policy pushing our health-

Integrated Care and Health Disparities care systems toward holistic ser vices. Payment and billing systems force providers to make challenging decisions around patient care. Research increasingly provides evidence that health is more effectively achieved and maintained when care considers the inextricable links between physical and mental health. And, with increased knowledge of their rights, patients are demanding more efficient and effective care. The impact integrated care can have on patients is perhaps no better described than through knowledge that more people who die by suicide have contact with a primary care provider than a specialty mental health provider agency in the months preceding their suicide (Luoma, Martin, and Pearson 2002). Recognizing heightened patient risk for suicide may require some level of involuntary behavioral health intervention. Most participants would say the imperative outweighs the approach. The promise of integrated care to help reduce health disparities, destigmatize help-seeking for mental health ser vices, and positively impact people with said needs is no doubt compelling. We can only hope research supports these societal gains. However, we must be careful to consider potential unintended consequences of integrated care. Specifically, how patients may perceive our efforts to treat their health care holistically and how providers perceive their responsibility to treat behavioral health conditions and interact with behavioral health clinicians. Both substantively impact the patient’s experience of health care. We must remember that not everyone shares the same understanding of mental health nor is everyone who comes for a primary care visit ready to receive information relative to a need for behavioral health care. Lest we get lost in our own good intentions and desire to effect positive change for people long enduring disparities in their health and health care, it behooves us to consider whether patients perceive our efforts as unwittingly coercive or an idea whose time has finally returned to health-care practice.

Discussion Questions 1. Consider how you might approach a patient in an integrated care health setting who screens positive for a behavioral health or substance use concern. In groups of two discuss the following: a. What specific words or phrases might you say to engage the patient? b. How you would explain your role on the health-care team? c. How would you proceed if the patient does not seem to want your ser vices? d. The patient identifies as part of a cultural community that greatly stigmatizes mental health conditions. What approach would you take with the patient to break down some of the relevant barriers to provide needed care?

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Practice Applications with Involuntary Problems and Settings 2. You are a behavioral health clinician working as part of an integrated care team at a local community health center. A patient has made an appointment with the physician because lately she has been really tired, irritable, and unmotivated to do the things she needs to do to take care of herself. Her behavioral health screen indicates she may be experiencing some level of depression. You learn during her appointment that she has type 2 diabetes that she’s struggling to get under control. Because you are an informed behavioral health clinician you are aware that diabetes and depression often go hand in hand. Write a brief reflection on how you might talk with the patient about what she’s feeling and experiencing. Discuss what sorts of interventions you might use to get her to partner with the health team to improve her own health status.

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Practice Applications with Involuntary Problems and Settings Shiver, J., and J. Cantiello. 2016. Managing Integrated Health Systems. Burlington, MA: Jones and Bartlett Learning. Smedley, B. D., A. Y. Stith, and A. R. Nelson. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press. Smith, A. L., and C. S. Cashwell. 2010. “Stigma and Mental Illness: Investigating Attitudes of Mental Health and Non-Mental Health Professionals and Trainees.” Journal of Humanistic Counseling, Education and Development 49 (2): 189–202. Snowden, L. R., and D. Pingitore. 2002. “Frequency and Scope of Mental Health Ser vice Delivery to African Americans in Primary Care. Mental Health Services Research 4: 123–130. Sofaer, S., and K. Firminger. 2005. “Patient Perceptions of the Quality of Health Ser vices. Annual Review of Public Health 26: 513–559. Stanhope, V., S. Marcus, and P. Solomon. 2009. “The Impact of Coercion on Ser vices from the Perspective of Mental Health Care Consumers with Co-occurring Disorders.” Psychiatric Services 60: 183–188. Substance Abuse and Mental Health Ser vices Administration. 2014. “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.” HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Ser vices Administration. Thielke, S., S. Vannoy, and J. Unutzer. 2007. “Integrating Mental Health and Primary Care.” Primary Care: Clinics in Office Practice 34: 571–592. U.S. Agency for Healthcare Research and Quality. 2013. National Healthcare Disparities Report, 2013: Highlights from the 2013 National Healthcare Quality and Disparities Reports. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/research /findings/nhqrdr/nhdr13/highlights.html. U.S. Department of Health and Human Ser vices. 1999. Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Ser vices Administration, National Institutes of Health. U.S. Department of Health and Human Ser vices. 2001. Mental Health: Culture, Race, and Ethnicity— A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Ser vices Administration, National Institute of Mental Health. U.S. Department of Health and Human Ser vices. 2003. The President’s New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America (Report no. SMA-0303832). Rockville, MD: Author. Valentijn, P. P., S. M. Schempman, W. Opheij, and M. A. Bruijnzeels. 2013. “Understanding Integrated Care: A Comprehensive Conceptual Framework Based on the Integrative Functions of Primary Care.” International Journal of Integrated Care 13: 1–12. Vega, W. A., B. Kolody, S. Aguilar- Gaxiola, R. Catalano. 1999. “Gaps in Ser vice Utilization by Mexican Americans with Mental Health Problems.” American Journal of Psychiatry 156: 928–934. Vega, W. A., M. A. Rodriguez, and A. Ang. 2009. “Addressing Stigma of Depression in Latino Primary Care Patients.” General Hospital Psychiatry 32: 182–191. Walker, K. O., A. Labat, J. Choi, J. Schmittdiel, A. L. Stewart, and K. Grumbach. 2013. “Patient Perceptions of Integrated Care: Confused on the Term, Clear on the Concept.” International Journal of Integrated Care 13: 1–9. Wang, P. S., M. Lane, M. Olfson, H. A. Pincus, K. B. Wells, and R. C. Kessler. 2005. “TwelveMonth Use of Mental Health Ser vices in the United States: Results from the National Comorbidity Survey Replication.” Archives of General Psychiatry 62: 629–640.

Chapter 14

Strengths-Based Strategies for Improving Quality of Life Among Dementia-Affected Older Adults and Their Care Partners

Justine McGovern

This chapter explores clients’ involuntary status as it manifests itself in the context of dementia. While a dementia diagnosis is by its very nature involuntary, in that no one chooses to be affected by the disease, it also often positions those affected by the disease as resistant, obstinate, or noncompliant, in concrete ways. Labeling behaviors as “resistant” betrays a deficit perspective that can be nefarious to quality of life for affected persons and their carers. Reframing resistance as resilience, for example interpreting insisting on doing something on one’s own rather than asking for help as strong rather than stubborn, can have consequences not only on quality of life for the person with the diagnosis but also for carers. Moreover, resistance in dementia can result from fear or sadness, emotions often experienced by those living with the disease. From this perspective, resistance can be interpreted as the manifestation of an affected person’s personhood, even while it may interfere with social expectations or standards of behavior, such as eating, sleeping, or bathing. When perceived as an affirmation of self rather than a signifier of loss, “resistance” becomes something to work with, rather than something to work against. Persons affected by dementia experience mounting losses. Beyond loss of self, memories, relationships, and relatedness, these include loss of agency and freedom of choice. The losses ensue from the progressive nature of the disease, which impairs the brain and cognitive and bodily functions over time, resulting in death. Most often aware of these progressive losses, persons living with dementia and their partners in care, both formal and informal,

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Practice Applications with Involuntary Problems and Settings often experience frustration, anger, and despair. As a result, they can become unwilling, or involuntary, actors in a performance they did not choose in the first place. The chapter explores ways to support those affected by the illness in ways that promote agency and quality of life in challenging circumstances by providing choices not only for those with the illness, but also those who care for them. Resistance to care in dementia can take many shapes. Refusing care can be a symptom of dementia among affected persons, and of denial among care partners who often struggle with facing the reality of progressive cognitive impairment in a loved one. In addition, lack of training and challenging working conditions can dissuade professional care providers from engaging effectively with this vulnerable population, a different manifestation of resistance. While dementia is often perceived as a fate worse than most, those implicated in the disease also report experiencing quality of life, once they have adopted a new definition of quality of life. The strengths perspective applied to dementia care partnering supports this paradigm shift. Person-centered care translates the perspective into practice. Approaches to care that are person-centered and focus on communication and connectedness encourage participation in care among care partners on both sides of receiving and providing care. This is significant as quality of life is improved for all involved as a result. By providing tips on how to work with agitation, bathing, and mealtime, the chapter illustrates how gaining a new perspective can translate to new practices, reduce resistance to care, and improve quality of life for persons facing great challenges. By adopting a strengths perspective, the chapter suggests tips on how to promote affirmative, person-centered care, which encourages participation and reduces resistance (Kitwood and Bredin 1992). Resistance to care in dementia can take many forms and implicates all those affected by the illness. Refusing care can be a symptom of the illness itself among persons with the disease, and of denial among informal carers who often struggle with facing the reality of progressive cognitive impairment in a loved one (Family Caregivers’ Alliance 2016). In addition, helping professionals’ lack of knowledge about the illness and how to work with affected clients, perceptions about older adults in general, and frustrations with clients unable to accept their ser vices can interfere with their practice. Adopting a strengths perspective and favoring personcentered care allows for new dementia-care options to emerge, which can have a positive effect of resistance among all those affected by dementia. Through the lens of the strengths perspective, resistance can be reframed as an affirmation of self and a mechanism for warding off despair, symptomatic of a person’s resiliency and as an effective coping skill (Saleebey 2013). From this perspective, resistance becomes a positive rather than negative manifestation of the disease that approaches to care can build on, rather than seek to reduce. Further, by situating communication and connectedness front and

Strengths-Based Strategies for Improving Quality of Life center in dementia care, person-centered care puts the strengths perspective into practice not only by assuming that more positive outcomes in dementia are possible, but also by seeking to affirm essential qualities of affected persons and relationships (Kitwood and Bredin 1992). However, a shortage of information and training, negative age-based beliefs, and the strain of multiple losses and escalating care demands combine in ways that can exacerbate resistance rather than reduce it, decreasing opportunities to sustain quality of life.

Dementia Basics Definition According to the Alzheimer’s Association (2016), by 2030, 50 percent of Americans over the age of sixty-five will be diagnosed with some kind of cognitive impairment. Alzheimer’s disease is one type of dementia, and has become a blanket term in the culture at large for the debilitating, irreversible, and progressive brain disease that affects over twenty-five million Americans and their caregivers. Other dementias on the rise include frontal temporal lobe dementia, which tends to affect people under the age of sixty-five; Parkinsonian and vascular dementia, stemming from Parkinson’s and heart disease, respectively; and dementia resulting from brain trauma and injury. While medical progress is occurring, particularly in the area of early detection, still no cure or durable treatment exists. Moreover, the causes of dementia are not completely understood at the time of this writing. Genetics, injury, illness, lifestyle, and environmental factors seem to play a part (Alzheimer’s Association 2016; National Institute on Aging [NIA] 2015). Dementia has consequences on all areas of functioning. Cognitive decline, including loss of memory, speech ability, decision making, and interpretation of events, is the most recognized symptom. Other symptoms can include psychoemotional disorders, such as depression, delusions, and agitation; and functional disruption, such as the inability to participate in activities of daily life and manage self-care (Alzheimer’s Association 2016; NIA 2015). The impact of the disease extends beyond the person who receives the diagnosis. According to the Alzheimer’s Association (2016), upward of 70 percent of persons affected by dementia are cared for by family members, usually a spouse or adult child, in the home. The cost to families is high. Caregiving families experience an increase in depression, illness, injury, and financial distress (Robison et al. 2009). However, the single greatest area of challenge reported by both caregivers and those with dementia is the sense of loss: loss of self, and loss of significant relationships due the forgetting that erases not only awareness of one’s own self but also of the shared memories and feelings that capture closeness (Robinson, Clare, and Evans 2004).

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Practice Applications with Involuntary Problems and Settings While memory loss can be attributed to many causes, such as medication side effects, chronic alcoholism, illness and injury, and even depression, anxiety, and posttraumatic stress disorder, and is often reversible, dementia-related cognitive impairment tends to progress through stages. These range from nondetectable impairment that can only be discovered through brain testing, to mild cognitive impairment (MCI), when a person’s functioning is beginning to be affected, to full-on dementia. Dementia itself progresses through stages, from mild to moderate to severe, culminating with the person’s depending completely on others for basic activities of daily living. Dementia is a terminal illness (Alzheimer’s Association 2016; NIA 2015).

Diagnosis Diagnosing dementia can be tricky. Beyond the personal resistance to receiving difficult news, which most likely confirms one’s worse fears, other conditions can mask and cause dementia, and denial can get in the way. It is often difficult for those who are affected to face their fears and proceed with medical evaluation. Further impairing diagnosis, dementia does not present or progress in the same way for each individual. Symptoms tend to first appear when a person reaches the mid-sixties, but someone who is affected by MCI might not progress to full-blown dementia (Alzheimer’s Association 2016; NIA 2015). Moreover, there are increasing numbers of persons affected by early-onset dementia, primarily due to brain injuries. Veterans and athletes, among others, are demonstrating increasing rates of cognitive impairment (Jellinger 2004).

Symptoms The first symptoms of dementia vary from person to person. Memory problems are typically the first signs of cognitive impairment related to dementia, but mood swings, personality changes, and weight loss are also associated with the onset of the illness. Other nonmemory capacities, such as vision/spatial issues and impaired reasoning or judgment, may indicate the very early stages of dementia. In the early stages of the illness, issues such as wandering and getting lost, difficulties handling money and paying bills, repeating things, and taking longer to complete tasks become more frequent. As the diseases progress, more words are lost and other challenges arise, such as no longer recognizing loved ones, hallucinating, experiencing paranoia, losing impulse control, and repeating behaviors. In the final stages, persons with dementia are completely dependent, may communicate verbally only in groaning and grunting, may have seizures and skin infections, and are prone to pneumonia and other lung infections. (Alzheimer’s Association 2016; NIA 2015).

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Resistance Through the Stages of Dementia Resistance to care can occur among persons with the disease, caregivers, and helping professionals (Family Caregivers’ Alliance 2016; Seiffer, Clare, and Harvey 2005). Different stages of the illness provide different openings for resistance to care. In the early stages, both the person suffering memory loss and carers may experience denial, often attempting to compensate for memory loss and other lapses and avoiding asking for help or being evaluated. Resistance to accepting the reality of the illness and to receiving or providing adequate care is often most pronounced when awareness of loss of capacity, frustration, and fear are most present, as in the early stages. Both carers and those with the disease can be complicit in this type of resistance. Carers’ resistance can take different shapes, sometimes putting themselves, their loved one, and the public at risk. Examples include not taking away an affected loved one’s privileges such as driving, or not making changes in the home, such as putting locks on doors or cooking appliances, or not succeeding in making the affected person wear identification tags to avoid the worst consequences of wandering. It is important to note, however, that many carers report a time of respite in the middle stages when the affected person is no longer aware of the losses, and is not yet profoundly incapacitated. Acceptance by the carer may come more easily with the relief that the loved one is suffering less (McGovern 2015; Seiffer, Clare, and Harvey 2005). Moreover, the mood swings and personality changes that may be manifested by the person affected by the disease as it progresses into moderate stages, are not necessarily difficult to endure by carers. Family carers have reported enhanced closeness with loved ones during the middle stages of dementia when life-long interpersonal challenges sometimes fall away, making interaction smoother and easier (McGovern 2015). The more advanced stages of the illness are often most difficult on carers who struggle with meeting a loved one’s mounting needs and are aware of the illness’s trajectory. Examples of carer resistance in late stage dementia include disengagement with preparing for death, accepting increased use of medications, or personal neglect on the part of the carer. Lack of self-care can result in injury or illness among carers (Family Caregivers’ Alliance 2016). Little is known about how persons with the diagnosis experience the end stages of dementia, as there is little research on the advanced stages of the illness from their perspective (de Boer et al. 2007). Helping professionals, including doctors, nurses, social workers, and therapists, can have a significant impact on carer support (Family Caregivers’ Alliance 2016). Normalizing carers’ mixed emotions, typically relief that the end is near, guilt at feeling the relief, and anticipated grieving, can significantly reduce carer resistance. In addition, providing adequate interventions for both members of a care partnership can make a difference. These might include

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Practice Applications with Involuntary Problems and Settings facilitating conversations about preparing for death, making referrals to support groups for carers, and supervising use of medications such as antidepressants and painkillers for both partners (Family Caregivers’ Alliance 2016). Unfortunately, helping professionals often experience their own resistances as well. Among helping professionals, resistance to working with older adults in general reflects ongoing ageism that persists despite many advances in agebased cultural competency training (Butler 2005). The belief that growth and positive change is inaccessible to older persons is a first area of challenge that feeds resistance to joining fields of gerontology and geriatrics (Administration on Aging [AoA] 2014; Butler 2005). Progressive cognitive impairment creates an additional obstacle. Referred to as the “dread disease,” dementia is often considered a fate worse than cancer or worse than death itself (Shenk 2003). Emotion-driven fear of contagion and limited knowledge about how to work effectively with affected persons, which is associated with resistance among helping professionals, contribute to workforce shortages, high attrition, and poor standards of care (Benbow et al. 2011; Tsaroucha et al. 2013). Because affected persons remain sensitive to interactions, they may be aware of helping professionals’ resistance to fully engage with them. This may increase their own resistance, for example refusing to speak at a doctor’s appointment or challenging a home-aide’s skill and helpfulness. Willingness to participate in care is improved when care is person-centered and attuned to communication and connectedness needs (Benbow et al. 2011; Tsaroucha et al., 2013).

Managing Challenging Behaviors: A New Perspective on Practice What qualifies as a challenging behavior will vary from person to person, and may change across time. However, three behaviors are repeatedly mentioned as the most difficult: agitation, eating, and bathing (Alzheimer’s Association 2016; Family Caregivers’ Alliance 2016). These are often portrayed as examples of resistance on the part of the person with dementia, yet resistance rarely emerges in a vacuum. Most often, it is associated with clients who refuse to accommodate expectations of civil behavior, which, it is important to mention, are often governed by cultural dictates. Their breakdown tends to upset not those with the disease but their loved ones and carers. Examples include maintaining standards of hygiene, eating a healthy diet at set times, sleeping at night, not repeating everything, and controlling impulses in public. In small doses, none of these “acts of resistance” seem to amount to much. However, over time, they may come to affect the person with dementia. Significantly, they are strongly associated with formal and informal carers’ feeling escalating frustration and anxiety about the breakdown of expectations about

Strengths-Based Strategies for Improving Quality of Life what is socially acceptable, despite their best intentions. Acts of resistance by both care partners can be either conscious or unconscious. (Alzheimer’s Association 2016; Family Caregivers’ Alliance 2016). In most cases of dementia, clients remain safe and do not pose a threat to others or themselves, but the risk is real and carers report that the thoughts are always there—What if he drives into another car? What if she wanders and is lost forever? What if he leaves something cooking on the stove? Safety is a priority, but what this chapter strives for is more than basic safety. The tips for care provided here address resistance by suggesting a shift in perspective that guides a shift in practice, to increase quality of life for the person with the diagnosis, loved ones, and the professionals dedicated to providing quality care under challenging circumstances.

Perspective: Adopting a Strengths-Based, Person-Centered Approach to Care Based on Kitwood’s and Bredin’s (1992) groundbreaking working establishing selfhood for persons affected by cognitive impairment, a person-centered approach to care in dementia aims to validate the self as it remains, nurture an ongoing sense of relatedness between carers and the person with the diagnosis, and implement individualized care strategies (Love and Pinkowitz 2013; Mitchell, and Agnelli 2015). Five key steps not only encourage participation in care among persons living with cognitive impairment, but also reduce frustration for carers and enhance well-being all around. They focus on communication, connectedness, and quality of life. A first step requires adopting a strengths perspective to remain in the present moment and focus on what remains rather than on what is lost. Related to this is letting go of some preconceived notions about what “must” or “should” happen, and when. Where communication and connectedness are concerned, next steps, include validating an altered reality by not arguing with the client or loved one, reaching for feelings rather than facts, and finding ways to communicate through means other than words, such as touch, smiles, and laughter. Quiet spaces without too many distractions facilitate conversation. When talk is possible, conversations about the good old days are often accessible to persons suffering from dementia (NIA 2015). Significantly, these support the self, which reduces feelings of upset, and contribute to shared pleasurable moments, thereby increasing connectedness (Tsaroucha et al. 2013). When meaningful conversation is no longer possible, other forms of communication can occur. Affectionate touch, smiles, and laughter, the application of lotion on hands and face, gentle hair brushing, and massage are examples of nonverbal interaction that encourage connectedness and can fill communication gaps, improve trust, and support engagement in care. Loud voices,

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Practice Applications with Involuntary Problems and Settings arguing, baby talk, scolding, hitting, and withholding attention, medications, and comforts are examples of behaviors that not only contribute to resistance to care, but also may be determined neglectful and abusive (McGovern 2015; NIA 2015). Last but not least, person-centered care approaches prioritize safety. Dementia-proofing homes can include adapting locks, stoves, bathrooms, and stairs to evolving needs. Further, many families register persons with the illness in programs such as Safe Return, a registry that can track lost older adults (Alzheimer’s Association 2016; Love and Pinkowitz 2013). Practice: Spotlight on Agitation, Eating Habits, and Bathing Agitation, disorganized eating, and refusal to bathe are three common areas of resistance affecting quality of life in dementia. Care practices described here combine a person-centered approach and strengths perspective, which together encourage participation in care and promote quality of life. Agitation Resistance to care often presents as agitation among persons with dementia. Agitation can become apparent in several ways. Relentless repetitions, restlessness, and aggression are common manifestations of agitation. These vary in seriousness, and safety remains a top priority for both the person with dementia and the carer. Causes of agitation vary. A person-centered approach suggests that even agitation is a form of communication. Agitation might communicate concern, worry, pain, or discomfort of some sort; feeling out of control, lonely, or overwhelmed; or that medications are interacting or that the illness has reached a new stage. If there is a pronounced change in behavior, or the behavior is extreme, a consultation with a doctor or other helping professional is a first step. However, most agitation is less egregious and is managed by primary carers (NIA 2015). Paying attention to early warning signs is a key step in preventing the escalation of agitation. At the first signs, such as repeating the same question over and over, tugging at a shirt, or moving around carers can help by slowing things down, reducing levels of stimulation, and giving the person with dementia some personal attention. Further, distracting the person with dementia with a new topic of conversation, soft music, and a snack are also effective means of changing a mood or feeling. Looking at familiar images and photographs is an effective way of increasing a person with dementia’s sense of connectedness, which is significant in reducing agitation (McGovern 2015; NIA 2015).

Strengths-Based Strategies for Improving Quality of Life Healthy Eating Habits While healthy eating habits continue to be important into later life, eating is not only about health when dealing with dementia. Carers in particular report that mealtimes offer opportunities for important and sustaining social interaction for both the carer and the person with the illness (McGovern 2011). Reducing distractions, keeping voices low, and serving what the person with dementia wants to eat can promote warm and meaningful interactions, as well as healthy eating (NIA 2015). Foods that are easy to prepare by the carer or the person with dementia and do not require much decision making may be best for some. However, other clients may benefit from home delivery of meals from organizations such as Meal-on-Wheels. In any case, foods that meet the capacity level of the client, that the client prefers, and can be easily prepared by the carer are a top priority. To ascertain what a client prefers, carers who provide few choices fare best. For example, “would you prefer salad or green beans?” Persistent refusal to eat may indicate pain or discomfort. Under these circumstances, a first step would be to consult with a medical professional. Maintaining familiar routines is an effective way of reducing resistance and promoting healthy eating habits among persons with dementia. Quantity of food remains a troubling area for carers, who often resist accepting that quantity may not matter quite as much as it once did for persons with dementia. However, a refusal to eat that lasts more than a day or two requires immediate professional attention (NIA 2015). Dehydration is a significant risk among older adults in general, and persons with cognitive impairment may forget to drink, or may not recognize the symptoms of thirst. This can be remedied by offering beverages often, and by preparing foods than have substantial amounts of liquid in them, such as soups, soft stews, yogurt, cereal, fruit salads, and sweet or savory smoothies (Stevenson 2015). Facilitating Bathing Eventually, all dementia patients will require help with hygiene. For some persons with the disease, bathing is most successful when the helper is an intimate. However, some individuals do not want their nearest and dearest to witness their reduced capacities and do not want to expose their vulnerabilities to them to this extent. In this case, bathing often proceeds more smoothly when a professional takes charge, if one is available. A first step in achieving successful bathing is to explore the wishes of the person in need of help—is she more comfortable with an intimate or a professional? And what can the person with the disease do on his own? Offering more choices, such as possibly not bathing as often or as thoroughly as one did before acquiring the disease, supports self-sufficiency, sometimes at the cost of exemplary cleanliness,

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Practice Applications with Involuntary Problems and Settings and can reduce resistance to bathing. Regardless of who is helping, the following tips can support bathing, so that it occurs regularly. Significantly, hygiene beliefs are often cultural rather than health based. Daily bathing is a cultural preference, usually not a health-based necessity (Alzheimer’s Association 2016; NIA 2015). There are no medically recommended guidelines for timing of bathing. Some persons are more open to morning bathing, while others prefer to bathe in the evening. Carers should be attentive to mood and energy in the person they are helping, and aim to attempt challenging tasks when mood and energy in the person with dementia are high, rather than focusing on former routines or social expectations about schedules. Preliminary steps include creating a collaborative and trusting atmosphere. Gentle talk about what is going to happen, the absence of arguing, and a prepared bathing area (with soap, washcloth, towels, and shampoo within reach) will support collaboration. Collaboration reduces resistance. Checking water temperature is an essential precaution. Older adults’ skin can be very sensitive, and their body temperature drops. Moreover, during a bath or shower, naked persons feel very vulnerable and exposed. Partially covering them with a towel and washing underneath it may reduce these feelings. An important step is to allow and encourage the person with dementia to do as much as he or she is capable of. This increases a sense of control, reduces the sense of vulnerability, and encourages trust and collaboration instead of resistance (NIA 2015).

Conclusion: Getting from Resistance to Acceptance and Increasing Quality of Life This chapter has introduced strategies for reducing resistance among persons affected by dementia, defined here as those suffering cognitive impairment, and both formal and informal partners in care. Resistance in dementia takes on different characteristics depending on who is experiencing it. Among those with a cognitive impairment diagnosis, resistance can manifest as a refusal to meet expectations about behavior, hygiene, and nutrition. Physical aggression, hostile talk or silence, spitting out medications are common acts of resistance to care that can have serious negative consequences on quality of life for all and outcomes for the person with the disease. While dementia medications can only slow symptom progression at this point, they can nonetheless be effective when taken as prescribed. In addition, poor hygiene can affect interactions with others, who may hesitate to spend time with clients who refuse to bathe or may reduce physical contact with them. Beyond having consequences for physical health, like hygiene, food intake also has an impact on social interactions. Meals are signifi-

Strengths-Based Strategies for Improving Quality of Life cant factors in social bonding (Stoller 1989). Food- and meal-related disruptions can be upsetting and off-putting to carers intent on providing social support and maintaining family and cultural traditions based on mealtime. Feeling incapable of sustaining previously meaningful activities can be discouraging to carers, who might then withdraw from their engagement with care (Family Caregivers’ Alliance 2016). Among informal carers, usually family members, resistance can take many shapes. Beyond withdrawing as a result of being emotionally or practically overwhelmed, denial of the loved ones’ diagnosis or progressing symptoms is a frequent form of resistance. Often rationalized as encouraging a loved ones’ autonomy, ignoring symptoms can delay onset of affirmative care and put the person with dementia and others at risk for harm. Among carers, resistance can also manifest as rigidity, where flexibility might engender more cooperation from the person with dementia. Insisting on a bathing or meal schedule is often due to social expectation, health beliefs and cultural traditions but may need to be abandoned for baths and eating to occur at all. Once a carer accepts the new reality, including the disease’s progress and the limits of his or her power where care is concerned, more realistic goals emerge. These are more often met with cooperation by the person with the disease, thereby reducing resistance in both members of the intimate care partnership. Among helping professionals, resistance can take the form of reluctance to engage fully with clients affected by dementia due to several factors. These include a lack of information about the capacities of persons suffering from progressive cognitive impairment, a lack of skills for caring for these clients at a level which they are accustomed to providing, and, as a result, a lack of confidence in performing their job competently and meeting clients’ needs. Combined, these can dissuade professionals from working with a growing population in need of competent care that is attuned to their special needs. Adopting a strengths perspective to provide person-centered care can turn resistance into acceptance, with consequences to quality of life for persons affected by dementia and their carers. Aiming to enhance quality of life by focusing on communication and connectedness, person-centered care supports quality of life for persons with dementia and their carers while also increasing job performance and satisfaction among helping professionals. However, quality of life in dementia requires a new definition that moves beyond cognitive and physical functioning. Focusing on levels of cognitive and physical capacity highlights areas of deficit for those living with dementia and, as a result, implies that that they are incapable of quality of life (Ettema et al. 2005). When it is measured in new terms, such as shared present moments rather than memories, and capacities, including affection and emotion, that remain rather than those that have been lost, such as verbal and interpretive skills, quality of life becomes available again to persons affected by dementia (Ettema et al. 2005). Significantly,

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Practice Applications with Involuntary Problems and Settings carers report that their quality of life improves when they perceive that those they care for are experiencing greater quality of life (McGovern2015; Love, and Pinkowitz 2013). Care goals should aim to nurture and sustain quality of life for all persons affected by dementia— persons with the diagnosis, their loved ones, and professional caregivers—as a matter of ethical practice. Translating a strengths perspective into person-centered care, which supports connectedness and communication, can reduce resistance, increase acceptance, and improve quality of life for all persons facing challenging circumstances, whether they are living with the disease or are formal or informal carers.

Discussion Questions: 1. How might “acts of resistance” be reimagined? Identify three behaviors that illustrate resistance among dementia care partners and reframe them to uncover how they might demonstrate strengths rather than resistance. 2. Imagine a scenario in which a person affected by dementia stays up at night and sleeps during the day, a common condition referred to as “sundowning.” How could you care for this person from a personcentered perspective? What steps could you take to support quality of life for all those affected in the care partnership? References Administration on Aging. 2014. A Profile of Older Americans: 2014. Washington, DC: Administration on Aging. Alzheimer’s Association. 2016. Alzheimer’s Facts and Figures. Washington, DC: Alzheimer’s Association. http://www.alz.org /facts/. Benbow, S., A. Tsaroucha, M. Ashley, K. Morgan, and P. Kingston. 2011. “Patient and Carers’ Views of Dementia Workforce Skills.” Journal of Mental Health Training, Education and Practice 6 (4): 195–202. Butler, R. 2005. “Ageism.” Generations: Journal of the American Society on Aging 29 (3): 84–86. de Boer, M. E., C. M. Hertogh, R. M. Dröes, I. I. Riphagen, C. Jonker, and J. A. Eefsting. 2007. “Suffering from Dementia—The Patient’s Perspective: A Review of the Literature.” International Psychogeriatrics 19 (6): 1021–1039. Ettema, T., R. Droes, J. deLange, M. Ooms, G. Mellenbergh, M. Ribbe. 2005. International Psychogeriatrics 17 (3): 353–370. Family Caregivers’ Alliance [FCA]. 2016. Dementia, Caregiving and Controlling Frustration. San Francisco: FCA. https://www.caregiver.org /dementia- caregiving-and- controlling -frustration. Kitwood, T., and K. Bredin. 1992. “Towards a Theory of Dementia Care: Person and WellBeing.” Ageing and Society 12 (3): 269–287.

Strengths-Based Strategies for Improving Quality of Life Love, K., and J. Pinkowitz. 2013. “Person-Centered Care for People with Dementia: A Theoretical and Conceptual Framework.” Generations: Journal of the American Society on Aging. http://www. asaging .org / blog /person - centered - care -people - dementia -theoretical - and -conceptual-framework. McGovern, J. 2011. “Couple Meaning-Making and Dementia: Challenges to the Deficit Model. Journal of Gerontological Social Work 54 (7): 678–690. McGovern, J. 2015. “Living Better with Dementia: Strengths-Based Social Work Practice and Dementia Care.” Social Work in Health Care 54 (5): 408–421. Mitchell, G., and J. Agnelli. 2015. “Person- Centred Care for People with Dementia: Kitwood Reconsidered.” Nursing Standard 30 (7): 46–50. National Institute on Aging. 2015. “Alzheimer’s Disease Fact Sheet.” Publication No. 15– -423. Washington, DC: National Institute of Health. https://www.nia .nih.gov/alzheimers /publication. Robinson, L., L. Clare, and K. Evans. 2004. “Making Sense of Dementia and Adjusting to Loss: Psychological Reaction to Diagnosis of Dementia in Couples.” Aging and Mental Health 9: 337–347. Robison, J., R. Fortinsky, A. Kleppinger, N. Shugrue, and M. Porter. 2009. “A Broader View of Family Caregiving: Effects of Caregiving and Caregiver Conditions on Depressive Symptoms, Health, Work and Social Isolation.” Journal of Gerontology Social Sciences 64B (6): 788–798. Saleebey, D. 2013. The Strengths Perspective in Social Work Practice. Boston: Pearson. Seiffer, A., L. Clare, and R. Harvey. 2005. The Role of Personality and Coping Style in Relation to Awareness of Current Functioning in Early Stage Dementia.” Aging and Mental Health 9 (6): 535–541. Shenk, D. 2003. The Forgetting, Alzheimer’s: Portrait of an Epidemic. New York: Anchor Books. Stevenson, S. 2015. 25 Easy Recipes for Senior Nutrition. http://www.aplaceformom.com/blog /2013-3-15-easy-recipes-for-senior-nutrition/. Stoller, P. 1989. The Taste of Ethnographic Things. Philadelphia: University of Pennsylvania Press. Tsaroucha, A., S. Benbow, P. Kingston, and N. Le Mesurier. 2013. “Dementia Skills for All: A Core Competency Framework for the Workforce in the United Kingdom.” Dementia 1291: 29–44.

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Chapter 15

Substance Abuse Treatment A Field in the Midst of Change

Katherine van Wormer and Laura Parker

“No one willingly comes to substance abuse treatment”—this is a truism commonly heard by professionals in the field. The clients tend to come because they are court ordered, often due to a drinking and driving offense; are mandated to treatment from the Department of Human Ser vices as a parent at risk of losing custody of a child because of neglect or abuse; and because a relative or spouse has threatened to cut off ties if the person with an alcohol or other drug problem does not get treatment. The substance abuse treatment centers in the United States are geared to treat involuntary clients, and so involuntary clients are what they get. This is one of the basic assumptions of this chapter. A second basic assumption is that times are changing, and that although there is still the legacy of the past to contend with, old treatment models are being modified or are giving way to alternative approaches. Still, total abstinence is required, and often random urinalysis tests are used to determine whether or not the clients remain alcohol and drug free. Treatment progress is generally reported to the authorities (for example, the child welfare department or probation/parole ser vices) who referred the person in the first place. And total abstinence is the expectation of these departments. But even this is changing in one regard— the use of mood altering medications and even addictive medications increasingly are allowed in some circles. At the same time that treatment philosophies are moving toward more evidence-based and pragmatic approaches in the United States, treatment needs are changing as well. We are referring to the epidemic in opioid pre-

Substance Abuse Treatment scription drug misuse and heroin overdoses, the death toll from which is staggering. The demographics of the population in trouble with drugs has changed from inner-city minority residents to rural and suburban white middle class people. Accordingly, a major emphasis in this chapter is the prescription drug crisis, with a focus on Appalachia. Following the definition of substance use disorder as revised in the Diagnosis and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (APA 2013), the starting point for this chapter is the opioid epidemic. Then we discuss how the contemporary epidemic is being addressed at the highest levels of government and in the regional treatment centers. Special attention is paid to the historical context of substance abuse treatment and to the gradual introduction of harm reduction principles and policies that would have been considered anathema even one decade earlier. Finally, we argue for treatment options that would be more appealing to people in need of help so that instead of being coerced into treatment they would enter treatment of their own accord and work with counselors to shape a treatment program that would be uniquely tailored to meet their needs.

Substance Use Disorder Defined In the past, substance abuse counselors assessed clients sent by the court for treatment to determine if they were substance abusers or if they had a fullblown dependency to the substance. Now, since 2013, the American Psychiatric Association (APA), in its Diagnosis and Statistical Manual of Mental Disorders, has shaped substance use problems along a continuum to better reflect empirical research findings concerning the nature of addiction. Treatment centers abide by this manual in order to obtain insurance reimbursement and Medicaid reimbursement for their treatment of clients, so the impact of any change in definition cannot be underestimated. Another major change in the recent DSM is that the term “addiction” is used in place of the term, “dependence.” Addiction, clearly is not an either-or phenomenon, so substance use disorder now joins the abuse and dependence criteria into one unitary diagnosis. Substance use disorder now is dimensional, in the sense that the larger the number of criteria met, the more severe is the disorder and the associated dysfunction. For all DSM-5 disorders (for example, alcohol use disorder, opioid use disorder, tobacco use disorder, stimulant use disorder), there is a range denoting severity that extends from mild (two criteria), to moderate (four criteria), to severe (six or more criteria). As provided by the APA (2013), the criteria for alcohol use disorder are as follows. A problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following criteria over the same twelve-month period:

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Practice Applications with Involuntary Problems and Settings 1. Alcohol used in larger amounts or over a longer period of time than intended. 2. There is a persistent desire or unsuccessful attempts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use leading to failure to fulfil major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol. b. Alcohol or a closely related substance (such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms or continued use of the same amount of alcohol achieves a markedly diminished effect. (APA, pp. 490-491) (Note: The criteria for other substance use disorders, such as opioid use disorder is very similar with the substitution of the particular substance for alcohol.) The DSM-5 also includes the addition of diagnostic criteria for conditions not previously included in the DSM, such as cannabis withdrawal and caffeine withdrawal. The inclusion of gambling disorder is a major recognition of the nature of addiction, that it is not solely a result of ingesting a substance, but rather is rooted in reactions in the neurotransmitters in the brain. As Peele

Substance Abuse Treatment and Thompson (2015) indicate, this is a recognition that addiction can occur with something other than psychoactive chemicals. The experience of “getting a high” becomes a drive toward repetition of that feeling of euphoria, and cravings to return to that state can seem irresistible. We can infer from this reclassification of gambling as an addictive disorder and placing it under the category Substance-Related and Addictive Disorders as a behavioral disorder that addiction is closely associated with changes in the brain.

The Opioid Epidemic Natural opiates include morphine and codeine. Semisynthetic, humanmade opioids are created in labs from natural opiates. Semisynthetic opioids include hydrocodone and oxycodone (the prescription drug OxyContin), as well as the street drug heroin, which is made from morphine. Previously, the conventional wisdom was that patients receiving opioid medication for pain relief would not develop psychological addiction to the drugs despite the physical dependence that might occur because patients would only have medical associations with the drugs. But then anecdotal reports started emerging of former patients engaging in doctor shopping to get extra dosages of the painkilling drugs even months and years after they had had surgery. Increasingly there were anecdotal reports of respectable people going to the streets to buy heroin and children stealing drugs from their parents’ medicine cabinets. As time passed, the statistics revealed a serious problem with opioid drug addiction in the United States. The rapid increase of heroin and prescription drug overdoses (over 47,000 overdose deaths in 2014) and increases in addiction has put our nation in crisis mode with everyone from parents to presidential candidates looking for new solutions (LaSalle 2016). In 2016, 64,000 died of overdoses, many associated with the powerful prescription drug fentanyl (Katz, 2017). On response to the severity of the situation, one city— Seattle—is considering becoming the first U.S. injection site for heroin addicts. One state stands out as having the highest opioid overdose rate in the United States: West Virginia. Experts attribute this fact to a combination of factors (Jacobs 2016). First, liberal prescribing practices, and second, a disproportionate number of jobs involve manual labor, such as coal mining, timbering, and manufacturing. These jobs come with a high injury and disease rate that, combined with a lack of pain medication specialists in these rural areas and a desire to keep injured workers on the job, led to the liberal prescribing and usage of heavy pain medication. Finally, the shutting down of the mines and manufacturing jobs in the region created a different sort of pain in the area— depression associated with feelings of hopelessness. Heavy alcohol and other drug use are common in such situations. At the same time, the illicit drug

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Practice Applications with Involuntary Problems and Settings trade flourishes as the desire for opiates is widespread. Reports from substance abuse treatment centers in the regions of Appalachia hardest hit by unemployment reveal that the composition of clients went from over 90  percent alcoholism to over 90 percent painkiller addiction. As if this situation is not bad enough, as the supply of opioid medication has dropped, heroin and other synthetic drug dealers have moved in to meet the demand. This example from one community shows the importance of prevention in situations of high risk and the need for ready availability of counseling and public health programming. Even an emphasis on bringing steady employment into the area would be helpful in restoring a sense of purpose in life. More treatment centers are also needed to stop this epidemic. The drug Naloxone is used to assist in preventing and lowering the number of deaths related to drug overdose.

Basic Facts Concerning the State of Treatment in the United States Only one in seven persons who have both a substance use disorder and only one in three of persons with a mental health disorder receives the treatment they need (SAMHSA 2014). According to the SAMHSA website, 21.2 million Americans aged twelve and older could have benefited by treatment for an illegal drug or alcohol use problem in 2014. Although most of these people did not wish to have treatment, lack of access was a problem for many others. And we know also from surveys that approximately 45 percent of Americans seeking substance use disorder treatment have been diagnosed as having a mental health disorder. This indicates that the presence of co-occurring disorders is common. Of those who do get treatment, most receive mental health treatment only, and only a fraction receive integrated treatment geared to their special needs. In the state system, only a fraction (11 percent) of the 80 percent of state prison inmates with substance use problems receive the treatment they need (National Center on Addiction and Substance Abuse 2010). Most of the treatment provided in the 14,000 or so substance abuse facilities in the United States is traditional (SAMHSA 2014). Total abstinence is a tightly enforced goal. Mandatory drug testing of clients is a practice in 86 percent of facilities, presumably only for outpatient treatment. Because of funding considerations, outpatient ser vices are strongly favored, although sometimes residential treatment is available on a short-term basis. A slight majority of the facilities are private nonprofits. A review of the survey results relative to treatment ser vices and models used reveals an expansion in treatment offerings compared to previous survey data. The term “harm reduction” does not appear in the survey. Specialized programming is provided for LGBT clients in 12 percent, for women in 44 percent, and older clients in 12 percent

Substance Abuse Treatment of the treatment facilities. However, many treatment centers now provide or allow for medication-assisted therapy (e.g., methadone or Suboxone) to reduce drug cravings. These are the most recent data available at the time of this writing is from 2013, which show an expansion in treatment offerings. Recent events as described below are indicative of further advances in the substance abuse treatment field. The fact that the employment outlook is highly favorable according to the U. S. Bureau of Labor Statistics (2015) gives grounds for optimism. Employment of substance abuse and behavioral disorder counselors is projected to grow 22  percent from 2014 to 2024, much faster than the average for all occupations, according to the report. The prediction is based on anticipated growth as addiction and mental health counseling ser vices are increasingly covered by insurance policies.

How the Substance Abuse Treatment Field Is Changing This section discusses the trends in substance abuse treatment with relevance to the treatment needs of the clientele with addiction problems. We have filtered out from the literature and drawn from our personal knowledge of the treatment field the following trends: changing attitudes by the general public toward people with substance use disorders; impact of the Affordable Care Act (ACA), recent passage of the Comprehensive Addiction and Recovery Act of 2016, and other government initiatives; changes within treatment programs toward motivational/harm reduction and pharmaceutical interventions; and a national focus on rehabilitation and treatment within the criminal justice system.

More Flexible Attitudes by the General Public The heroin and prescription drug epidemic seemingly has launched a more progressive attitude toward opiate addiction; an attitude that extends to the very concept of addiction itself. An article in the Christian Science Monitor suggests that the sea of change is a result of changing demographics (Jackson 2016). In other words, heroin is no longer associated with people “on the fringes of society.” As we know from a review of the history of the criminalization of drug use, the matter of which population is using the drug in question largely determines the political response to users. Now that opiate addiction is seeping into suburban and rural communities and affecting middle- and upperclass families, the government and law enforcement officials seem ready to see addiction as the illness that it is. National surveys show that two-thirds of the public favor treatment, not jail, for people in trouble due to heroin or cocaine use (Pew Research Center

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Practice Applications with Involuntary Problems and Settings 2014). Just 26 percent think the government’s focus should be on prosecuting users of such hard drugs. And most states are acting to revise drug laws: Between 2009 and 2013, forty states took some action to ease their drug laws according to a separate analysis of data by the Pew Research Center. Compared to previous years, the more recent survey shows a significant liberalization in attitudes.

Support for a Harm Reduction Model by Professional Organizations In its policy statement handbook, the National Association of Social Workers (NASW (2015) endorses a comprehensive public health approach for the prevention of alcohol, tobacco, and other drug problems. It also endorses “harm reduction approaches and alternatives to incarceration” for persons affected by such problems (196). And the recent publication by NASW Press of Harm Reduction for High-Risk Adolescent Substance Abusers by Maurice Fisher (2014) is evidence of NASW’s endorsement of strengths-based harm reduction models. In contrast to the moralistic approach to drug abuse and a heavy reliance on law enforcement, the harm reduction model views addiction as an adaptive response to a wide range of variables that influence behavior (Sowers 2015). Such variables would be experiences such as trauma, homelessness, other highly stressful situations, and biological factors. The view that addiction is a disorder with biological roots is compatible with a harm reduction model. The American Society of Addiction Medicine (ASAM), the largest professional society of doctors dedicated to treating and preventing addiction, released a new definition of addiction that called it a brain disorder rather than a behavioral problem (ASAM 2011). This acknowledgment was helpful to the addiction treatment field. ASAM was responding to compelling scientific evidence that the brain adapts to the presence of addictive substances and changes following long-term exposure to drugs. This understanding undermines a moralistic view of addiction problems and of people who have them. From a harm reduction perspective, the challenge is to help people break the addiction cycle and to avoid negative consequences related to their behavior, even if they are unwilling to give up the source of the addiction altogether.

A Paradigm Shift in Substance Abuse Treatment Bolstered by extraordinary brain research showing the physiological basis in addiction, substance abuse treatment is moving slowly toward a more scientific, empirically based approach. We might even say that a revolution of sorts

Substance Abuse Treatment is brewing in substance abuse treatment circles, a paradigm shift in our understanding of the nature of addiction. Much of the impetus for change of course is strictly economic. After expanding wildly in the 1980s, residential twelve-step– oriented treatment programs are falling on hard times; insurers and employers are seeking cheaper, less intensive alternatives (Taxman and Belenko 2012). Since the 1990s the field of substance abuse treatment has been rapidly professionalizing. The importance of insurance company reimbursement meant that evidence-based treatment was prioritized, so the reliance on therapists whose sole credential was their own history of substance in recovery was no longer enough to satisfy third-party payers. The current focus is on both certification and academic credentials. The influx of mental health professionals into the field impacted treatment offerings. While the insurance companies favored models that were evidence-based, such as motivational interviewing, which had the economic advantage of requiring a shorter treatment duration than other models (see Maisto, Galizio, and Conners 2015, esp. 410), the professionally trained recruits in the field were philosophically ready to work with a more eclectic approach to treatment. A breakthrough of sorts took place when, somewhat belatedly, the National Institute of Alcohol Abuse and Alcoholism (NIAAA) concluded what addiction researchers have been saying for some time, that many people with alcohol use disorders at one point in time can learn to control their drinking or likely will do so, on their own, later in life. According to NIAAA (2009), “alcoholism isn’t what it used to be.” The irrefutable evidence came years ago from the National Longitudinal Alcohol Epidemiologic Survey which began gathering information in 1991 and surveyed over 43,000 individuals, representative of the U.S. population based on criteria for a diagnosis of alcoholism (Grant, 1997). The results, which were not even recognized by representatives of the treatment community until 2009, showed that: • Twenty years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence. • About 75  percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment. (NIAAA, 2009, 5th paragraph) Because the survey was conducted in the general population, it provides a very different view from studies that have been conducted using clinical

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Practice Applications with Involuntary Problems and Settings samples—that is, people already seeking help for their problems with alcohol. We need to keep in mind that people who present themselves at specialist treatment agencies (often by court order, as is typical in the United States) are apt to have severe problems including a history of legal violations and to represent the extreme end of the continuum. For this reason, we should refrain from generalizing about addiction and recovery to the general population based on the biased sample from the treatment population when more than three-fourths of all persons with addiction problems, as Heyman (2009) estimates, never enter treatment and recover on their own. What these results show is that many people who are addicted to alcohol can later manage to drink moderately. This bit of evidence has thrown the belief that total abstinence is the only path to sobriety, the predominant teaching of the disease model, into a tailspin. That alcoholism and other drug addiction is always progressive has been a major teaching of virtually all the twelve-step–based treatment programs for decades. Significantly, as well, research evaluation studies now measure recovery in terms of improvement in healthy living and reduction in drinking and other drug use. This approach replaces the earlier strategy of simply asking the question, “When did you have your last drink or when did you last use an illegal drug?” in the posttreatment effectiveness evaluations (van Wormer and Davis 2012).

Use of Medications to Control Cravings and Prevent Relapse Solutions, to be true solutions, must be directed at the source of the problem. And if we agree with the teachings of the National Institute on Drug Abuse that addiction is a brain disease, it makes sense to seek solutions that are medically based (Volkow and Koob 2015). Hence, the focus today by the national institutes tends to be almost exclusively on medical research and the use of medications to quell the biological urges to relapse is revolutionizing the field of addiction treatment. The development of medications to treat substance dependence has ushered in a new era of treatment and attitudes toward treatment (Vimont 2015). The shibboleths of the profession are changing from the old absolutes mandating abstinence from all mood-altering substances to a much greater acceptance of the use of nicotine patches and antidepressants. Because one of the leading causes of relapse is depression, medications that help replenish the brain with the natural opiates should be an effective adjunct to relapse prevention. Naltrexone, a drug in a different category from the dopamine and serotonin-boosting medications, functions by blocking cravings for addictive substances. Because naltrexone targets the opiates in the brain, it reduces the

Substance Abuse Treatment reinforcing effects of alcohol and curbs cravings for both opioids and alcohol (SAMHSA 2009). Because people who strug gle with chemical addictions seem to have an underlying vulnerability to a number of compulsive behaviors, including compulsive gambling and eating disorders, medication geared toward normalizing brain functioning might reap benefits in these related areas as well. There are two major risks as we move in this direction, however. The first is that much of the personal therapy that we see in the field of substance abuse counseling will be replaced with a prescription for a bottle of pills. The second is that the medication prescribed will be only of the expensive variety and of more benefit to the pharmaceutical companies than to the individuals in need of care.

Individualized Treatment and Motivational Strategies Fortunately for our purposes, the SAMHSA (2014) survey mentioned previously obtained results from its questionnaire concerning treatment modalities and offerings. This gives us an objective source of information to gauge changes in the addiction field. Results show that a wide variety of approaches are used, many of which are individualized. Medication-assisted treatment, for instance, was provided by around 8 percent of the facilities, and 27 percent of all clients received methadone, presumably to prevent withdrawal from heroin. A twelve-step facilitated focus was the guiding framework in 74 percent of the facilities. (Twenty years ago this approach was used in virtually all the substance abuse clinics [van Wormer and Davis 2012]). At least some of the time, motivational interviewing strategies were used in 88  percent and a cognitivebehavioral approach in 92  percent of the facilities. Specialized groups for gay/ lesbian/transgender populations were available in 12  percent of the treatment centers, women-only groups in 44 percent, groups for older adults in 12 percent, gambling addiction treatment in 12  percent, and a family violence focus in 20  percent, while 71  percent provided trauma-related counseling. What these statistics show is that treatment has come a long way from the one-size-fits-all programming that dominated the field for well over sixty years. The term “motivational interviewing” is most closely associated with psychologist William R. Miller, who first devised the strategies inspired from the work of Carl Rogers. Today the strategies are spelled out in numerous SAMHSA treatment improvement protocols, in videotapes by Miller, and in the book, Motivational Interviewing: Helping People Change (Miller and Rollnick 2012). This approach, which is shown to be far more effective in helping people change than a confrontational style of counseling, is guided by the following basic principles:

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Practice Applications with Involuntary Problems and Settings 1. Express empathy. The motivational style is warm, respectful, and accepting and the counselor puts himself or herself in the place of the client to establish rapport. Irrational ideas and ambivalence about change are accepted as a normal part of human experience. 2. Develop discrepancy. Create and amplify the discrepancy between present behavior and important personal goals. Reflective listening and focused feedback can help to highlight discrepancies using the client’s own words about living a healthier life. 3. Avoid argumentation. According to this philosophy, if you get clients to state their defensive position, they will become entrenched in it. You want to elicit statements in a change-seeking direction. A good strategy is to ask where clients are on a scale of 1 to 10 with 10 as “quit drinking or using drugs.” When they say 5, for example, ask “Why did you not pick 2?” Their response will help convince them of reasons to address the problem. 4. Roll with resistance. Helping the client feel he or she has a choice is especially effective with teenagers and clients who are angry. In fact, Project MATCH proved that a motivational approach works best with people who are hostile while the twelve-step approach works best with religious people. 5. Support self-efficacy. If people have no hope for change, then regardless of how serious they perceive the problem, they will not make an effort to change. It is important for the counselor to impart faith that the person can move in the direction of change. This strategy is similar to a strengths perspective.

Progressive Policy Developments at the National Level and Counter Measures The passage of the now historic Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 was a promising development. This act required health insurers and group health plans to provide the same level of benefits for mental health and substance use treatment and services as they do for medical and surgical care. The Affordable Care Act of 2010 further expanded the MHPAEA’s requirements by ensuring that qualified plans offered on the Health Insurance Marketplace covered many behavioral health treatments and ser vices (SAMHSA 2017). Former President Barack Obama signed the Comprehensive Addiction and Recovery Act (CARA) into law in 2016. This legislation was specifically designed to address the opiate and heroin drug addiction epidemic. It was a comprehensive piece of legislation in that it addressed prevention, early intervention, treatment, and recovery. Among other things, the legislation created a Pain Management Best Practices task force, increases ac-

Substance Abuse Treatment cess to Naloxone, a drug that prevents overdose, improves prescription monitoring programs, provides funding for more treatment centers, and increases treatment to those who are already incarcerated (U.S. Congress 2016). There was much excitement at the time over the passage of these progressive acts. But although President Trump has declared the opioid death toll a public health crisis, he has not yet requested special funding for prevention and treatment (Davis, 2017). And the president’s stated plan to end the treatment mandates as stipulated under the Affordable Care Act does not portend well for the future of addiction treatment (Sheff, 2017). Another positive development that is now under threat was the exceedingly generous proposal for federal funding for treatment for people with substance use disorders (The White House 2016). The former government’s emphasis on treatment as opposed to punishment for drug users was in line with research on cost-effectiveness (with data from national statewide studies showing that every $1 of treatment saves at least $11 in health care and criminal justice costs [The White House 2012]). It was also in line with the new national impetus toward sentencing reform. Under the Affordable Care Act of 2010, overall funding for substance abuse ser vices and treatment options increased, as this form of treatment became better integrated into the mainstream of general health care. Reform provisions have shifted ser vices away from residential and stand-alone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is less stigmatized and more medically based and person-centered. In work with certain populations, for example, homeless people with cooccurring disorders, the United States increasingly has moved toward a harm reduction model that is appealing to the people in need of housing as well as treatment. Generous federal funding was made available for Housing First options, which provided housing to homeless people with serious alcohol and other drug problems whether they abstain from substance use or not. And the harsh confrontation models that have characterized substance use treatment since the early days have been replaced with a kinder, client-centered approach. Nevertheless, treatment programs are still highly structured and geared to work with people who do not want to be there and who are resistant to giving up their substance of choice. And under the harsh leadership of Attorney General Jeff Sessions, there is every indication that the war on drugs will resume (Sheff 2017).

What We Can Learn from Other Countries In other parts of the world, such as the United Kingdom, Switzerland, and the Netherlands, the substance abuse treatment philosophy is different. Treatment

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Practice Applications with Involuntary Problems and Settings is available for people who wish to get help, perhaps just to pop in to discuss an addiction that seems to have gotten out of hand. At many of these neighborhood establishments, young people come of their own free will. They might be referred to a doctor who can legally prescribe the substance. In these countries, a harm reduction approach predominates. Treatment is paid for through the national health system, and it is not considered to be a public threat in any way. As in a number of European countries, Vancouver, Canada, has had a supervised injection facility for over a decade. Called InSite, the facility consists of little stalls where people can inject their drug of choice, with medical staff standing by in case of overdose and to connect people with treatment ser vices if they want them. Research shows that as the drug users grow accustomed to “shooting up” at these safe sites, they begin to develop relationships with the staff, and some of them eventually decide to enter treatment (Jaywork 2015).

The Case for Harm Reduction According to the disease model, addiction is a progressive illness with no cure and abstinence is the only known way to halt its progression (Marlatt and Witkiewitz 2010). But now that we know total abstinence, although desirable, may not be a realistic goal at the outset of treatment and that many people will eventually moderate their drinking and drug use or substitute a safer drug for a more addictive one, it is time to offer treatment plans to match what we know about recovery. And the most viable alternative to an abstinence-based treatment method and the best way to attract people with substance use problems to get the help they need is harm reduction. The realization that no single substance abuse treatment approach is effective for everyone represents a major step forward. Motivational strategies that are client-centered and nonconfrontational are less time-consuming than some other approaches. There is simultaneously a trend, for prevention purposes, to treat alcohol and drug users with only mild problems (e.g., problem drinkers) (White 2010). Non-abstinence–based treatment programs, such as Moderation Management, which allow problem drinkers a set number of drinks, are becoming increasingly more acceptable (see www.moderation .org). Extensive empirical data on the success of this program are not available, but researchers regard this approach as most appropriate for people with less severe drinking problems (Miller et al. 2011). Despite all these advances, a full-blown harm reduction approach in which clients decide how to reduce their alcohol and other drug use and can continue in treatment regardless of their continuing substance use is not a viable option at U.S. treatment facilities at the present time. Yet requiring abstinence can hinder the potential for recovery because clients are frightened away by

Substance Abuse Treatment the thought of giving up their substance of choice all at once; keeping clients away, in turn, means that the treatment providers will not get a chance to address the mental health and medical problems that these clients may also have. Change occurs over time. Getting the person in need of making life changes in the door is a major first step toward recovery.

Conclusion As the addictions field has matured, it has moved away from the dogmatic authoritarianism of the early days to the use of motivational strategies geared to clients’ individual needs. While the twelve-step facilitated approach is still the dominant treatment modality used in U.S. substance abuse treatment clinics, this approach is bolstered by new understandings about the workings of the brain, the nature of addiction, and the psychology of helping people to get motivated for change. Substance use disorder is now officially defined as existing along a continuum (APA 2013), rather than seen as an either-or diagnosis, that is, either you are an alcoholic or you are not. At the same time, NIAAA has finally acknowledged that many people with a clear pattern of alcoholism can mature out of the problem and become moderate drinkers. Regarding persons addicted to illicit drugs, substitutes are prescribed by doctors to keep patients stabilized. These are both examples of harm reduction. In this chapter, we have seen how a public health or harm reduction approach is making inroads, primarily as a strategy that places saving lives above moralism. The widespread use of medications to reduce cravings and prevent relapse is a significant change that can be considered the way of the future. Today, to save lives from opioid and heroin overdoses, medical technicians, police officers, and family members are being equipped with the antidote drug naloxone (Narcan), which they can administer to an unconscious person who might other wise die from respiratory failure. A major area of needed improvement is to abandon the principle of total abstinence from all alcohol and other drugs as a requirement for treatment and replace it with a desire to get better and develop healthier personal habits. This policy would attract people who come on their own to get help and it is consistent with an integrated treatment approach to health to be instituted under the Affordable Care Act.

Discussion Questions 1. Read the portrait of Oceana, West Virginia, at oxyana.com /about .html. Then, watch the trailer to the documentary Oxyana (2:23

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Practice Applications with Involuntary Problems and Settings minutes). Discuss how prescription painkillers have the potential to destroy entire communities. What can be done to stop this epidemic? Note: Consider watching the entire documentary, which can be rented online or viewed in YouTube. 2. On July 22, 2016, President Barack Obama signed the Comprehensive Addiction and Recovery Act (CARA), Public Law 114–198 (http://www.cadca.org /comprehensive-addiction-and-recovery-act -cara). What changes will come about as a result of this legislation and how will these changes impact the way drug and alcohol treatment is currently perceived? 3. Do you agree or disagree with the use of methadone/suboxone treatment for those who are addicted to prescription pain medications or heroin? What are some of the pros and cons? References American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington, DC: APA. American Society of Addiction Medicine (ASAM). 2011. Public Policy Statement: Definition of Addiction. Chevy Chase, MD: ASAM. Fisher, M. 2014. Harm Reduction for High-Risk Adolescent Substance Abusers. Washington, DC: NASW Press. Grant, B. F. (1997). “Prevalence and Correlates of Alcohol Use and DSM-IV Alcohol Dependence in the United States: Results of the National Longitudinal Alcohol Epidemiologic Survey.” Journal of Alcohol Studies 58(5): 464–473. Heyman, G. 2009. Addiction: A Disorder of Choice. Cambridge, MA: Harvard University Press. Jackson, M. 2016. “Obama’s $1 Billion against Heroin Reflects Shifting Views of Addiction.” Christian Science Monitor. February 2. Jacobs, H. 2016. “Here Is Why the Opioid Epidemic Is So Bad in West Virginia—The State with the Highest Overdose Rate in The United States.” Business Insider. May 1. Jaywork, C. 2015. “Seattle Could Be the First City in the U.S. to Host Safe-Injection Sites for Heroin Users.” Seattle Weekly News. November 17. Katz, J. 2017. “The First Count of Fentanyl Deaths in 2016.” New York Times, September 2. Retrieved from www.nytimes.com. LaSalle, L. 2016. “Legislation Would Create Drug-Use Facilities, Decriminalize Possession of Small Amounts.” Baltimore Sun, February 4. Retrieved from www.baltimoresun.com. Maisto, S. A., M. Galizio, and G. Connors. 2015. Drug Use and Abuse, 7th ed. Belmont, CA: Cengage. Marlatt, G., and K. Witkiewitz. 2010. “Update on Harm-Reduction Policy and Intervention Research.” Annual Review of Clinical Psychology 6: 591–606. Miller, W. R., A. Forcehimes, and A. Zweben. 2011. Treating Addiction: A Guide for Professionals. New York: Guilford Press. Miller, W. R., and S. Rollnick. 2012. Motivational Interviewing: Helping People Change. New York: Guilford Press. National Association of Social Workers (NASW). 2015. “Substance Use Disorder Treatment.” In Social Work Speaks: NASW Policy Statements 2015–2017, 10th ed., 296–297. Washington, DC: NASW Press.

Substance Abuse Treatment National Center on Addiction and Substance Abuse. 2010. Behind Bars II: Substance Abuse and America’s Prison Population. New York: Columbia University Press. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2009. “Alcoholism Isn’t What It Used to Be.” NIAAA Spectrum 1 (1). Retrieved from https://www.spectrum.niaaa.nih.gov. Peele, S., and I. Thompson. 2015. Recover! An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life. Boston: Da Capo Lifelong Books. Pew Research Center. 2014. America’s New Drug Policy Landscape. Washington, DC: Pew Research Center. Sheff, D. 2017. “Trump’s War on Drug Users: Column.” USA Today, May 9. Retrieved from www.usatoday.com. Sowers, K. 2015. “International Perspectives on Social Work Practice.” In Social Workers’ Desk Reference, eds. K. Corcoran and A. R. Roberts, 3rd ed., 888–893. New York: Oxford University Press. Substance Abuse and Mental Health Ser vices Administration (SAMHSA). 2009. Incorporating Alcohol Pharmacotherapies Into Medical Practice: A Treatment Improvement Protocol: TIP 49. Rockville, MD: SAMHSA. Substance Abuse and Mental Health Ser vices Administration. 2014. National Survey of Substance Abuse Treatment Services: 2013. Rockville, MD: SAMHSA. Substance Abuse and Mental Health Ser vices Administration. 2017. Implementation of the Mental Health Parity and Addiction Equity Act. Rockville, MD: SAMHSA. Retrieved from https://www. samhsa .gov/ health-financing /implementation-mental-health-parity-addic tion-equity-act. Taxman, F., and S. Belenko. 2012. Implementing Evidence-Based Practices in Community Corrections and Addiction Treatment. New York: Springer. U.S. Bureau of Labor Statistics. 2015. “Substance Abuse and Behavioral Disorder Counselors.” Occupational Outlook Handbook. https://www.bls.gov/ooh /community-and-social -service/substance-abuse-and-behavioral-disorder-counselors.htm. U.S. Congress. 2016. Comprehensive Addiction and Recovery Act of 2016. https://www.congress .gov/bill/114th-congress/senate-bill/524. van Wormer, K., and D. R. Davis. 2012. Addiction Treatment: A Strengths Perspective. Belmont, CA: Cengage. Vimont, C. 2015. Q & A with Hazelden’s Dr. Marvin Seppala on Medication Assisted Treatment. New York: Partnership for Drug-Free Kids. Volkow, N., and G. Koob. 2015. “Brain Disease of Addiction: Why Is It So Controversial?” Lancet Psychiatry 2: 677–679. The White House. 2012. Cost Benefits in Investing Early in Substance Use Disorders. Washington, DC: Office of National Drug Control Policy. The White House. 2016. Fact Sheet: President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic. Washington, DC: Office of the Press Secretary. White, W. L. 2010. “On Science and Ser vice: An Interview with Tom McLellan, Ph.D.” Counselor Magazine 11 (4): 24–35.

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Chapter 16

Work with Unmotivated Clients

Per Revstedt

No one is hopeless. Everyone can become motivated. These sentences summarize the idea behind motivational work. The method is based on a new paradigm that relates to motivating clients and patients. One basic difference between motivational work and other methods is how we look at and meet defense, how we deal with burnout, and how we use relationship and method.* Motivational work is aimed at all types of clients, including those with the most destructive behavior. There is no preconceived technique to which the client must adapt, but instead the method is adapted to clients’ behavior. Motivational work consists of three parts: values and theory, the motivational relationship, and method and techniques. Values and theory are the most important part of creating a protective suit against burnout, so that the motivational worker can maintain his commitment and not be drained of energy. The motivational relationship with the client is the practical application of motivational work values and theories. It conveys the commitment that the client needs. Method and techniques only work if there is a motivational relationship. They allow motivational work to proceed faster.

* In the general passages, both the motivational worker and the client have been given a male gender. Since I am a man, it felt natural for me to use the male pronouns he, him, and his. This does not imply in any way that male motivational workers are more suited to the job or that personnel should concentrate more on male clients.

Work with Unmotivated Clients The predominant motivational methods, such as motivational interviewing and the transtheoretical model, are all based on the psychotherapeutic model. This means that the client is sufficiently in contact with his inner self to be able to reflect on his own situation. He can thus make a fairly rational assessment of the advantages and disadvantages of making changes. Motivational work goes one step further to reach clients who lack a capacity for selfreflection (see section “Continuum of Client Motivation”). In addition, these clients are often those who most need help and who exhibit the most destructive behavior. Methods based on the psychotherapeutic approach generally put demands on the client that are adapted to people from a middle-class environment, such as being able to meet regularly with the motivational worker, to be able to verbalize their thoughts and feelings, and to listen to, understand, and reflect on the motivational worker’s reactions. There is a risk that this communication may feel strange to a client who is not accustomed to relating in this way. It may mean that other, less privileged, groups in society are often beyond help. I am a clinical psychologist, licensed psychotherapist, and licensed supervisor in psychotherapy. Regarding methods of psychotherapy, I am qualified in Rogers’s client-centered therapy, psychodrama, and psychodynamic therapy. Motivational work is built on my own experience of motivational work and the guidance of others. The evidence for the work is thus based on case study method (i.e. clinical experience). My aim is to use case studies to deepen and develop the theory and explain complex phenomena and occurrences (Yin et al. 2012; Fishman et al. 2016). Certain cases have also been used as examples of best clinical practice (Fishman et al. 2016). One advantage of case studies is the access to rich, qualitative mental phenomena, which can be explained and understood. The method also provides insights for further research. Its disadvantages include the fact that it is not possible to generalize to a larger population. In addition, the researcher’s own subjective experiences influence the results (researcher’s bias) (Yin et al. 2012; Fishman et al. 2016). Robert Yin provides further detail on the possibility of generalizing results from case studies (Yin et al. 2012). The disadvantage of this method is that it is not possible to make a statistical generalization; that is, the results from a number of cases cannot be generalized to a larger population. On the other hand, it is possible to use analytic generalization, which means that one can make use of the theoretical framework to create a logic that may be applicable to other situations. The case study method involves two steps. The first is to describe how the facts in the case relate to the concepts and theoretical model. The next step is to use the same theoretical concepts to cover other situations outside the case study, in which similar concepts and theory could be relevant.

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Practice Applications with Involuntary Problems and Settings Daniel B. Fishman (2016) also deals with the disadvantage of the case study method for generalizing results. He believes that if we carry out an analysis of the description and the theory in many case studies, the overall results may strengthen the generalizability of the theory. What has been especially important for me is being able to deepen the qualitative information through case studies; this, in turn, gives rise to a new theory and can partially confirm it. The case study method has given me a more detailed knowledge of motivational work. At the same time, I am aware that my observations are partly biased by my own subjectivity. I hope, therefore, that motivational work will also be evaluated through statistical generalization. My case studies are based on my forty years of experience with unmotivated and destructive clients, of which thirty-three years have been as a teacher and supervisor in motivational work. I have worked in a therapeutic community for addicts, psychiatric departments, and have run my own psychotherapy clinic. As a motivational worker, I have met voluntary clients and those forced to attend, always in the role of psychologist. I have met clients in voluntary situations and those in compulsory care. The clients have sometimes been required to meet me, or I have tried to build a relationship with them after looking them up. During my years as a supervisor I have guided all possible activities in psychiatry, social ser vices, and correctional treatment, such as open and closed psychiatric care for children and adults, social childcare, foster home activities, youth care, open and closed youth institutions, care of addicts, detoxification, social economic aid, custody conflicts, domestic violence, incest investigations, prisons, remand centers, and probation. Through all this experience, and being fully aware of the problems associated with the case study method, I believe I have seen clear indications that motivation work really is effective and that no one is a hopeless case.

Historical Perspective Perhaps the easiest way to present motivational work is by explaining its origins. Around forty years ago I was working at a therapeutic community institution. The treatment was focused on addicts, but other groups of clients were also accepted, mostly from prison and psychiatric referrals. The approach at the institution was that clients must be motivated to gain admission for treatment. This would be achieved by placing many compliance demands that were considered integral to motivation. For example, a prospective client had to make the phone call himself to arrange an appointment for an admission interview, where his motivation would be assessed. Another demand was that clients had to stay off drugs throughout their stay at the institution. A client would not be discharged immediately for substance abuse, but

Work with Unmotivated Clients only a few relapses were allowed. If a client threatened anyone or used physical violence of any kind, he was automatically discharged. If anyone went missing from the institution without alerting the staff and failed to make contact within 24 hours, they were discharged. Requirements on constructive behavior were therefore imposed in a similar way as they are in psychotherapy. It is assumed that every client has a properly functioning constructive side, with which we can cooperate. This type of relationship is often called a “working alliance” and originates from psychoanalysis (Greenson 2000). A similar concept is found in motivational interviewing (Millner and Rollnik 2013). The working alliance involves a paradox, however. The client is unmotivated but, at the same time, has a rational and sensible side that allows him to set limits for himself and have constructive behavior. The question is: How can he be motivated and unmotivated at the same time? Although requirements were placed on the clients at the therapeutic community institution, most of them were unmotivated to varying degrees, just like many other clients from the social ser vices, prison, and psychiatric practice. The staff there, including myself, were trained in the use of Rogers’s clientcentered therapy (Rogers 1951) and we tried to adapt the method to our unmotivated clients. In this respect, you could say that we were already working with the basics of motivational interviewing as early as the 1970s. Rogers’s client-centered psychotherapy and motivational interviewing are based on the client being able to open up emotionally, decide to cooperate, and have enough contact with himself to reflect on his thoughts and feelings. One condition for this method is that the client and practitioner can meet and talk with each other. The therapist remains neutral in the situation and is there to help the client think for himself. In short, it requires that the client is relatively well-functioning. Our experience of working with this method was that clients who had at least some motivation were able to complete all or parts of the treatment program and were helped. Many clients who were enrolled for six weeks or more managed to make improvements in their lives (Jenner 1979). One characteristic of this group was that they applied for the program themselves, participated actively in the program, tried to open up emotionally, were not hostile or aggressive, and did not have many relapses. Those who, in relative terms, needed treatment least gained the most. The more unmotivated clients either did not apply for the program themselves or did not complete it due to noncompliance with the rules and requirements. About 50 percent of the clients were discharged before they had been there six weeks (Eriksson and Revstedt 1978). These clients did not often come voluntarily or were admitted through someone else’s initiative, only participated in the program sporadically, did not open up emotionally, were threatening and aggressive, and had many relapses. Those who were most in need

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Practice Applications with Involuntary Problems and Settings of help received the least. It is this dilemma that arises if treatment relies on motivation on the part of the client, who must cooperate constructively; that is, agree to the treatment, follow the practitioner’s method, and be able to reflect on his life situation. As a practitioner I did not want to accept this “motivation paradox.” Instead of having the point of departure that the client must live up to the requirements of the method, I wanted to adapt the method to the client and his life situation. In this way, I tried to motivate very unmotivated clients to come to the institution, who would other wise never have applied for treatment there. I also tried to motivate clients to stay who other wise would have been discharged for infringing on the rules or would have broken off the treatment themselves. A theory and a method of how to motivate people evolved from these experiences. Fairly soon I began to teach and supervise others in motivational work as I continued to work at the therapeutic community. I also had the opportunity to summarize the method in the form of a book. The book was first published in 1986, and was quickly adopted as a textbook at universities in Sweden and Denmark (Revstedt 2014b). After nine years I resigned from my job at the environmental therapy institution and decided to work with very unmotivated and very destructive patients in psychiatry who had been detained. My job as a psychologist was in the closed wards, the patients there being the most difficult to treat and manage at the psychiatric hospital. Many of them were diagnosed with schizophrenia. There were also patients who were sentenced by a court to closed psychiatric care. They had committed murder, rape, incest, assault, or other serious crimes. It was in this environment that I had the opportunity to develop my work on motivation theory and practice. Many patients refused to have contact with me, were threatening, aggressive, or extremely compliant. They often missed meetings that had been previously arranged. Many of them were using psychotropic drugs or drugs that had been smuggled in. In addition, they were forced to be at the hospital. None of them were there voluntarily. I worked in this psychiatric department for seven years. During the same period I continued working with various supervisory and training assignments. I left the job in psychiatry in 1990 and now run my own psychotherapy clinic and take on training and supervision assignments. In order to describe my method in detail and spread knowledge of it, I decided to write an English script (with the help of two translators) so that I could convey my ideas more widely. At the same time, I wished to give a full description of my theory so that everyone could understand the thinking behind it (Revstedt 2014a). In this chapter, I have attempted to give a fair picture of the method that is contained in the 1,700 pages and 600 case studies found in the book.

Work with Unmotivated Clients Through my own motivational work with clients and the supervision of other staff that use it, I have become even more convinced that there are no hopeless cases. It is possible to motivate anyone, even those who are unmotivated.

Helper Burnout A crucial part of motivational work is to avoid becoming burned out. All unmotivated clients and patients have one thing in common: they give negative feedback to helpers. They do not come to meetings, they leave abruptly, they are aggressive, insulting, threatening, violent, under the influence of drugs or alcohol, or they are compliant (that is, they adapt superficially to the personnel’s expectations). To sum up, you only get negative confirmation for being engaged with them. Furthermore, they are emotionally cut off, so deep contact cannot be established. This negative behavior creates feelings of meaninglessness and hopelessness in helpers. Contact with unmotivated clients and patients is emotionally draining. It seems that they do not want any help. Why invest time and energy in them when the effort is without any reward? There is therefore a risk of burnout. The motivational worker begins to feel hopeless and loses his positive commitment and self-confidence. If this process is allowed to continue, more and more mental energy is lost and the motivational worker sees breaking off contact as the only option. Psychotherapeutic methods and motivation interviewing do not deal with burnout. The situation is resolved by stating that the client does not suit the method, quite simply.

Continuum of Client Motivation However, during the time period after he created client-centered therapy, Carl Rogers (1967) raised the dilemma of motivation. He did this in conjunction with his examination of the process of change in psychotherapy clients. The result was built on recorded psychotherapy sessions. It is the fundamental principles of Rogers’s theory that form the basis of my notion of change in the unmotivated client. Rogers divides the therapeutic process into seven stages. The first two correspond to what we would call unmotivated clients, the other five to motivated clients. Rogers gives the image of a completely set and rigid person at the beginning of the process. You could liken the person to a block of ice or a concrete bollard. The part that is set is his inner emotional state and the cognitions he has about himself and the outside world. No changes can take place. At the end of the therapy process, the person is completely open to his inner feelings and can question his perceptions of himself and reality.

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Practice Applications with Involuntary Problems and Settings A client in the first stage does not voluntarily go to treatment. In general, he is characterized by an inability to talk about himself and his own feelings and experiences. He only wants to discuss external events and has no contact with his inner feelings. The cognitions the client has of himself and the rest of the world are rigid, unchangeable, and without nuance. He sees them not as his own pictures of reality but as facts. In the second stage, the client will voluntarily go to treatment, but no change takes place. He is still predominantly latently motivated, but not to such a large extent as in the first stage. In stage two, he does not seek treatment to help with his fundamental problems but to escape from an acutely painful situation. When the immediate suffering is over, there is no longer any motivation to stay in treatment. It is not until stage three that the client more openly cooperates with the motivational worker. The client’s motivation has started to take over. According to Rogers, it is only now that psychotherapeutic work is possible. The client openly expresses his emotions for the first time in the third stage. This means that he shows what he really feels, even if this only happens sporadically. You could say that the client has begun to lift his lid. Cognitions are no longer regarded as facts, but as personal images of reality. Contradictions, too, are perceived as contradictions. The client’s changed view of his cognitions is very different from what it was in the past. Now that they are no longer facts, he is exposed to the possibility of questioning them. Here, too, the client helps the treatment in an open, constructive manner. All methods based on a psychotherapeutic paradigm are primarily adapted to clients from stage three onwards. The most important factor according to Rogers is that the client has emotional contact with himself and dares to open up. What this means in practice is that he has the strength to face his own pain, as well as the capacity for a trusting relationship with the psychotherapist. The client is able to reflect on himself and his life situation (Rogers 1967). There are limitations to Rogers’s investigation, however. He was working with clients who were already seeing psychotherapists. There are other clients, though, who are so destructive that it is not possible to achieve a discussion of the type described. This means that in reality there are more stages according to motivational work. Stage zero-zero includes patients who are extremely unmotivated and near death, while those in stage zero exhibit destructive behavior that is slightly less pronounced and more like Russian roulette; that is, the will to live is stronger than in stage zero-zero. If your ambition is to meet all types of clients, including those with very destructive behavior, you are constantly confronted with the dilemma of burnout. It is essential to find a constructive way of managing this risk. Motivating all types of clients involves meeting those who are aggressive and threatening, do not want any contact, do not come to meetings, abuse psychotropic medicines and other drugs, and do not have any contact with them-

Work with Unmotivated Clients selves and therefore cannot reflect on their situations. The challenge for the motivational worker is to find a way to treat clients that increases their motivation and creates a relationship. Ulla, a twenty-five-year-old committed patient has been diagnosed as schizophrenic. The patient has attacked several staff members with no provocation. In the staff supervision group, support is given to keep a positive approach to Ulla as a person, regardless of her aggressive behavior. After talking with the supervisor, the staff decide to have a group confrontation with Ulla. The staff have now been assembled for a meeting with her and the psychiatric unit manager, at a time that suits the majority. A number of staff tell Ulla that they do not want her to be violent with anyone in the unit. They also tell her they care about her, and that she cannot be feeling good about being violent. Ulla sits there quietly, looking at the floor. Suddenly, she attacks the member of staff who is sitting closest to her. Several others rush over and manage to get hold of her, and they stick to their agenda by telling Ulla that they will not accept such behavior, conveying their feelings of commitment, anger, and sadness. Ulla responds by screaming at them to let go of her. She finally calms down and the staff can let her go and end the meeting. The following week, a new meeting is arranged, in which Ulla shouts aggressively and threatens violence, but takes it no further. A third meeting is held, and this time Ulla listens to the staff without using her “shouting screen.” After these meetings, Ulla stops being violent toward the staff and other patients. The staff must manage to maintain a positive attitude toward the patient. There is other wise a risk of burnout. Ulla’s constant attacks on the staff can make them dislike her or feel frightened. Supervision provides the staff with support for keeping a positive commitment toward Ulla. Further help is given through the supervisor making proposals on how to treat Ulla to increase her motivation. As she gains more motivation, her destructive behavior will also decrease. The staff’s attitude and behavior enable them to protect their commitment to Ulla and to make even closer contact with her.

Values and Theory Motivational work has its roots in humanistic psychology. This approach includes Carl Rogers’s person-centered therapy (Rogers 1967) and psychodrama (Moreno 1978). Humanistic psychology has a humanistic approach as its core value. This foundation is shared by motivational work. The humanistic approach means that we believe every human being has an inner core that is good. Destructiveness and evil are not innate in humans; they come from the environment. The newborn infant has a positive inner core through and through; it has only pure goodness.

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Practice Applications with Involuntary Problems and Settings This means, among other things, that no one wants to destroy himself with drugs or harm others. This view of people can neither be proved nor disproved— either you believe in it or you do not. No external confirmation is required to be sure that the client has a positive core. No matter how unreasonable he seems to be in his behavior, we can still believe that he has a positive core. One conclusion from the humanistic approach is that there are no hopeless cases. Because everyone has a positive core, there is a potential in everyone that can be kindled and encouraged to evolve. This basic belief leads to the motivational worker always having hope for change in the client. He is thus able to keep up a positive commitment and not become burned out. Motivational work is never meaningless. There is always the possibility of change. In addition, the motivational worker gives out positive expectations all the time. The client is acknowledged and feels that there is hope for him. The objective of motivational work is to nourish positive energy in the positive core. Such an approach also reduces the risk of burnout, as no external affirmation is needed in the client’s behavior to fulfill this objective. Instead, motivational work aims at intrinsic change, which may only achieve expression in outward behavior after a long time. The more motivational work is tied to observable, distinct (and often immediate) changes in the client, the more likely it is that the worker will feel disappointed and redundant in his contact with the client. Vivian is a twenty-seven-year-old woman with an occasional destructive drinking problem. She lives in a state of fear of other people and isolates herself from her neighbors. The only people she has any contact with are her mother and her ex-husband. Her TV, oven, and telephone are all out of order. Vivian has been frequently abused by her ex, and even raped. A female social worker has been in sporadic contact with her for the past three years, while Vivian has spent days, even months, in seclusion. The social worker tries to make contact on these occasions, and when they meet Vivian talks about the meaninglessness of life and her wish to end it all. A few months earlier she met a new man, and although he is an alcoholic he treats her well, even tenderly. The external social context of the client does not change very much during the first years of contact with the social worker. However, if you consider the intrinsic goal, her relationship with her social worker may have boosted her life force so much that it dispels her suicidal tendencies. In this sense, meetings with the social worker have a great purpose: they help to maintain Vivian’s will to live. She has much destructiveness within her, as manifested in her thoughts and life. She puts herself into situations where she is repeatedly abused and she isolates herself from others. Her meetings with the social worker may have been particularly meaningful to her, given that she really has no one else to turn to other than her mother and ex-husband. After two-and-a-

Work with Unmotivated Clients half years, Vivian’s external life also starts to show signs of improvement. She meets a new man, who, according to the social worker, treats her well and does not show the destructiveness of her previous partners. This change can be seen as confirmation that her positive core has been strengthened and that she is enjoying a greater quality of life. The term “unmotivated” is actually misleading. The prefix “un” implies the absence of motivation. However, the humanistic approach posits a motivation in everyone in the shape of the positive core. This means that the “unmotivated” client does have motivation, but it is dormant and not noticeable in his behavior. An unmotivated person can therefore be called latently motivated, or possessing a motivation that is too weak to be expressed. Redefining the lack of motivation can thus help to instill a more hopeful approach in the motivational worker toward the client. The motivational process is therefore directed at enhancing the life force in the latently motivated client so that it is made explicit in his behavior, at which point he becomes manifestly motivated. From an emotional perspective, the client’s defensiveness is the most difficult aspect for the motivational worker to deal with, as his unreceptiveness and emotional distance convey a powerful negative confirmation of the motivational worker’s efforts. The motivational worker’s views of defense and resistance are therefore critical, as they are also his primary working material. The fundamental tenet of the theory that will now be discussed is that the prime purpose of all forms of defense and resistance is to make contact indirectly. It is a way of getting closer to the other person without the risk of being openly rejected, and at the same time it tests how much the other person can be trusted. This indirect communication strategy is called a “contact rebus.” A “rebus” is a puzzle of pictures, words, or letters that can be decoded into a particular word or phrase. The theory of the contact rebus helps the motivational worker to understand the client’s dissociation and destructiveness, supports his long-term commitment, and enables him to see different opportunities in the motivational situation. The latently motivated person does not have enough life force to cope with his mental pain. He is in a dilemma. In his positive core he wants help and wishes to move forward in his life. At the same time, he finds it is difficult to become closer to himself and to other people. He would then experience the pain that he does not believe he can manage alone. He is therefore very dependent on the other person being there to help him. What a latently motivated person wants most of all is to avoid being alone without any defense against his suffering. Until he has found someone who can support him, he must find ways of coping with his pain without having direct contact with it. He does this by defending himself against it. The method transforms pain into destruction. It is more bearable for him to do this than to be in contact with

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Practice Applications with Involuntary Problems and Settings his original suffering. The gain for the latently motivated person is not visible to the outside world, but he removes his anguish and pain through destruction. Destructive behavior gives him some internal relief. The ingenious part of this behavior is that the defense is simultaneously an indirect cry for help. The defense, or contact rebus, helps the latently motivated person to endure his pain and, at the same time, seek help from others. The pain that the latently motivated person carries is often related to other persons. He has been badly treated in different ways. It could be experiences from childhood or later in adult life. The latently motivated person does not want to be betrayed again. At the same time, he wants to have help from others. Thus, he needs to be as sure as possible that he has found the right person before he can trust them. This “trust testing” is done through the contact rebus. Because the latently motivated person needs so much motivation, his contact rebus is designed to obtain as much of this positive life force as possible. You could say that the destructive transformation boosts his attempts at making contact. The latently motivated person is looking for someone that he dares to trust and connect with. By choosing destructive contact, he gets a very clear idea of his relationship with the other person. If the person still wants to approach him, despite his destructiveness, this is even more confirmation of positive commitment. The destructive transformation pressures the other person to respond intensively. The function of creating and maintaining a relationship also becomes stronger. Destructiveness requires an energetic response and determination from the other person for a relationship to be created and developed. There are three types of contact rebus. The first is to make contact in an openly negative way. Ronald, a twenty-five-year-old patient, comes walking toward his unit’s male psychologist in the hospital grounds. Although the psychologist has individual professional contact with some patients in this unit, Ronald is not one of his patients. Keeping a good distance between them as he walks past, Ronald starts to shout at the psychologist, accusing him of being mentally ill. Some days later they bump into each other in the unit’s day room. Ronald jumps when he sees the psychologist, rushes toward him and stands less than a meter away from his face and launches into a new tirade of abuse about how the psychologist has caused Ronald’s girlfriend to have a miscarriage. The psychologist feels that the patient is threatening, but after a while Ronald calms down and they can both sit down in the discussion room, where Ronald now talks about his girlfriend’s miscarriage. The psychologist had previously been informed about this by the unit staff. The patient uses a destructive and aggressive contact rebus towards the psychologist, who is subjected to two different varieties of this. When the psychologist meets the patient, he is confronted with aggressive, verbal destructive

Work with Unmotivated Clients contact rebuses that Ronald uses to maintain his distance. By being threatening and rejecting, he tests whether the psychologist still has a positive attitude toward him. When this is confirmed, he dares to get even closer to the psychologist. The second form of contact rebus involves adapting to the expectations of others. Anders is twenty-six years old and has been in a closed ward for three weeks. He behaves in a very calm and collected manner and could easily be mistaken for a member of staff. In conversation, he says that he has no particular issues with himself or his life situation, but he does plan to have treatment at a therapeutic institution for alcohol and drug abuse, and gives this information in what appears to be a very informed way. He is exemplary in his participation in ward activities and he follows the rules. Anders was married until two years ago and has two young children. He says he has a good relationship with his former wife and children, and was in regular employment throughout his marriage. Anders is hiding behind a conciliatory attitude. This is his way of protecting himself from his own pain and the pain inflicted by others. Anders is looking for the right person to trust and help him, his search being conducted through a test that leads to his reliance on the person who sees through his highly polished act. However, should someone, such as a motivational worker, take Anders at face value and believe what he says, he would not trust that person. Anders’s compliant behavior is a way for him to build a relationship with someone he trusts. According to the author’s own experience as a teacher and supervisor, this transformation principle is usually the most difficult one to understand. On the surface you have positive contact. The staff have the type of client they want. In addition, the client gives staff the impression that he really means what he says. The positive behavior is only a mask, however. It may be easier to detect and understand contact rebuses that show openly destructive behavior such as aggression, self-harm, or insulation. Anders’s contact rebus is equally destructive, though. The behavior appears to be positive but it destroys his life situation. He has a serious problem with substance abuse. Instead of daring to show who he is, he lives up to many of the staff’s expectations. Anders turns the destructive force on himself, that is, he denies himself. The staff confront Anders. They are concerned that he says he feels good even though he has a serious addiction that led to hospitalization. They cannot believe he means what he says, and they wonder where his anxiety is. When the staff start to question Anders’s compliance, he quickly becomes very aggressive and hostile. This means that he takes on an aggressive contact rebus, which is positive. He is now turning his aggression outwards instead of inwards and he dares to test the staff more openly. A connection process has started.

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Practice Applications with Involuntary Problems and Settings The feeling behind all compliance contact rebuses is that the client thinks he has no intrinsic value. He tests whether the staff see through his compliance, understand his mask, and really want to help him. Many of these clients run a high risk of suicide. Anders was taken into care after being found on a forest hillside after a severe overdose of alcohol and tablets. If had he been discovered an hour later, he would have died. A third type of contact rebus is withdrawal. Even if the motivational worker never actually meets the client, the client may find out about his efforts to contact him in other ways, which may come to light when they both meet later on. Some clients test staff by putting an end to the relationship completely. One type of support for a motivational worker faced with this contact rebus is to remember that the most important thing is to strengthen the positive core and not contact the client. Kettil has a borderline diagnosis. He also uses heavy drugs and has been released from a psychiatric hospital for a trial period. His contract with the clinic involves going to regular meetings with a discharge group. Kettil stops attending after just a few meetings. The group staff (who have previously agreed with Kettil that they will come and visit him in the event of his absence) go to his flat to look for him, but no one is at home. They go back on a number of occasions at different times, always leaving a note in the letter box to say they had come to see him. Eventually, Kettil is returned to the hospital by the police. The discharge group has a meeting with Kettil at the unit, expressing how concerned they have been and how relieved they are to have contact with him again. The staff now have a good basis on which to continue their motivational work. As it turns out, Kettil had read all the notes they left, giving him physical proof that the discharge group had made an effort to contact him and kept their side of the agreement. By withdrawing and not opening up for motivational workers, Kettil is given tangible proof of how much he can trust them. They have strengthened his positive core without actually contacting him on their visits to his home. An emotional test is also involved in pursuing contact. The motivational worker emotionally reflects part of the contact rebus when he meets the client again. In the case of Kettil, the discharge group is genuinely happy to have regained contact with him. Instead of withdrawing emotionally or becoming aggressive and offensive, the motivational relationship is maintained. The disadvantage of destructive contact rebuses is that not everyone understands the concealed attempt at contact. It is easy to focus on the facade, which can be physically observed. The latently motivated person is reaching out a hand wrapped in barbed wire. The motivational worker then has a choice, to concentrate on the barbed wire or on the concealed but outstretched hand. Through this type of destructive contact, the latently motivated person alienates many. The advantage is that he may finds someone he can really trust and who can give him back the life force he needs to build up his motivation.

Work with Unmotivated Clients Based on the theory of the contact rebus, there is a huge emotional importance for the motivational worker in how he sees the client’s defense and communication. If he only focuses on the facade and the client’s negative confirmations, there is a risk that he will start to feel hopeless and burn out. However, if he also sees the indirect attempt at contact, he can see more opportunities in the situation and will be less open to the risk of hopelessness. He will also be positively acknowledged if he sees that the client is contacting him. We can summarize the approach of the contact rebus like this: If the client is latently motivated, the primary function of his behavior is to make an indirect contact gambit. In other words, such clients do not mean what they say and do. Their words and actions conceal a subtextual meaning. The client is so suspicious and insecure that he opts to hide behind a mask rather than reveal his true self. It is important to emphasize that the client does not do this in a deliberate or planned way. The process is subconscious. The theory of the contact rebus says that clients who are in Carl Rogers’s stages one and two and in motivational work’s stages zero-zero and zero always communicate in an indirect and complicated way. It is a hidden cry for help. When a client has reached stage three, he makes more open contact and has become manifestly motivated. He can now communicate more directly and clearly. The necessary diagnostic in motivational work is, therefore, to establish whether a client is latently or manifestly motivated. This determines how you approach and respond to the client. It is important to point out that even manifestly motivated people use contact rebuses. Unlike those who are latently motivated, they are not consistent and only use them when they need an extra shot of life energy. In addition, the contact rebuses of manifestly motivated people are less complex and much less destructive, because they do not have the same desperate need for life energy. Motivational work also includes a theory of how the client’s motivation changes over time and with the bonding process to the motivational worker. This theory is the single most important support in preventing the motivational worker from losing commitment. The finding is based on my own experience of motivational work and when acting as a supervisor for motivational workers. The motivation of a client changes like a wave. An increase in motivation is always followed by recoil, during which the client acts destructively. This destructive recoil is often the hardest aspect for a motivational worker to deal with. After a client appears to have made progress, a setback follows, which seems to indicate that there has been no positive change. The greatest risk here is that the motivational worker loses commitment to the client and gives up. However, if he realizes that the recoil is a positive confirmation of the earlier positive change in the client, this will increase the chances of his

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Practice Applications with Involuntary Problems and Settings continuing the motivational work. The destructive recoil is a necessary part of the change process, which motivational workers will always experience in their work. Leopold is a twenty-seven-year old patient in compulsory psychiatric care. He has been at the hospital for five years and has been given traditional treatment using medication. Leopold, whom the staff consider to be a chronic case, has occasional psychotic phases, during which he acts aggressively; he even tried to stab another man to death (although this happened before he was detained). Leopold is also a drug addict. A motivational worker, inspired by a sense of positive commitment, decides to try motivating Leopold. He is somehow attracted to Leopold and is concerned about the length of time he has been in hospital without any signs of improvement. The motivational worker also feels that Leopold’s destructive behavior is a challenge. A little later he arrives at the hospital unit and asks to talk to Leopold, who agrees. The motivational worker starts to explain why he wanted to meet Leopold. After a while Leopold starts to show signs of agitation, becomes aggressive in his manner, stands up, adopts a very threatening posture, and looks like he will hit the motivational worker, who just continues to talk. Leopold then storms out of the room into the corridor. He is no longer aggressive, but yells at the motivational worker to stop talking. The motivational worker follows Leopold into the corridor and asks why he left the room. Leopold goes back to his ward, throws himself onto his bed, and covers his head with a pillow. All the time, the motivational worker continues to talk. Leopold then rushes into the bathroom and locks himself in. The motivational worker simply stands on the other side of the door and continues the dialogue. Inside, Leopold is quiet but runs the taps and keeps flushing the toilet to drown out the motivational worker’s voice. The motivational worker now stops challenging Leopold as his consultation time is over, and promises the patient that he will return. After this encounter, the motivational worker feels even more committed to Leopold and is determined to continue the motivational process. For various reasons, the motivational worker is unable to see Leopold until three weeks later. On this occasion, Leopold returns to the session room with him and almost immediately flies into a temper, refuses to listen, and storms out of the room again. After a while the motivational worker goes out to Leopold, who is standing in the corridor. He is calmer now and returns to the room with the motivational worker, who feels for the first time that he is able to have a conversation with Leopold. The patient explains that he doesn’t believe his problems are beyond his control; for instance, he intends to quit his drug habit, and he can do it without help from anyone else. He has been clean for a long time and has decided to behave in a decent, proper manner.

Work with Unmotivated Clients He is also feeling good and has no major problems. This time too, the motivational worker feels his commitment to Leopold strengthen. On their third meeting (a month after their first meeting) they are able to talk to each other without Leopold storming out of the room. Leopold says he realizes that the motivational worker is trying to help him, and the motivational worker invites Leopold to join a patient group that he leads. Leopold agrees, even though he does not feel he has much of a problem. Leopold attends the next two group sessions, although he does not take an active part. He just listens and watches. On the third occasion, Leopold announces that he wants to leave the group. The motivational worker asks him why, which enrages Leopold, who leaves the group after just fifteen minutes. The motivational worker feels even more committed to Leopold now, but is also worried that he is not making any progress. The next time, however, Leopold joins the group and is very active, talking openly about himself. He realizes now that he actually does have problems, which reinforces the motivational worker’s sense of commitment to Leopold, whom he feels is showing signs of becoming genuinely motivated. After two months of regular attendance, during their first meeting after the Christmas break, Leopold announces once again that he wants to leave and yells at the motivational worker for being useless. He stays in the group, however, and just before the session is finished he says he thinks he will continue to attend. The next time, Leopold is very active and takes up serious relationship problems. During the time Leopold is with the group, the motivational worker has been helped by the hospital unit’s staff, who do not let Leopold go to occupational therapy when the group is due to meet. The staff also tell Leopold they approve of him attending the group. During this process, the motivational worker sees the patient’s shift between positive and negative rebounds as positive confirmation of his work. The motivational worker also receives additional life energy through regular conversations with an experienced colleague, as he feels they give him a chance to get things off his chest. He also gets confirmation from his colleague, and from the fact that the staff are loyal to his motivational work with Leopold. All this makes the motivational worker feel that the process of helping his patient towards a better life is meaningful. The motivational worker never lets up in his commitment to his patient, with whom his bond constantly becomes stronger. His positive attitude remains unchanged, regardless of the patient’s various aggressive and destructive behaviors. We can now formulate what is needed in the protective suit that the motivational worker needs to be committed and to avoid burning out. The following values and theories are basic conditions for being able to carry out motivational work:

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Practice Applications with Involuntary Problems and Settings • All clients have potential. There are no hopeless cases. • The motivational worker must be very familiar with the signs of latent motivation. • The latently motivated client always appeals for help via his contact rebuses (theory of contact rebuses). • Emotional change always involves two steps forwards and one step back (theory of life-energy processes).

The Motivational Relationship It is through this relationship that the motivational worker conveys certain emotional attitudes to the client, who receives emotional power for his positive nucleus. This strengthens the client’s motivation. The client’s positive core needs three conditions above all others: commitment, hope, and trust. Commitment is the most important part of the motivational relationship. It means that the motivational worker communicates the fact that he cares about the client and considers him to be important. In addition, the motivational worker expresses emotional reactions to the client, such as anger, sadness, or anxiety, as a result of his commitment. The unmotivated client is often a suspicious person who finds it difficult to believe that someone cares about him. Although the motivational worker shows emotional reactions, further confirmation is needed for the client to start believing in him. This means that in order to be credible, he must also communicate his commitment in actions. These actions may involve contacting the client, helping in concrete terms to improve the client’s social situation, offering him a meal, and so on. The motivational worker must show that he cares about the client both in feelings and in actions. Being credible in his commitment to the client also means that he tries to limit the client’s destructive behavior through actions and words. Setting limits is an essential part of the motivational relationship for this very reason. The second part of the motivational relation, hope, is really the practical application of the humanistic approach. As above, the aim is to convey a feeling to the client: that he is able to change. The motivational worker cannot guarantee that things will become better, but he can definitely convey the idea that it is possible. Trust means that the motivational worker conveys the feeling that the client has his own capacity and is able to use it. The motivational worker communicates this at a general level, and in the context of a specific task for the client to carry out. He must first ensure that the client really has the ability to carry out the task; other wise trust will not be established.

Work with Unmotivated Clients A prerequisite for being able to put across these three conditions of commitment, hope, and belief is that they are real and genuine. You cannot fake them. Since a latently motivated person feels so generally deceived and abandoned, the motivational worker must have credibility if the client is to feel enough courage to connect with him. The motivational worker must have the energy to be emotionally involved in the client without apparently receiving anything positive in return. It is feeling this involvement that is most important for the client. Because of his destructive contact rebuses, it can be very difficult for the motivational worker to feel positively about the client. The motivational worker may feel fear, dislike, or indifference. One reasonable professional requirement he may have is to be honest with himself, even if this leads to painful insights that his commitment is weakening. In this situation, supervision is a great help in working through the motivational worker’s emotional relationship with his client. Twenty-seven-year-old Gudmar has been committed for serious violent abuse. In an unprovoked attack, he knocked down a fourteen-year-old boy and jumped repeatedly on his head, resulting in permanent brain damage. Joel, Gudmar’s contact on the psychiatric ward, finds it difficult to sympathize with his client at first, as his crime prevents him from having any positive feelings toward him. Joel feels that what Gudmar has done is so repugnant that he is losing the desire to help him. He takes up his dilemma with his supervisor. He also has several motivational sessions with the client. On the surface, Gudmar is compliant and behaves as Joel would expect. Joel recognizes the compliance contact rebus but also senses that, behind the facade, his client feels very lonely and hopeless about his life situation. Being able to see this suffering aspect allows Joel to start having positive feelings about Gudmar. By looking beyond the contact rebus and meeting the suffering person, Joel gets past his negative feelings. He is no longer focusing on the aggressor, but is discovering new sides to his patient. To be motivated, the client needs to have the three conditions of commitment, hope, and trust fulfilled from outside himself. He has a lack of commitment to himself, feels hopeless, and lacks all confidence in his abilities. This emotional force must be mediated by someone else. In this sense, the motivational relationship is largely one-sided and demands input from the motivational worker. For this reason, it is essential to have a protective suit to prevent the motivational worker from being drained of positive life energy. The motivational relationship is the response that the client is searching for through his contact rebuses. He wants to find a person who will constantly give him commitment, hope, and trust, no matter how much he tests the person with his rebuses. You can compare a motivational relationship to a cliff by the sea. The client’s rebuses are the waves that beat it. No matter how high and strong the waves are, the client does not want the rock to break.

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Practice Applications with Involuntary Problems and Settings Every time the motivational worker responds to a rebus with the motivational relationship, the client’s positive core is strengthened. At the same time, the relationship between them will gradually become closer and more trusting. The most impor tant part of motivational work is thus the motivational worker’s emotional response to the client.

Method and Techniques When a motivational worker employs method and techniques, he must already have a motivational relationship with the client. If this is missing, the technique will be an empty structure and cannot be effective. Method and techniques can accelerate motivational work since the motivational worker tries to take advantage of all possible ways of making his work more effective and efficient, thus reducing the time required for a client to become manifestly motivated and suffering as little as possible. Techniques help the motivational worker to achieve the necessary distance between himself and the client, thus becoming part of his protective suit against burnout. In meeting the client, the motivational worker concentrates not only on his emotional reactions, but also on methodology. If his emotions are the only focus, it may be more difficult to maintain the necessary distance for methodology. The two main methods of motivational work are confrontation and continuity. The general definition of “confrontation” is a response from the motivational worker that aims to concentrate on the here-and-now situation with the client, which contains both the motivational relationship and a technique of dialogue. Consequently, there are two components: emotions and technique. The latter is consciously planned by the motivational worker. The dialogue part also involves conscious decisions on how he will make use of his emotional reactions. The method is mainly applicable when the motivational worker is in a professional situation and has the appropriate distance from his client. Before going into further detail, we should consider the ethics of confrontation. The method is “energetic” in that the motivational worker tries to maximize the supply of life energy to his client. He takes on a large amount of responsibility when he uses confrontation. There is a considerable danger of harming the client, so it is impor tant that the motivational worker is fully aware of how confrontation should be used. The objective of confrontation is to solve the client’s contact rebuses in the here-and-now situation, and it is via these contact rebuses that the motivational worker can connect with his client’s transmuted emotions. The confrontation technique within the parameters of the motivational relationship is

Work with Unmotivated Clients able to bring maximum intensity to the interaction with the client. The technique itself is also a form of affirmation, as the motivational worker is clearly doing every thing in his power to help his client. Confrontation can be seen as the dialogue method of motivational work, but not the same kind of dialogue that a motivational worker would have with a manifestly motivated client. A latently motivated person can be compared to a drowning person. If a motivational worker were to talk to a drowning client in the same way as he would to a manifestly motivated client, he would ask “How are you managing?” or perhaps, “Would you like me to throw you a lifebuoy or stretch out a boat hook?” This motivational worker is just as blind to the client’s predicament as the client is himself. If he confronts the drowning client instead, he would shout (while holding out the boat hook), “Grab hold of this!” and “Hang in there!” Hopefully, the latently motivated client would then feel more trust in his “rescuer.” The metaphor falls apart a little here, since in motivational work a motivational worker cannot order his client around. However, he does express in no uncertain terms that he wants the client out of his destructive life situation (in terms of the analogy, he wants him up out of the water), and that he is ready and willing to help him. The fundamental methodology of confrontation is that the motivational worker turns directly to the suffering person behind the contact rebuses, and does not concern himself with the outwardly destructive, transmuted persona. Methodology in confrontation varies according to whether it is the client’s feelings or cognitions that are in focus. Confrontation includes the possibility of addressing both areas. The focus chosen by the motivational worker is determined by the situation and the client’s rebuses. If the focus is on the client’s emotional experiences, the motivational worker’s objective is to actively try to guide the discussion on an emotional level and reach the person who is suffering behind the contact rebus. There are two different methods that the motivational worker can use. The first method is to show that he understands how the client feels behind his rebus. The motivational worker become a mirror that reflects the client’s innermost feelings “ here and now. The method could therefore be called mirroring. As an example, let us take a client who has a contact rebus of acting tough and indifferent. The motivational worker then reflects what he understands: that the client is desperate and sad. Mirroring is not a general description of how a client feels. The motivational worker follows the client’s ongoing, here-andnow flow of experience. He reflects the feelings that the client has at that moment in time. He continues to do this, regardless of what the client does or says. The client will always hide his flow of experience behind the contact rebus. One difficulty in using this method is, clearly, that the motivational worker has to reflect such feelings without the client giving any direct clues

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Practice Applications with Involuntary Problems and Settings about his inner self. Nor will he be able to openly confirm that the motivational worker has intuited correctly. This technique is similar to Rogers’s client-centered therapy and the method used in motivational interviewing. The difference is that motivational work goes deeper into the soul than interviewing techniques can. The confrontation process also avoids asking questions; it makes statements, which involves closer contact and commitment. Generally speaking, confrontation is more inspired by Carl Rogers’s later work with schizophrenic patients (Rogers et al.1967), encounter groups (Rogers 1973) and the approach in J. L. Moreno’s psychodrama (1972, 1978). A second method of gaining a deeper emotional contact with the client involves the motivational worker himself expressing what he feels in the “hereand-now” situation. The motivational worker is completely open with his experiences in the meeting with the client. This method can therefore be called “own feelings.” It is the opposite of the mirror method, where the motivational worker concentrates on his client’s experiences. If the mirror method alone is used, the motivational worker becomes distanced and does not give sufficiently strong positive confirmation back to the client. A prerequisite for the motivational worker showing his feelings is that they originate from the motivational relationship; that is, his experiences arise from his commitment to the client. If we look at the confrontation of cognitions, the methodology changes. The focus is no longer on the client’s emotional experiences, but is now on his thoughts and images of himself and the real world around him. The goal is to demonstrate the inconsistencies of cognitions. One technique used in the confrontation of cognitions is to point out improbabilities, mistakes, and factual inconsistencies in the client’s reasoning, that is, to confront the illogical. The motivational worker then formulates the client’s logic in a new way. This often involves the client’s negative formulation becoming positive instead. The technique can therefore be called the qualitative leap. An example would be when a client expresses his hopelessness regarding treatment and change. The motivational worker can then point out the positive side of feeling hopeless. It has no demands and is free of stress. The client does not have to worry about failing and avoids the pressure in trying to change. Hopelessness becomes a pillow on which to rest the head. The second method used in the confrontation of cognitions is “maximizing.” The motivational worker extends the client’s logic much further than the client does. This process clarifies the lack of internal structure in the contact rebus. It is important that the motivational worker is not ironic or satirical in a negative way. The best method of preventing this is to consolidate the motivational relationship and for the motivational worker to feel at ease with the method.

Work with Unmotivated Clients An example of maximization could be when a client says he feels so aggressive that when he gets angry he cannot control himself or take responsibility for what might happen next. The motivational worker could react by saying he will call an ambulance so that the client can quickly get to the emergency department at the psychiatric clinic. The client is clearly not able to control himself and is steered entirely by his impulses, like an acutely psychotic person. The motivational relationship is the most important safety rule. Without the motivational relationship, confrontation could give free rein to the client’s destructive forces. It would then give further confirmation of how useless and bad the client is and how hopeless his situation is. Actually, it is not so difficult to break down a person’s defenses, but to do it in a constructive and positive way is more of a challenge. Here is an example of confrontation. The motivational worker and the client are in an open clinic for addicts. The techniques used by the motivational worker are within parentheses. client: I have nowhere to go—I don’t feel well—it’s so cold outside. motivational worker: You’re feeling the cold in more than one way. It sounds like you’re in a lonely place. (mirroring) client: Yes, that’s true. motivational worker: I think you’re taking drugs. (mirroring) client: No, I’m not. motivational worker: We needn’t discuss it further, but you have taken drugs. (mirroring) client: I want to go to hospital. motivational worker: You’re feeling bad right now and want to find a solution. As usual, you seem to have solved your problems by taking drugs. (mirroring) client: Yes, that’s right. I’m thinking of taking an overdose. motivational worker: I don’t think that’s a good idea at all. I feel angry and upset when I hear you say that. You have so many other options. (own feelings; the motivational relationship and setting limits) client: I don’t want to die. motivational worker: Your pain is so much that you want to die, but you want to live too. (mirroring) client: Yes, that’s right. motivational worker: Your pain is so bad that you want to die to escape it; taking drugs isn’t enough. (mirroring) client: I broke up with my girlfriend this week. motivational worker: You must be very sad. (mirroring) client: Yes (looks like he’s about to cry).

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Practice Applications with Involuntary Problems and Settings motivational worker: Now we have to think about how you’re going to cope over the weekend—look, I’ve booked an appointment for you on Monday. Will you get through the weekend OK? (own feelings; motivational relation) client: Yes, I’ll manage. motivational worker: It’s not just about this immediate problem—it won’t take long before you’re in the same situation again. Look, this is a matter of life and death. If you carry on like this you’ll soon be dead. (own feelings; maximization) client: I don’t know what to do. motivational worker: I don’t believe that. It’s hard to change. But if you’re willing to die you might also be willing to try rehab first. It does seem like you want to quit drugs. (own feelings; motivational relation; qualitative leap; mirroring) client: Yes, I do want to quit. motivational worker: Breaking up with your partner is very painful for you, so you deal with it in the usual way. (mirroring) client: Yes, but doing drugs makes me feel bad too—I want to quit. Can you arrange for me to go to detox? motivational worker: I’ll do my best. But you also have to pluck up the courage to go for it. Last time you never even made it to detox. (own feelings; qualitative leap) client: I won’t run off this time. motivational worker: I’ll call the detox unit straight away then. (own feelings; motivational relation) (Comes back) motivational worker: You can go and see them for an assessment. I can’t say for certain they’ll take you in. (own feelings; caring) client: Yes, I realize that. The motivational worker then ensures that the client gets to the detox unit, where he is admitted. During the night, the client attempts to commit suicide but the staff manage to defuse the situation without too much difficulty. Such a suicide attempt could not have been prevented since the client’s level of motivation is so low. The motivational worker is aware of this in his confrontation, which is the reason for his concentrating on creating contact. Since it is unlikely he can entirely prevent a suicide attempt, it is imperative that he tries to give as much life force as possible to reduce the impact of the client’s impending destructive act. A higher level of contact with the client is achieved during confrontation, which may have helped to lift the client’s motivation to a level that results in a less determined suicide attempt. The only thing that

Work with Unmotivated Clients can really prevent the client from killing himself is a stronger positive core. However, in terms of his continued development, the motivational process has started. He stays in detox for the whole program, before starting on a rehabilitation course of two months and is now in a positive rebound. The second method in motivational work is “continuity.” This means that the motivational worker tries not to abandon the client, either emotionally or in his actions. The client does not only test the motivational worker in the here-and-now; he also uses his contact rebuses to discover what the motivational worker’s motivational relationship means in the long term. The most fundamental concern of the client in a relationship is whether or not he will be abandoned, so he needs to test whether the motivational worker can give more than just fleeting security. We could say that continuity is more a matter of heeding the motivational process and a method of dealing with the client’s motivational process. The motivational worker can manage to solve this aspect of the contact rebuses as long as he does not fall into a negative relationship with the client and prematurely ends his relationship with him, which is the usual—but not inevitable— outcome of such a development. First and foremost, the motivational worker must feel that he has a motivational relationship with the client, or if this is not yet fully developed, at least a positive basic feeling towards him. After the initial assessments, the motivational worker makes a choice to embark on a program of motivational work. To start off this process, he first draws up a contract. Since the client is latently motivated, there is no conscious individual to make a contract with, and his response to the motivational worker’s proposed contract will be a destructive and highly transmuted contact rebus. Either the client will be compliant, and apparently consenting, or he will employ a withdrawal or aggressive contact rebus and show all the signs of refusal. He never means what he says. This means that the motivational worker has to take more of the responsibility for the contract and its content than he does with manifestly motivated clients, and has to draw it up in a way that puts reasonable demands on both parties. Until the client has become manifestly motivated, it is also up to the motivational worker to make sure that the contract is honored. These responsibilities are the main difference between making a contract with a manifestly motivated and a latently motivated client. The planned length of the motivational work is really the most significant aspect of the work and an important part of the contract. The motivational worker decides how long he plans to be in contact with the client. The worst outcome of motivational work, both for the motivational worker and the client, is if it is broken off prematurely. The client receives confirmation yet again

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Practice Applications with Involuntary Problems and Settings that he cannot trust anyone. The motivational worker is not able to achieve his goal. The motivational work may be interrupted for practical reasons, or because the motivational worker’s relationship has become negative. In both cases, the original agreement is not adhered to. When motivational work is broken off due to the motivational worker being burned out, the client has a doubly negative confirmation: he is abandoned both practically and emotionally. It is thus very important that the motivational worker takes responsibility, as far as possible, for the treatment period he has promised. Realistically, he can only guarantee the time he is certain about. If a motivational worker has a temporary job at a psychiatric hospital, he cannot promise more time than the period he is appointed as a substitute. He may feel relatively sure that he can continue with the job, but as long as he cannot guarantee that time, he risks disappointing his client. What is crucial for the client is not that motivational work is carried out over a long period of time, but that the start and end are very clear. The client is then able to adjust emotionally to the circumstances. This gives him greater clarity about what he will test. The contract also helps the motivational worker. By making an agreement with the client, he has clearly stated for himself that he is entering a relationship with another person and taking on responsibility. This helps him to maintain the energy to continue and not burn out. In motivational work, sooner or later the client will not come to scheduled meetings or he will interrupt the connection in some other way. The principle of continuity means that the motivational worker then has responsibility for ensuring that contact continues. When the client does not appear at the agreed time, it is a contact rebus. The client wants to confirm that he means something for the motivational worker by testing the limits. At the same time he tests the self-esteem of the motivational worker; that he does not feel unsafe or offended. Being absent is a rebus that often occurs in the rebound phase of the motivational process. Through his testing behavior, the client invites the motivational worker to give up contact. The most important thing is not that the client comes regularly for the motivational work, but that his positive core is reinforced. The client can be just as positively acknowledged by knowing that the motivational worker tried to make contact in various ways, even if they do not meet any more. Continuity, then, does not only involve meeting the client. It is equally important that the motivational worker does not lose emotional contact with the client through a deteriorating motivational relationship. The handling of the treatment relationship has already been addressed in the section on the motivational relationship. This aspect of continuity is especially important when the client cannot avoid contact, such as in enforced care of different kinds. The fact that care is enforced means that the motivational worker has no problems in meeting the

Work with Unmotivated Clients client, but if he loses the motivational relationship, there is no point in having contact. The risk of this increases when care is obligatory. Since the client is under maximum pressure, he has a great need to test the motivational worker. This means that his contact rebus pushes the testing process to the limit. The motivational worker’s protective suit is almost at breaking point and he finds it extremely difficult to keep up the motivational relationship.

Summary I hope that this chapter has provided insight into motivational work. The word “work” obviously indicates that the method is active and intense with people who bear a large amount of pain. They have shut down emotionally because they cannot cope with their sorrow. Instead, the pain is transformed into destructive behavior. Such acts are an indirect cry for help and are a very complex way of communicating. The latently motivated person is drowning in the cold water and does not appear to want any help. The manifestly motivated person, in contrast, has reached land and has a blanket wrapped around him. He is able to express that he wants support. The latently motivated person has the same needs as Odysseus, when he is fighting for his life in the Aegean Sea after Poseidon has destroyed his raft. Leucothea, the sea nymph, lends him a scarf that enables him to keep afloat for two days and eventually get to a beach. Motivational work is like Leucothea’s scarf for all the shipwrecked people who want to reach the mainland. Strip off those clothes and leave your craft for the winds to hurl, and swim for it now, you must, strike out with your arms for landfall there. Phaeacian land where destined safety waits. Here take this scarf, Tie it around your waist—it is immortal. Nothing to fear now, neither pain not death. But once you grasp the mainland with your hands untie it quickly, throw it into the wine-dark sea, far from the shore, but you, you turn your head away! Homer, The Odyssey

References Eriksson, A., and P. Revstedt. 1978. Utvärdering av skede ett vid Hindbyhemmet (Evaluation of Phase One at Hindbyhemmet). Malmö: Internal Report, Hindbyhemmet.

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Practice Applications with Involuntary Problems and Settings Fishman, D. B., J. C. Norcross, G. R. VandenBos, D. K. Freedheim, B. O. Olatuni, eds. 2016. APA Handbook of Clinical Psychology: Theory and Research. Washington, DC: American Psychological Association. Greenson R. R. 2000. Technique and Practice of Psychoanalysis. Madison, CT: International Universities Press. Jenner, H. 1979. Goals and Reality in a Therapeutic Community. A Study of Treatment Process and Effects in an Institution for Drug Abusers. Stockholm: Almqvist & Wiksell. Millner R. M., and S. Rollnick. 2013. Motivational Interviewing— Helping People Change. 3rd ed. New York: Guilford Press. Moreno, J. L. 1972. Psychodrama: First Volume. Beacon, NY: Beacon House. Moreno, J. L. 1978. Who Shall Survive? Beacon NY: Beacon House. Revstedt, P. 2014a. Motivational Work. Charleston, NC: CreateSpace. Revstedt, P. 2014b. Motivationsarbete. 4th ed. Stockholm: Liber. Rogers, C. R. 1951. Client- Centered Therapy: Its Current Practice Implications and Theory. Boston: Houghton Mifflin. Rogers, C. 1967. On Becoming a Person. London: Constable & Co. Rogers, C., E. T. Gendlin, D. J. Kiesler, and C. B. Trauz, eds. 1967. The Therapeutic Relationship and Its Impact: A Study of Psychotherapy with Schizophrenics. Madison: University of Wisconsin Press. Rogers, C. 1973. Encounter Groups. Hammondsworth, UK: Penguin Books. Yin, R. K., H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindkopf, and K. J. Sher. 2012. APA Handbook of Research Methods in Psychology. Vol. 2: Research Designs: Quantitative, Qualitative, Neuropsychological and Biological. Washington, DC: American Psychological Association.

Chapter 17

Bringing Up What They Don’t Want to Talk About Use of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Alcohol Misuse and Depression in a Community College Health Center

Melinda Hohman, Christine Kleinpeter, and Tamara Strohauer

Background While adolescents and young adults are seen by social workers in settings such as behavioral health clinics or counseling centers, young people are more likely to utilize primary care for the health needs that often accompany high-risk behaviors or mental health concerns (Ehrlich et al. 2006). Primary care and other medical settings such as emergency departments are seen as “opportunistic” in that they can provide an opportunity to discuss behaviors, such as alcohol and substance use or depression, even though patients may be expressing some other problem or concern (Agley et al. 2014). While not considered “involuntary” as described to other chapters in this book, the topic of an opportunistic discussion may not be what the young adult had in mind when visiting a doctor. This chapter provides an overview of a protocol for these discussions, Screening, Brief Intervention, and Referral to Treatment (SBIRT), which has been recommended (and widely implemented) as a secondary public health prevention and early intervention strategy to reduce harmful drinking and substance use in adolescents and adults (Borus, Parhami, and Levy 2016; SAMHSA 2011). It has more recently been utilized to screen for depression (Dwinnells 2015). We review what SBIRT is, some of the research regarding its efficacy, its use in the context of university and community college students, and how it is implemented both as a model and clinically. We also provide a case vignette to demonstrate how an SBIRT interview is conducted.

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What Is SBIRT? In the prior edition of this book, our chapter contained information on brief intervention therapies. Brief interventions (BIs) set the stage for the development of SBIRT, one of the most common forms of BI. Brief interventions are typically short and structured, last one to five sessions (Bien, Miller, and Tonnigan 1993), and are often implemented in a setting that is not specific to the topic of the intervention. Their overall goals are to raise awareness of a possible problem and to motivate clients to reduce or change their behavior or to seek treatment if needed. SBIRT was chosen as the focus for this chapter because of the extensive research supporting its effectiveness and the current interest in social work education to train students in the model (Cochran and Field 2013). SBIRT is an evidence-based practice for identification, prevention, and reduction of problematic use, abuse, and dependence on alcohol and substances as well as for prevention/intervention around other high-risk behaviors. It is used in a variety of settings, including emergency departments, medical offices, and, more recently, college health and counseling centers (Monti, O’Leary, and Borsari 2005; Naegle, Himmel, and Ellis 2013; SAMHSA 2013; Seigers and Carey 2010). SBIRT is a public health, harm reduction approach considered effective in screening and providing feedback to persons about health risks and life consequences of alcohol or substance use who may not other wise present for treatment; brief interventions for at-risk use; and referral to treatment for problem use. A routine visit to a medical office may provide a “teachable moment” that enables a person to potentially recognize and address, for instance, substance use before experiencing adverse consequences (Agerwala and McCance-Katz 2012) or due to substance use-caused medical consequences such as an injury (Ehrlich et al. 2006). SBIRT was originally developed to address alcohol use and studies of its outcomes found it to be effective (Madras et  al. 2009). Meta-analyses have found that SBIRT reduced alcohol use in clients treated in general primary care settings when mea sured at twelve months after the intervention (Ballesteros et al. 2004). Due to its effectiveness, SBIRT interventions have been expanded to address substance use, depression, tobacco use, and domestic violence (SAMHSA 2011). The first component of SBIRT is screening by a health-care or behavioral health provider utilizing personal interview, pen and paper, or computer-based standardized instruments (Cronce et al. 2014; SAMHSA 2013). For instance, the Alcohol Use Disorder Identification Test (AUDIT; Saunders et al. 1993) was developed by the World Health Organization in an effort to create a standardized measure for assessing alcohol use behaviors including consumption, dependence, and alcohol-related problems, and is frequently used in SBIRT ser vices (SAMHSA 2013). Typically, clients are assessed to be at low risk,

Bringing Up What They Don’t Want to Talk About at-risk, or high-risk, depending where they fall on the cutoff scores of the screening tool being used (ONDCP 2012). Those who fall into the at-risk or high-risk categories receive a second component of SBIRT, which is a BI. This is a patient-centered strategy for addressing concerns and potentially inciting behavioral changes (SAMHSA 2013). For alcohol use, feedback is provided including education on standard drinks and physicians’ recommended healthy guidelines for drinking of no more than three drinks per occasion or seven per week for women, and no more than four drinks per occasion or fourteen per week for men (NIAAA 2005). SBIRT utilizes a single counseling session ranging from five to ten minutes for those who are considered low risk to a longer twenty- to thirtyminute discussion for those who are moderate/at-risk for adverse outcomes (SAMHSA 2013). BIs include feedback on questionnaire responses, discussion of health risks, potential consequences of alcohol/substance use, assessing motivation to reduce use, as well as affirmations for healthy behaviors. For adolescent clients, feedback and recommendations regarding alcohol use include abstinence due to underage drinking laws, however, advice to reduce drinking can be given if the client is reluctant to embrace abstinence (Clark et al. 2010). The third component of SBIRT is referral to treatment for those who score high risk for adverse health and life outcomes on standardized screening instruments. This may include behavioral health referrals for further counseling sessions, psychotherapy, or substance use disorder treatment (SAMHSA 2013).

Basics One of the most empirically supported and standardized BIs among adolescents and young adults is the Brief Alcohol Screening and Intervention for College Students (BASICS; Dimeff et al. 1999; Fachini et al. 2012). BASICS differs from SBIRT, which views the health office as a “teachable moment,” in that it may be the actual referral (intervention) offered to college students who have scored as being “at risk” on an alcohol screening measure (Martens et al. 2007) or a mandated intervention for students who present with alcoholrelated consequences (Logan et al. 2015). BASICS is a preventive, harm reduction focused intervention for college students ages eighteen to twenty-four who are considered at risk for broad ranging alcohol-related problems including academic difficulties, injuries, blackouts, overdoses, physical or sexual assault, changes in brain function, and even death (Amaro et al. 2010; White and Hingson 2013). BASICS consists of a two-session intervention that includes a fiftyminute assessment session and a fifty-minute feedback session, combining

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Practice Applications with Involuntary Problems and Settings motivational interviewing, cognitive-behavioral skills training, and personalized feedback (Whiteside et al. 2010). Along with assessing drinking behaviors, alcohol dependence symptoms, and family history, BASICS assesses for perceived normative drinking behaviors of other college students. Between sessions, students are asked to document drinking behaviors, and a personalized feedback report is generated based on assessment. Motivational interviewing is utilized during the feedback session to present person-specific alcohol use information as well as addressing discrepancies between students’ perception of typical use by other college students and actual representative use, which is generally much lower than heavy drinking students initially identify (Dimeff et al. 1999; Martens et al. 2007). Extensive research studies including meta-analyses have shown BASICS to reduce risky drinking behaviors and negative alcohol-related consequences among college students up to four years post-intervention (Amaro et al. 2010; Baer et al. 2001; Fachini et al. 2012). Additionally, a recent randomized controlled trial of BASICS comparing volunteer to mandated heavy drinking college students (Terlecki et al. 2015) showed reduced alcohol consumption and decreased alcohol-related problems, both short term (4 weeks, 3 months, 6 months) and sustained (at 12-month follow up), regardless of the voluntary or mandated status of participants. BASICS participants showed a significant decrease in weekly drinking, typical alcohol consumption, and peak alcohol consumption with medium to large effect size and fewer alcohol problems with large effect compared to control groups. These findings suggest BASICS as an effective intervention for both voluntary and mandated college students. Further, success of BASICS for alcohol use may converge with screening and intervention for depression, as alcohol has been shown to be a commonly used coping mechanism among depressed adolescents and young adults who may be at higher risk for adverse life outcomes including suicidality (Archie, Zangeneh Kazemi, and Akhtar-Danesh 2012; White and Hingson, 2013).

SBIRT for Depression It is crucial that college students who are at risk for developing stress-related medical or mental health disorders be identified and referred for appropriate treatment. Recognizing this, the National College Depression Partnership (NCDP), which is made up of twenty institutions in the State University of New York system, began to screen for depression in students during routine health clinic visits. The screens chosen were the nine-item Public Health Questionnaire-9 (PHQ-9) (Kroenke, Spitzer, and Williams 2001) or the shorter version of two items, the PHQ-2 (Kroenke, Spitzer, and Williams 2003). These screening tools are Likert-type surveys that can be used in a pencil and paper method or by computer. Scale scores identify those who endorse items consis-

Bringing Up What They Don’t Want to Talk About tent with depression or anxiety so that they can be referred for further mental health assessment and treatment. PHQ-9 scores range from 0–27 with scores of 5, 10, 15, and 20 indicating mild, moderate, moderately severe, and severe depression (Kroenke, Spitzer, and Williams 2001). Over 100,000 students took one of these screens and 2,000 were identified as positive regarding depression and were referred for treatment (Chung, Klein, and Greenberg 2009). Based on the success of this model, SBIRT for alcohol use was combined with depression screening at several of the universities (Naegel, Himmel, and Ellis 2013). No studies to date are available on the outcomes of this project. There is more research on SBIRT screening for depression in populations other than college students. Native American women of child-bearing aged received screening for alcohol use and depression at health clinics. Over one-third (36  percent) screened positive for depression and drank at higher rates than their nondepressed counterparts. They were also more likely to reduce their alcohol consumption after receiving the SBIRT intervention. The authors reasoned that for the women in their study who were depressed, the SBIRT intervention with personalized feedback may have supported the change inspired by the assessment process itself (Montag et al. 2015). Sahker and colleagues (2016) conducted a study using a U.S. National Guard sample. The authors screened military personal for depression using the PHQ-9 and substance misuse using the AUDIT. The SBIRT was used to identify and provide intervention for soldiers who could benefit from treatment. Findings indicated that depression was an important factor in determining unhealthy drinking as soldiers aged. It was recommended to use SBIRT as part of a universal screening for military personnel and for assistance with appropriate referrals, including programs catering to co-occurring disorders.

Why SBIRT in University/Community College Settings? Heavy drinking and binge drinking are considered a rite of passage by many college students. One study found that 45  percent of university students reported binge drinking in the past month (Hingson, Zha, and Weitzman 2009). Cremeens-Matthews and Chaney (2016) found that 59.4 percent of university students and 49.7  percent of community college students were considered high-risk alcohol users. The effects of alcohol misuse on students are well documented. The American College Health Association (ACHA) reported that college students who were drinking experienced unprotected sex (20.0 percent), sex with someone without the partner’s consent (0.6 percent), sex without my own consent (1.8  percent), physically injuring self (14.4  percent), physically injuring another person (2.4  percent), and seriously considering suicide (2.2  percent) (ACHA 2013). The academic impacts of drinking include receiving a lower grade on an exam or project, receiving a lower grade in a

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Practice Applications with Involuntary Problems and Settings course, receiving an incomplete or dropping a course, or experiencing a significant disruption in thesis, dissertation, research, or practicum work (ACHA 2013; Creemens-Matthews and Chaney 2016). Stress is also common among college students and is recognized as a contributing factor to mental health disorders (Eisenberg, Hunt, and Speer 2013). Students in a general survey reported symptoms of stress (28.5 percent), anxiety (19.7  percent), and depression (12.6  percent) and rates of these problems were even higher in a treated population (ACHA 2013). Clinicians in a university-based counseling center reported that their clients’ top concerns were anxiety (57 percent), stress (46.6 percent), and depression (45.9 percent) (CCHM 2015). Community college students most often present for counseling with academic problems, stress, anxiety, and depression, according to the Community College Task Force (CCTF 2013). The average number of counseling sessions provided to students who utilized the counseling ser vices at the community college was three to five per academic year. The percentage of the student body utilizing counseling ser vices ranged from 1 to 5 percent. Community colleges tend to attract working and lower income students compared to students who attend four-year universities (Juszkiewicz 2015). While some students seek services because they fear failure of a class, others seek ser vices because they are experiencing multiple life stressors that are preventing them from being successful academically. Many stressors at one time can put college students at risk for psychological distress (Eisenberg et al. 2011).

SBIRT in Student Health Centers SBIRT is a secondary public health prevention model to identify risky healthrelated behaviors and intervene with a large number of people in opportunistic settings. For university or community college students, this setting is usually the student health center (Clark et  al. 2010; Ehrlich et  al. 2006; Naegle, Himmel, and Ellis 2013). A review of the research of SBIRT in student health clinics found that there were many variations of the model in terms of implementation (Seigers and Carey 2010). One example was that not all programs used a screening tool for alcohol use. Six of the eight controlled SBIRT studies examined by Seigers and Carey (2010) found significant reductions in alcohol use in the SBIRT intervention groups. Another study examined the acceptability of SBIRT to students who received an SBIRT intervention (for alcohol use). After three months, 92  percent reported that the information they received on alcohol use was clear, 90  percent thought that the health clinic setting was appropriate for an SBIRT interview, and 75  percent found the interview to be helpful (Ehrlich et al. 2006).

Bringing Up What They Don’t Want to Talk About

Implementation of SBIRT As stated previously, SBIRT is usually implemented in health settings but is not limited to these (Agerwala and McCance-Katz 2012). A recent project has implemented a computer-based intervention for domestic violence to clients in a probation agency (Gilbert et al. 2016). SBIRT can be delivered by physicians, social workers, health promotion professionals, nurses, counselors, and even peers (Babor et al. 2005). This can be done through the use of in-person interviews or even through online, computer-based programs or text messaging (Kypri et al. 2008; Suffoletto et al. 2011). One of the biggest concerns in health centers, including college health centers, is patient flow. Often those who are new to SBIRT want to know how this can be done with the minimum of disruption to the health-care process. A survey study of physicians, nurses, therapists, drug and alcohol counselors, and psychologists in an integrated health center exploring facilitators and barriers to SBIRT implementation found that physician time, documentation needs, lack of fidelity to the SAMHSA model, and communication issues were significant barriers. Survey participants did report feeling more comfortable with discussing substance use and alcohol with patients after SBIRT was implemented. They suggested that a staff psychologist be dedicated to the SBIRT position to increase fidelity as well as to better facilitate current patient flow (Rahm et al. 2015). Another study of acceptability of SBIRT among health-care providers in a student health center found that 81  percent were supportive of SBIRT and 60 percent felt that it fit into routine procedures (Ehrlich et al. 2006). Experiences of those who provide SBIRT indicate that is important to discuss with a center’s multidisciplinary team the benefits and barriers to implementation as well as to have a “patient flow” grid of how it will be conducted along with decision trees of how to handle various client and staffing scenarios (Agley et al. 2014; Naegle et al. 2013).

Motivational Interviewing as the Counseling Style Fidelity to the SBIRT model includes following the SAMHSA guidelines: it is brief; it is a universal screening (everyone receives it); it is a validated screening measure; intervention is targeted to risk level; linkages with treatment providers are established (SAMHSA 2011). The other aspect of fidelity is the use of the recommended counseling style (DiClemente 2015). SBIRT is typically delivered using motivational interviewing (MI), which is defined as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” (Miller and Rollnick 2013:212). MI incorporates four processes: engaging, focusing evoking, and planning (Miller and Rollnick 2013). Social workers using MI work from a “spirit” that

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Practice Applications with Involuntary Problems and Settings is collaborative, accepting, and supportive of clients’ autonomy (Hohman 2012). For example, asking permission to proceed before beginning the SBIRT interview and asking what clients already know about the topic under discussion are examples of autonomy support. This is also a way to begin engaging clients. Focusing is where social workers and clients agree on the topic of the conversation through the use of reflective listening skills (simple and complex statements), open-ended questions, affirmations, and summaries. These help guide the conversation as well as demonstrate empathy for what clients have to say. These skills are also useful when clients argue or become upset with their social workers, rather than debating or trying to convince clients that they need to change (Miller and Rollnick 2013). The goal of the evoking process is to elicit clients’ change talk, or their desires, abilities, reasons, and needs around change. Sometimes this is done through the use of scaling questions that ask clients about importance and confidence in their ability to change, such as altering alcohol use or obtaining help for depression (Naar-King and Suarez 2011; Naar and Flynn 2015). At the planning stage, social workers ask clients for their own ideas and plans on how to change the behavior under discussion (Resnicow, McMaster, and Rollnick 2012). An SBIRT interview asks clients to identify the goal (for instance, not binge drink) and then the steps clients can do to meet that goal (e.g., “Set a limit of 2 drinks when I go out”). Clients who express distrust, unease, defensiveness, or anger at being asked about the behavior under discussion in an SBIRT interview are not considered “resistant” in the MI model but are experiencing “discord” with the social worker. Miller and Rollnick define this as “signals of disharmony in the collaborative relationship” (2013:204). Strategies for working with clients in this situation include examining one’s own contribution to the interaction (perhaps the social worker did not spend enough time in the engagement process), to apologize, to affirm to the client his or her autonomy to make decisions (“Only you can make the choice about changing your drinking”), to reflect the concerns that the client is expressing, or to affirm the client, among others. We demonstrate the SBIRT process and these skills in the following vignette.

Vignette This vignette is an example taken from a community college student health center that provides both medical and mental health treatment. In this setting, students are screened for alcohol use using the AUDIT and for depression with the PHQ-9. These are scored by the receptionist and included in the patient file sent to the attending physician who determines if an SBIRT interview is warranted.

Bringing Up What They Don’t Want to Talk About The student in the vignette sought medical treatment for a sprained ankle received while playing baseball. The physician treated him and, due to his scores on the PHQ-9, referred the student for an SBIRT interview. The student, a nineteen-year-old Latino male, is a new student at the college. He had completed a brief history and scored an 18 on the PHQ-9, which is in the moderate range. His AUDIT score was a 4, which indicate low-risk use of alcohol. We will call him AJ. Motivational interviewing skills are indicated in brackets. social worker: Good morning AJ, I am a social worker, please call me Karen. I imagine you are a bit surprised to be sent for another interview! I appreciate you taking the time for this. [engaging] student: (shrugs) Yes, well, I wasn’t expecting this but it’s okay. social worker: I have read the information that you provided on the screening form. I understand the reasons that brought you to the health center, but I do have some questions regarding your current situation. Would it be okay for me to ask you some questions? [asking permission] student: Okay. social worker: I see that you moved from Arizona to attend college in California. Well that is a bit of a change to come here! Tell me more about that. [engaging; open-ended question] student: I play baseball and this college offered a scholarship. I decided it was worth moving out of state in order to accept the scholarship. social worker: So then you moved to take advantage of the scholarship. [simple reflection] student: I really like the baseball team, but when I began school my mother was diagnosed with cancer. social worker: That came as a real shock, right when you just got here. You felt torn about being here and not being near her. [complex reflection] student: Yeah. I am not sure where to be, I mean, if I am at school I feel that I should be at home, but if I am at home, I feel that I should be at school. Since my mom’s diagnosis I feel that I should go home, but she and my dad insist that I should stay at school and complete my education. I am worried that I may be missing out on time with my mom because her cancer is very serious. social worker: This sounds like a terrible dilemma. On one hand you want to see your Mom and on the other hand your parents tell you to stay at school. It is difficult deciding what to do. [complex reflection] student: Yeah, I just don’t know what to do. I go to all of my classes, but I have trouble remembering what was covered in the lectures. I try to do my homework, but I can’t focus on that either. I go to baseball practice, but I really don’t want to be there. I’ve always loved being on that field, but lately I can barely bring myself to show up to practice. Even the games don’t

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Practice Applications with Involuntary Problems and Settings matter to me lately, but my financial aid is based on a baseball scholarship. I had a pounding heart one night and went to the ER and they said it was a panic attack. I have had several of these this past month. Also, I can’t sleep at night, which makes me very tired in the daytime. So some days I just sleep whenever I can. I feel bummed out and don’t really want to do anything, and now I can’t even if I wanted to with my ankle messed up. social worker: You have a lot going on AJ. While I am sorry that you have a sprained ankle, I’m glad that you have come to the health center today [affirmation]. Besides your concern about your mother, it sounds like you have had a number of things happen to you that concern you, including panic attacks, insomnia, difficulty with concentration at school, loss of interest in baseball, and generally feeling down [summary]. Would it be okay with you, if we talk about some of the questions and your answers on the form that you filled out today? [permission; focusing] student: Okay. social worker: First of all AJ, I would like to give you some feedback on the AUDIT questionnaire, which is the one that asks students about their alcohol use. Based on your score, you fall into the low risk category for alcohol use-related consequences and I want to congratulate you for that [affirming low alcohol use]. Thank you for sharing that with me. It looks like you drink monthly or less, normally just one or two drinks per occasion, which is well within healthy limits, that’s great! [simple reflection, affirmation] Because underage drinking is illegal, we recommend abstinence. For those who are 21 and over, doctors have developed healthy drinking guidelines to help reduce alcohol related health risks, which for men is two standard drinks per day but no more than four per occasion or fourteen per week. [giving information] student: Yeah, I normally just drink a beer or two if I drink, but I don’t really like it. I’ve let my friends know that, they tend to drink a lot more than I do. Social worker: You also said that less than monthly, you’ve had more than six drinks on one occasion, and have had some guilt or remorse after drinking. [simple reflection] student: Yeah, that was all the same night. I was really sad about my mom, and my friends kept encouraging me to drink more, telling me it would make me feel better. I had fun for awhile, I guess, but then I felt even worse. I missed class the next day and felt really bad about it. social worker: You recognized drinking wasn’t helpful for dealing with your sadness, and it’s awesome you have the courage to let your friends know you don’t really like to drink. It sounds like you are very aware of risks for you with alcohol and are taking care of yourself around drinking. [complex reflection; affirming low drinking] I know you brought up panic attacks, and you seem to be experiencing other pretty significant concerns

Bringing Up What They Don’t Want to Talk About that we can explore together if you want. [implied permission] You probably saw that we also asked you some questions on the form about depression. Before we talk about your answers though, can I ask you, what do you know about depression? [eliciting current knowledge] student: (shrugs) Not much, really. I think it means that you just sleep all the time which I don’t do other than a nap when I can. Are you saying I am depressed? All I did was come here because I need medication for my panic attacks. (begins to get cautious) Social worker: No, I am not here to label you, in fact, knowing if you are depressed takes a longer assessment interview. You are right, though, that many times people with depression sleep a lot. Would it be ok with you if I gave you some information on other aspects of depression? [giving information; asking permission] student: Okay. Social worker: Often, people who are depressed having feelings of hopelessness, insomnia, poor appetite, and difficulty concentrating. You answered these questions here on this form and scored an 18. That and what you are experiencing is consistent with many of the symptoms of depression. Scoring an 18 puts you in a “moderate” category but even more so, what is of most concern to me are your feelings of hopelessness, insomnia, loss of interest in baseball, and difficulty concentrating. Of course, a longer interview to assess these concerns would provide you with more accurate information. [giving information] student: Well, maybe . . . maybe you could be right. But I am not crazy! What do you think I should do? Social worker: The first thing to do would be to get a thorough assessment. If you are depressed, there are different types of effective treatments for depression that could help reduce your symptoms and improve your quality of life. If you are interested, we can discuss what they are and see if any make sense for your personal situation. [autonomy support; seeking permission] student: What kind of treatments? social worker: Sometimes, people who experience depression get help in counseling. Some people take medication. Some people do both. [giving information] student: I’m not sure about that. social worker: You aren’t sure which direction to take. [complex reflection] On a scale of 0 to 10, with 10 being the most important and 0 being not important at all, how important might it be for you to get a further assessment? [scaling question; evoking reasons change talk] student: 5. social worker: So it is somewhat important. Why is it a 5 and say, not a 2? [open-ended question]

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Practice Applications with Involuntary Problems and Settings student: Sometimes I feel like that I really can’t function with these symptoms. I don’t like the idea of counseling, but I don’t know what to do about all of this. social worker: Your symptoms are interfering with your life. [complex reflection] Why else might it be somewhat important to get an assessment and figure out what is going on? [evoking] student: I want to do well in school, I want to make my parents proud of me. I can’t continue on this way feeling like I am not good at anything. I just don’t know how I could fit something like counseling in. My schedule is already really tight. I am struggling to get every thing done. social worker: You are worried about how this will work and you are thinking that maybe an assessment might get some answers and that may help you to function better. You have a big commitment to succeeding in school and doing well at baseball, to make your parents proud. [summary] Let me ask you this: On the same scale of 0 to 10, with 10 being extremely confident and 0 being not confident at all, how confident do you feel that you could figure out how to fit an assessment, and possibly counseling, into your schedule? student: I don’t know, maybe a 7. social worker: Great, so you are fairly confident. What makes your confidence level a 7 and say, not a 3? [open-ended question; evoking change talk] student: When I put my mind to something, I am pretty good at figuring out how to do it. And I am tired of feeling so awful. Do you think I could get better? That if I went to counseling that it would help? social worker: You’re a pretty determined person to have gotten as far as you have. [affirmation] AJ, while there is no guarantee, counseling and medication, when warranted, have helped others. The health center here offers assessment and therapy sessions to students for a brief period (1 to 8 sessions). There are also counselors in the community who can help you with depression if you need that. If a further conversation reveals medication may be helpful, you can be referred to a physician who can assist you with that. [giving information] student: How do I know if I need medication or therapy or both? social worker: Well, having a longer assessment will help you and your social worker know for sure. If you are depressed, most people begin with therapy. Your social worker will determine if you need an evaluation for medication. If that is the case, she/he will help find a physician. [giving information] student: I think I like the idea of going through the health center here for at least an assessment. social worker: We will be happy to assist you AJ, thank you for your openness with me. I am very impressed with your commitment to taking

Bringing Up What They Don’t Want to Talk About care of yourself. [affirming] What are your ideas as to how to make this fit into your schedule? [planning; open-ended question] AJ discussed his schedule and how he could meet with a social worker at the health clinic to begin the assessment process. The social worker then provided him with a summary of what they had talked about including his plan to schedule an appointment on his way out.

Summary SBIRT has been widely implemented as a secondary public health prevention and early intervention strategy to reduce harmful drinking and substance use in adolescents and adults (Borus, Parhami, and Levy 2016; SAMHSA 2011). Additionally, it has been utilized to screen for depression in primary care and in university and college settings (Dwinnells 2015). SBIRT is a harm reduction approach considered effective in screening and providing feedback to persons about health risks and life consequences of alcohol or substance use and mental health disorders, who may not other wise present for treatment. After screening, brief interventions, such as education, are provided for low-risk behaviors and referral to treatment is offered for higher-risk behaviors. College health centers are beginning to recognize the value of SBIRT with the student population. This population may not come to the attention of substance use professionals or mental health professionals; however, physicians treating routine health needs, such as sports physicals, often see them. Further, students often utilize campus health centers for minor injuries that may have occurred during a night of drinking. The student health center offers an opportunistic setting for medical or mental health providers to screen for substance misuse and mental health conditions. Using SBIRT, students can be quickly identified through the use of a brief screening tool, given feedback about their scores, provided with education, and given referrals and follow-up when needed. Motivational interviewing as the communication method is helpful is engaging and guiding clients to open discussions about their alcohol or depression symptoms.

Discussion Questions 1. What are some of your concerns about discussing alcohol use or depression in a medical or other opportunistic setting, especially with young adults? 2. What are the benefits of SBIRT with young adults?

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Practice Applications with Involuntary Problems and Settings 3. Within your agency, what steps might need to be taken to enact a policy of utilizing SBIRT for mental health and alcohol and other drug misuse referrals? How would you get the “buy-in” of staff? References Agerwala, S. M., and E. F. McCance-Katz. 2012. “Integrating Screening, Brief Intervention and Referral to Treatment (SBIRT) Into Clinical Practice Settings: A Brief Review.” Journal of Psychoactive Drugs 44 (4): 307–317. Agley, J., R. McIntire, M. DeSalle, D. Tidd, J. Wolf, and R. Gassman. 2014. “Connecting Patients to Ser vices: Screening, Brief Intervention and Referral to Treatment in Primary Health Care.” Drugs: Education, Prevention, and Policy 21 (5): 370–379. Amaro, H., E. Reed, E. Rowe, J. Picci, P. Mantella, and G. Prado. 2010. “Brief Screening and Intervention for Alcohol and Drug Use in a College Student Health Clinic: Feasibility, Implementation, and Outcomes.” Journal of American College Health 58 (4): 357–364. American College Health Association (ACHA). 2013. National College Health Assessment II Web Survey. Boston: ACHA. Archie, S., A. Zangeneh Kazemi, and N. Akhtar-Danesh. 2012. “Concurrent Binge Drinking and Depression Among Canadian Youth: Prevalence, Patterns, and Suicidality.” Alcohol 46 (2): 165–72. Babor, T. E., J. Higgins-Biddle, D. Dauser, P. Higgins, and J. A. Burleson. 2005. “Alcohol Screening and Brief Intervention in Primary Care Settings: Implementation Models and Predictors.” Journal of Studies on Alcohol 66 (3): 361–368. Baer, J. S., D. R. Kivlahan, A. W. Blume, P. McKnight, and G. A. Marlatt. 2001. “Brief Intervention for Heavy-Drinking College Students: 4-Year Follow-Up and Natu ral History.” American Journal of Public Health 91 (8): 1310–1316. Ballesteros, J., J. C. Duffy, I. Querejeta, J. Arino, and A. Gonzalez-Pinto. 2004. “Efficacy of Brief Interventions for Hazardous Drinkers in Primary Care: Systematic Review and MetaAnalyses.” Alcoholism: Clinical and Experimental Research 28 (4): 608–618. Bien, T. H., W. R. Miller, and J. S. Tonigan. 1993. “Brief Interventions for Alcohol Problems: A Review.” Addiction 88: 315–336. Borus, J., I. Parhami, and S. Levy. 2016. “Screening, Brief Intervention, and Referral to Treatment.” Child and Adolescent Psychiatric Clinics 25 (4): 579–601. Center for Collegiate Mental Health [CCHM]. 2016. 2015 Annual Report (Publication no. STA 15–108). http://ccmh.psu.edu /publications/ Chung, H., M. Klein, and S. Greenberg. 2009. “The National College Depression Partnership: Changing How Campuses Address Depression.” NASPA Leadership Exchange (Spring): 16–21. Clark, D. B., A. J Gordon, L. R. Ettaro, J. M. Owens, and H. B. Moss. 2010. “Screening and Brief Intervention for Underage Drinkers.” Mayo Clinic Proceedings 85: 380–391. Cochran, G., and C. Field. 2013. “Brief Intervention and Social Work: A Primer for Practice and Policy.” Social Work in Public Health 28: 248–263. Community College Task Force. Survey 2012–2013. Alexandria, VA: American College Counseling Association. Cremeens-Matthews, J. and B. Chaney. 2016. “Patterns of Alcohol Use: A Two-Year College and Four-Year University Comparison Study.” Community College Journal of Research and Practice 40 (1): 23–33.

Bringing Up What They Don’t Want to Talk About Cronce, J. M., J. N. Bittinger, J. Liu, and J. R. Kilmer. 2014. “Electronic Feedback in College Student Drinking Prevention and Intervention.” Alcohol Research 36 (1): 47–62. DiClemente, C. C., T. B. Crouch, A. E. Norwood, J. Delahanty, and C. Welsh. 2015. “Evaluating Training of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use: Reliability of the MD3 SBIRT Coding Scale.” Psychology of Addictive Behaviors 29 (1): 218–224. Dimeff, L. A., J. S. Baer, D. R. Kivlahan, and G. A. Marlatt. 1999. Brief Alcohol Screening and Intervention for College Students. New York: Guilford Press. Dwinnells, R. 2015. “SBIRT as a Vital Sign for Behavioral Health Identification, Diagnosis, and Referral in Community Health Care.” Annals of Family Medicine 13 (3): 261–263. Ehrlich, P. F., A. Haque, S. Swisher-McClure, and J. Helmkamp. 2006. “Screening and Brief Intervention for Alcohol Problems in a University Student Health Clinic.” Journal of American College Health 54 (8): 279–287. Eisenberg, D., J. Hunt, and N. Speer. 2013. “Mental Health in American Colleges and Universities: Student Subgroups and Across Campuses.” Journal of Nervous and Mental Diseases 201 (1): 60–67. Eisenberg, D., J. Hunt, N. Speer, and K. Zivin. 2011. “Mental Health Ser vice Utilization Among College Students in the United States.” Journal of Ner vous and Mental Disease 199 (5): 301–308. Fachini, A., P. P. Aliane, E. Z. Martinez, and E. F. Furtado. 2012. “Efficacy of Brief Alcohol Screening Intervention for College Students (BASICS): A Meta-Analysis of Randomized Controlled Trials.” Substance Abuse Treatment, Prevention, and Policy 7: 7–40. Gilbert, L., D. Goddard-Eckrich, T. Hunt, X. Ma, M. Chang, J. Rowe, T. McCrimmon, et al. 2016. “Efficacy of a Computerized Intervention on HIV and Intimate Partner Violence Among Substance-Using Women in Community Corrections: A Randomized Controlled Trial.” American Journal of Public Health 106 (7): 1278–1286. Hingson, R. W., W. Zha, and E. R. Weitzman. 2009. “Magnitude and Trends in AlcoholRelated Mortality and Morbidity Among US College Students Ages 18–24, 1998–2005.” Journal of Studies on Alcohol and Drugs 16: 12–20. Hohman, M. 2012. Motivational Interviewing in Social Work Practice. New York: Guilford Press. Juszkiewicz, J. 2015. Trends in Community College Enrollment and Completion Data, 2015. American Association of Community Colleges, Washington, DC, March 1–7. Kroenke, K., R. L. Spitzer, and J. B. W. Williams. 2001. “The PHQ-9: Validity of a Brief Depression Severity Mea sure.” Journal of General Internal Medicine 16: 606–613. Kroenke, K., R. L. Spitzer, and J. B. W. Williams. 2003. “The PHQ-2: Validity of a Two Item Depression Screen.” Medical Care 4: 1284–1294. Kypri, K., J. D. Langley, J. B. Saunders, M. L. Cashell-Smith, and P. Herbison. 2008. “Randomized Controlled Trial of Web-Based Alcohol Screening and Brief Intervention in Primary Care.” Archives of Internal Medicine 168 (5): 530–536. Logan, D. E., J. R. Kilmer, K. M. King, and M. E. Larimer. 2015. “Alcohol Interventions for Mandated Students: Behavioral Outcomes from a Randomized Controlled Pilot Study.” Journal of Studies on Alcohol and Drugs 76 (1): 31–37. Madras, B. K., W. M. Compton, D. Avula, T. Stegbauer, J. B. Stein, and H. W. Clark. 2009. “Screening, Brief Interventions, Referral to Treatment (SBIRT) for Illicit Drug and Alcohol Use at Multiple Health Care Sites: Comparison at Intake and 6 Months Later.” Drug and Alcohol Dependence 99: 280–295. Martens, M. P., M. D. Cimini, A. R. Barr, E. M. Rivero, P. A. Vellis, G. A. Desemone, and K. J. Horner. 2007. “Implementing a Screening and Brief Intervention for High-Risk Drinking

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Practice Applications with Involuntary Problems and Settings in University-Based Health and Mental Health Care Settings: Reductions in Alcohol Use and Correlates of Success.” Addictive Behaviors 32 (11): 2563–2672. Miller, W. R., and S. Rollnick. 2013. Motivational Interviewing: Helping People Change. 3rd ed. New York: Guilford Press. Montag, A., S. Brodine, J. Alcaraz, J. Clapp, M. Allison, D. J. Calac, A. D. Hull, et al.. 2015. “Effect of Depression on Risky Drinking and Response to a Screening, Brief Intervention, and Referral to Treatment Intervention.” American Journal of Public Health 105 (8): 1572–1575. Monti, P. M., T. O’Leary Tevyaw, and B. Borsari. 2005. “Drinking Among Young Adults: Screening, Brief Intervention, and Outcome.” Alcohol Research and Health 28 (4): 236–244. Naar, S., and H. Flynn. 2015. “Motivational Interviewing and the Treatment of Depression.” In Motivational Interviewing in the Treatment of Psychological Problems, 2nd ed., eds. H. Arkowitz, W. Miller, and S. Rollnick, 170–192. New York: Guilford Press. Naar-King, S., and M. Suarez. 2011. Motivational Interviewing with Adolescents and Young Adults. New York: Guilford Press Naegle, M., J. Himmel, and P. Ellis. 2013. “SBIRT Goes to College.” Journal of Addictions Nursing 24 (1): 45–50. National Institute on Alcohol Abuse and Alcoholism [NIAAA]. 2005. Helping Patients Who Drink Too Much: A Clinicians Guide. NIH Pub No. 05–3769. Bethesda, MD: NIAAA. Office of National Drug Control Policy [ONDCP]. 2012. Fact Sheet: Screening, Brief Intervention, and Referral to Treatment (SBIRT). Washington, DC: ONDCP.https://www .whitehouse.gov/sites/default/files/page/files/sbirt _ fact _ sheet _ondcp-samhsa _7-25-111.pdf. Rahm, A. K., J. M. Boggs, C. Martin, D. W. Price, A. Beck, T. E. Backer, and J. W. Dearing. 2015. “Facilitators and Barriers to Implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings.” Substance Abuse 36: 281–288. Resnicow, K., F. McMaster, and S. Rollnick. 2012. “Action Reflections: A Client- Centered Technique to Bridge the WHY-HOW Transition in Motivational Interviewing.” Behavioural and Cognitive Psychotherapy 40: 474–480. Sahker, E., L. Acion, and S. Arndt. 2016. “Age Moderates the Association of Depressive Symptoms and Unhealthy Alcohol Use in the National Guard.” Addictive Behaviors 63: 102–106. Saunders, J. B., O. G. Aasland, T. F. Babor, J. R. de la Fuente, and M. Grant. 1993. “Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption-II.” Addiction 88: 791–804. Seigers, D. K. L., and K. B. Carey. 2010. “Screening and Brief Interventions for Alcohol Use in College Health Centers: A Review.” Journal of American College Health 59 (3): 151–158. Substance Abuse and Mental Health Ser vices Administration [SAMHSA]. 2011. SBIRT White Paper: Screening, Brief Intervention and Referral to Treatment (SBIRT) in Behavioral Healthcare. http://www.samhsa.gov/sbirt/resources. Substance Abuse and Mental Health Ser vices Administration. 2013. Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment. Technical Assistance Publication (TAP) Series 33. HHS Publication No. (SMA) 13–4741. Rockville, MD: Substance Abuse and Mental Health Ser vices Administration. Suffoletto, B., C. Callaway, J. Kristan, K. Kraemer, and D. B. Clark. 2011. “Text-Message-Based Drinking Assessments and Brief Interventions for Young Adults Discharged from the Emergency Department.” Alcoholism, Clinical and Experimental Research 36 (3): 552–560. Terlecki, M. A., J. D. Buckner, M. E. Larimer, and A. L. Copeland. 2015. “Randomized Controlled Trial of Brief Alcohol Screening and Intervention for College Students for

Bringing Up What They Don’t Want to Talk About Heavy-Drinking Mandated and Volunteer Undergraduates: 12-Month Outcomes.” Psychology of Addictive Behaviors 29 (1): 2–16. White, A., and R. Hingson. 2013. “The Burden of Alcohol Use: Excessive Alcohol Consumption and Related Consequences Among College Students.” Alcohol Research 35 (2): 201–218. Whiteside, U., J. M. Cronce, E. R. Pedersen, and M. E. Larimer. 2010. “Brief Motivational Feedback for College Students and Adolescents: A Harm Reduction Approach.” Journal of Clinical Psychology 66 (2): 150–163.

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Chapter 18

Involuntary Clients in Public Schools Solution-Focused Brief Therapy Interventions

Cynthia Franklin, Laura Hopson, and Samantha Guz

Intrinsically, public schools have characteristics that make them involuntary settings. Laws that govern compulsory education and truancy of adolescents mandate attendance in school for children within a particular age range as defined by the state in which they reside. In addition, mental health providers, such as school social workers, who practice in public school settings often work with adolescents who are involuntarily referred for ser vices. In a school setting, for example, a small percentage of adolescents who receive treatment are self-referred (Kuhl, Jarkon-Horlick, and Morrissey 1997). Students are typically referred for counseling by school staff for emotional or behavioral problems in the classroom (Weist, Evans, and Lever 2003). Adolescents may be reluctant to engage in mental health ser vices for a range of reasons that include developmental, social, and environmental issues. This chapter examines the nature of involuntary clients as it relates to adolescents in a school setting, the mental health needs of adolescents, and approaches that are likely to be helpful with this population. Particular attention is paid to solution-focused brief therapy (SFBT) interventions and research support for solutionfocused therapy with adolescents in a school setting.

Mental Health Needs and Ser vices in Schools Surveys estimate that 20  percent of American school-age adolescents have mental health needs (Merikangas et al. 2010). Unfortunately, only a small

Involuntary Clients in Public Schools percentage of these adolescents receive adequate mental health ser vices (Power 2015). If left untreated, these mental health challenges may continue into adulthood and result in tremendous costs for society. For example, adolescents burdened by emotional or mental distress will have difficult achieving academically and maturing emotionally (Colman et al. 2009). Late in life these troubles may manifest as unemployment (Healey, Knapp, and Farrington 2004), low economic productivity, destabilized family units, and increased physical health concerns (Belfer 2008). Schools are the ideal setting to address mental health challenges in young people (Humphrey and Wigelsworth 2016). In 2015, about 50.1 million students attended public elementary and secondary schools (National Center for Education Statistics 2015). Due to the large number of American adolescents passing through public education systems, school settings are an opportunity to conduct mental health screening and deliver mental health ser vices. Approximately 80  percent of schools have mental health professionals on staff, and more than 80  percent of schools report providing case management ser vices for students with behavioral or social problems (CHHCS 2000). Intervening with teens in a school setting is important because they may experience many stressors while at school. Adolescents may respond to stressful environments and situations with a range of behaviors that include fluctuations in mood, impulsivity, inattention, aggression, poor eating and sleeping habits, decreases in academic achievement, preoccupation with sexual issues, school absences, and substance use or abuse (CMHS 2003). Providing ser vices at school increases the chances that underserved populations, such as students of color and low income students, will receive necessary ser vices. School-based mental health ser vices have increased access to ser vices for at-risk populations (Amaral et al. 2011). Hispanic and African American children have the highest rates of need for mental health ser vices and are most likely to go without care. Hispanic youth are the least likely group to access mental health care (Haack, Kapke, and Gerdes 2016). Children from racial and ethnic minority groups also receive poorer quality mental health care (Nestor, Cheek, and Liu 2016). In addition to having the highest need for mental health ser vices, students of color often face oppression and racism within the school system. This oppression often comes in the forms of zero tolerance policies, harsh discipline, referrals to special education, and an overall feeling of marginalization from the education system (Darensbourg, Perez, and Blake 2010). The presence of these forms of oppression are referred to as the school-to-prison-pipeline, as these oppressive forces result in an overrepresentation of African American and Hispanic males in the criminal justice system. Mental health professionals serve a dual role for students of color. They are clinicians as well as advocates. Mental health professionals use their professional skills to communicate with teachers and staff, bridge cultural divides, and combat the experiences of racism and oppression students

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Practice Applications with Involuntary Problems and Settings of color face (Brown 2007). Other student populations, such homeless teens, immigrants, teen parents, and gay and lesbian youth, also experience marginalization and are in great need of mental health ser vices. These student populations may receive care only through institutions such as public schools, the criminal justice system, or health-care organizations. Public schools may be one of the best points of entry for at-risk youth because most have some contact with the public school system (Humphrey and Wigelsworth 2016). Another reason for intervening with students in a school setting is the relationship between unaddressed behavioral and emotional needs and poor academic performance. Bains and Diallo (2015) reviewed twenty-three studies to access the outcomes of school-based mental health ser vices. This extensive review found that, due their high accessibility, school-based ser vices were the best option for at-risk students. The review also found that school-based services provided resources to populations, such as homeless or low-income adolescents, who other wise would have gone without ser vices. Overall, the results of the review were promising and demonstrated high potential for school-based ser vices. Some of the studies included in the review presented data that indicated that students’ academic per formance was connected to their mental health needs (Bains and Diallo 2015). Currently, 30 percent of health visits to school-based services are to address mental health issues. As a setting for mental health ser vices, schools are an opportunity to reach a broad population of adolescents. It has been noted that students who are referred to outpatient ser vices often do not follow up with ser vices outside of the school (Barksdale, Azur, and Leaf 2010). School-based mental health ser vices are also important because teachers and other school staff observe and interact with students for extended periods of time and are often in a good position to detect mental health problems in children (Han and Weiss 2005). One intervention fact is certain: any effective model of intervention in a school setting requires as its base skills for collaboration and cooperation among many different service providers (Han and Weiss 2005). The treatment approach discussed in this chapter, solution-focused therapy, is one approach that offers many skills for helping practitioners develop collaboration in school settings. Working in a school requires close collaboration to ensure that students’ needs are met, but it also requires collaboration among teachers, counselors, social workers, and other staff. Each staff member may have different understandings about the best approach for the student, which can lead to conflicts or even to situations in which no one addresses the adolescent’s problem appropriately (Han and Weiss 2005). It is often not enough for staff to be located within the same school and update each other on their work with students. To maximize their effectiveness with students and create a supportive school climate, all staff will need to share information, respect the knowl-

Involuntary Clients in Public Schools edge and skills of other disciplines, and be flexible in integrating others’ ideas into their interventions (Streeter and Franklin 2002). The challenges of collaboration and cooperation among the adult providers of mental health services are complicated further by the involuntary nature of school-based mental health ser vices and the perceived resistance of adolescents by school mental health professionals.

The Developmental and Contextual Issues Leading to Perceptions of Adolescent Resistance Developmentally, adolescents are striving to achieve independence. In their effort to gain independence, adolescents begin creating their own support networks. These networks are often informal and consist of peers and adult mentors. Adolescents rarely seek out formal support from mental health professionals (Gulliver, Griffiths, and Christensen 2010). This gap between adolescent need and ser vice delivery is partly due to cultural perceptions of mental health ser vices (Guo et al. 2015). Adolescents may be reluctant to engage with a mental health provider because of the stigma attached to mental health treatment. For example, if their development goal is autonomy, the adolescent may perceive counseling as counterproductive to this goal (Logan and King 2001). Stigma can present barriers to serving at-risk adolescents because those who avoid seeing a provider due to stigma may be the most likely to need services (Tatar 2001). By normalizing instead of pathologizing adolescents’ experiences and empowering them to solve their own problems, practitioners can build students’ trust toward mental health ser vices (Guo et al. 2015). Developmental or cultural behaviors that may be interpreted as resistance include an effort to maintain strict boundaries in a session and not initiating contact with the ser vice provider. For these reasons SFBT is specifically used with adolescent populations, as it encourages practitioners to consider the cultural lens of the participant and to adopt the language of the client. Another potential barrier that aids resistance concerns confidentiality. Adolescents are highly sensitive to issues of confidentiality and are less likely to seek treatment if confidentiality is not guaranteed by the practitioners. Adolescents may avoid counseling because they feel their problem is too personal, they prefer to handle the situation on their own, or they feel that another person will be unable to help. Basic issues of trust have to be bridged, as well as a basic understanding of schools as institutions that may not maintain confidentiality well. The more the practitioner can understand and acknowledge the adolescent’s perspective and mediate the basic issues around confidentiality and respect between the school and the adolescent the more likely he or she is to gain the trust needed for the helping relationship.

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Changing the Viewpoints of Helping Adults Toward Adolescent Resistance Working with adolescents in a school setting requires mental health staff to be effective with involuntary clients. Even though adolescents are often perceived as involuntary clients in a school setting, mental health practitioners cannot assume that every adolescent will be difficult to engage. This also means that practitioners should avoid approaching adolescents with the assumption that they are resistant. If adults assume adolescents are difficult and treat them as resistant, this may place undue strain on the relationship; it may also be unwarranted (Tatar 2001). Research suggests that resistance from students in a school setting may be more attributable to the organizational structure of the classroom than to individual student characteristics (McFarland 2001). The assumption that the adolescent client is uncooperative is contrary to the assumptions of the solution-focused intervention approach that is discussed later in this chapter. The solution-focused approach can be successful with adolescents who are referred for treatment because it allows them to feel they are in control of the goals and tasks of treatment. By respecting the perspective of all clients, whether involuntary or not, the therapist helps adolescents develop a sense of self-efficacy and empowers them to achieve their own goals. The solution-focused approach also assumes that all clients are social beings with strengths and that they want to get along with people. It is up to the practitioner to begin where the adolescent client is in his or her unique social context and developmental level and to cooperate with him or her in a change process (Froerer and Connie 2016). The research suggests that the common perception that adolescents are unable to communicate their feelings has little empirical support. A study of adolescent help-seeking behavior found that adolescents identified guidance counselors, mothers, and teachers as good sources of help. Gender and ethnic differences were associated with variations in views about help seeking. Females had more positive attitudes toward seeking help than did males, and Asian Americans had less positive attitudes toward seeking help than did adolescents of other ethnic groups (Guo et al. 2015). To be effective with adolescents in a school setting, school mental health professionals need to assess each adolescent individually and examine and change their own attitudes about adolescent resistance. In interventions such as SFBT, the ser vice provider uses a strengths-based model to help the client build upon existing skills. However, to make the best use of the strengthsbased approach, the ser vice provider needs to utilize tools, such as the miracle question, coping questions, and scaling (Bond et al. 2013). These therapeutic tools reveal the clients’ strengths in situations where the client is reluctant to share, making it easier for helping professionals to maintain a strength-based perspective.

Involuntary Clients in Public Schools Strengths-Based Approaches with Involuntary Clients Strengths-based approaches developed within family therapy traditions are helpful with adolescent populations. These approaches include but are not limited to SFBT, structural/strategic, and the multisystemic models. SFBT is particularly useful for involuntary clients in schools because it concentrates on resources and hope. The practitioner recognizes and builds on the competencies of adolescents. The following section summarizes methods developed within the SFBT that are useful for working with involuntary adolescent clients who may be perceived by others as difficult or resistant to change. Franklin (2002) lists the following practices, which can be effective with involuntary clients: 1. Communicate a nonjudgmental acceptance of the client’s perspective on the problem. 2. Discuss the demands placed on involuntary clients. 3. Help the client define goals for the sessions even if the client’s goals are different from the reason for the referral. 4. Define the therapist’s role so that it is congruent with the client’s goals for the sessions. 5. Use reframing to help the client find similarities in his or her goals and the reasons for the referral. 6. Give the client as much choice as possible to minimize feelings of helplessness. 7. Educate clients about what to expect from therapy sessions. 8. Set specific, small, well-defined goals with the client. 9. Define goals that are not negotiable from the perspective of the referral source and discuss potential incentives for compliance. 10. Use the client goal of reducing negative interactions with the referral source to increase cooperation in sessions. 11. Be neutral in representing the viewpoint of the referral source and the client. 12. Take a relational approach, and ask questions that help the client to understand their feelings about what their expectations for therapy are. Solution-Focused Therapy with Involuntary Clients SFBT is particularly helpful in practicing the aforementioned approaches with involuntary clients because of its collaborative therapeutic stance and unique ways that language and questions are used to help clients change their perceptions and behavior. Therapists practicing SFBT seek to establish a consultative, cooperative approach to the client instead of a confrontational or

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Practice Applications with Involuntary Problems and Settings authoritative approach. This works well with most adolescents who react strongly to adults who lecture and cajole them or threaten them with overly strict demands. As a part of normal adolescent development, young people may assert their independence. An authoritarian stance by adults usually escalates power strug gles or alienates the adolescent from adults. Instead, solutionfocused therapists work to establish a cooperative relationship and to demonstrate great respect for the adolescent. Therapists show a belief that the clients are the experts in resolving their problems and assume that adolescent clients have the knowledge, strength, and skills to solve their own problems. They further hold the client responsible to solve their own problems and help them to experience the consequences of their own goals and solutions (Franklin 2015). Four underlying assumptions guide solution-focused therapy sessions: 1. Every client is unique. 2. Clients have the inherent strength and resources to help themselves. 3. Change is constant and inevitable, and small change can lead to bigger changes. 4. Since it is not possible to change the past, the session should concentrate on the present and future (de Shazer et al. 2007). Involuntary clients may respond well to a solution-focused approach because it views the client as expert. Solution-focused therapists define resistance as a message from the client that the intervention is not helpful and that the therapist needs to change their strategies for engaging the client. Yet the approach acknowledges that clients have different levels of motivation for change and that the style of the therapist has to change to accommodate the levels of change. For this reason, a therapist working with adolescents would not label them as resistant because it can result in an antagonistic relationship between the client and therapist (de Shazer 1988). Solution-focused therapists discuss the difference between a customer, a complainant, and a visitor (Berg 1994; Fish 2011). A customer is motivated to change and is, most often, willing to engage in a mutual, helping relationship. But at other times this may not be the case. A complainant is a person who complains about someone else and wants that person to change. Complainants are often the referring agencies or the loved ones who socially coerce the other person to come for the interview. They are often not motivated to change themselves but want the practitioner to change the person referred. A visitor is someone who comes to sessions and provides information but is not motivated to make any changes. Most mandated clients are visitors, and their greatest motivation may be for the visit to end. Even though this may be their initial intrinsic motivation, this does not nullify the client’s level of motivation as an important entry point for cooperation with the client. In order for the mandated or

Involuntary Clients in Public Schools involuntary client to be able to gain permission to stop the ser vices, they may be willing to participate in life-changing behaviors in order to make this happen. As such, adolescents may be willing to work with clinicians as a means to ending the requirement for treatment. Solution-focused therapists are trained to comprehend the relational nature of this process and use it to motivate clients. As the client changes and cooperates with the practitioner to get other people off their backs, surprising outcomes can sometimes occur. Positive feedback will be the result of positive behavior and more motivation and change will be the result and so forth. We are entering with the client into a positive feedback loop that amplifies positive behav ior,. This is why solution-focused therapists focus on strengths and the entry point for change instead of on resistance, particularly when working with adolescent clients. Solution-Focused Brief Therapy with Adolescents Some of the counseling techniques used in solution-focused therapy that are especially helpful with adolescents include taking a not-knowing approach, finding exceptions to the problem, scaling questions, setting goals, delivering compliments, and assigning behavioral tasks. Taking a Not-Knowing Approach The solution-focused therapist takes the position of “not knowing” by laying aside all preconceptions about the problem and its potential solutions (Berg 2002; Jordan, Froerer, and Bavelas 2013). The therapist allows the client to define the problem and does not impose his or her own ideas about the problem and its potential solutions (Smock et al. 2008). A respectful, not-knowing approach may decrease any feelings of distrust the adolescent may feel toward the therapist. The therapist accepts the client’s definition of the problem and demonstrates a commitment to understanding the client’s perspective (Berg 2002). Therapists can build rapport with an involuntary client by acknowledging the client’s feelings about participating in counseling. This approach leaves the client feeling that the struggles and concerns leading up to the counseling referral are legitimate and can demonstrate the therapist’s belief that the client has the ability to resolve the presenting problem (Froerer and Connie 2016). Finding Exceptions to the Problem To find exceptions to the problem, the therapist asks about times when the presenting problem could have happened but did not. By discussing examples of times when the problem was absent and how they prevented the problem,

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Practice Applications with Involuntary Problems and Settings clients may feel that they already have the skills and knowledge to succeed (Newsome 2004). When a client is having difficulty thinking of exceptions to the problem, the therapist can ask for times when the problem was less severe or less frequent (Berg 1994). Finding exceptions to the problem gives clients a sense of hope that things will get better. With adolescents, this can be especially helpful because they have difficulty seeing beyond the present situation and believing that things will improve (Jobes, Berman, and Martin 2000). Finding exceptions to the problem encourages students to think of ways they have coped with similar problems in the past, and they can imagine a future without the problem. They may also see that the problem could possibly be worse.

Scaling Questions Scaling questions are used for assessment in many areas, such as self-esteem, prioritizing problems, perceptions of hopelessness, and progress toward achieving goals. Scaling questions typically ask clients to rate their situation on a scale from 0 to 10, with 0 the worst/lowest and 10 the best/highest. Scaling is a versatile technique that most clients easily understand and can be especially helpful when clients are having a difficult time seeing their progress (Berg 1994; Reddy et al. 2015). Scaling questions work well with adolescents because they can relate to the idea of rating something on a scale from 1 to 10 (Reddy et al. 2015). They also help the student to identify potential solutions to a problem. If a student ranks the situation as less problematic in successive sessions, the therapist asks about the behaviors that cause the improvement (Berg 2002). This technique places the responsibility for evaluating progress toward achieving goals on the adolescent (Gingerich and Eisengart 2000; Iveson 2002). Scales can also be used in different ways, such as to determine if the goal that has been identified by someone else is at all important to the adolescent. For example: “On a scale of 1 to 10, with 10 being that this problem your teacher sent you here to solve is important for you change in some way and that you want something to be different and 1 being that you are happy with the way things are now, where are you on the scale?” If the adolescent says “5,” for example, then the therapist can ask about the rating and what it is about the problem that the adolescent agrees needs to change. If on the other hand the adolescent says “1” then the therapist will know that the goal is incongruent with what the adolescent wants and can seek to find out what the adolescent wants. Additionally, scales can be used to determine how motivated the client is to change the problem. For example: “If 1 means ‘I am not really interested in working too hard to change the problem as described’ and 10 means ‘I am willing to do anything it takes’ where are you on the scale?”

Involuntary Clients in Public Schools Setting Small Achievable Goals Adolescents often define their problem in vague, ambiguous terms and may need help creating manageable goals (Bond et al. 2015). Solution-focused therapy emphasizes the importance of setting small, specific, achievable goals. Working toward small goals can help the adolescent feel that the problem is within their control. Goals are also stated in positive terms indicating what clients want to be present in their lives instead of what they want to be absent. This is important in engendering hope and creating goals that clearly define actions the client can take to improve the situation (Iveson 2002). Solution-focused goals are based on the client’s ideas about potential solutions and are expressed in their own words. When clients develop their own goals, they are more motivated to achieve them. With involuntary clients, the therapist can clarify the client’s role in identifying goals to reinforce their ownership of the goals (Osborne 1999). Even if an adolescent states a goal as getting the assistant principal to leave him alone, the adolescent works with the therapist to identify steps toward reaching that goal. The therapist can often reframe the requirements of the referral source as consistent with the client’s goals for therapy. An adolescent may need to do X, for example, in order to get out from under the scrutiny of the principal. Many adolescents may protest but would rather comply to avoid worse consequences as long as they have a choice in the matter. Delivering Compliments The solution-focused therapist delivers genuine compliments based on the client’s strengths (Iveson 2002). Delivering compliments helps clients see their own strengths and increases an awareness that they can solve their problems. With an adolescent, genuine compliments can continue the process of identifying client strengths and resources that they already have. The therapist should use only genuine compliments based on session content and should not overcompliment adolescents because they are likely to view this behavior as insincere. The counselor can complement students for choosing to engage in counseling, which reinforces their decision-making power (Iveson 2002).

Behavioral Tasks The solution-focused therapist and the client can also set a behavioral task for the client to complete before the next session. Tasks may be defined by behaviors the client has indicated as helpful through exception questions. The therapist will talk to the client about “doing more of the same” for behaviors that clients have described as helpful. Clients will be directed to “do

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Practice Applications with Involuntary Problems and Settings something different” when they indicate that they have tried one way of coping numerous times with no success (Berg 1994, 2002). Such strategies result in concrete tasks that adolescents may be likely to complete, because they are based on strategies that they have defined as helpful or not helpful. With involuntary clients, it is important that therapists present recommendations for tasks as options, not prescriptions. Clients will take more ownership of a task if they feel they have some decision-making power in defining the task (Osborne 1999).

Solution-Focused Brief Therapy in School Settings SFBT is well suited for schools because of its emphasis on brief treatment and interdisciplinary collaboration (Kim and Franklin 2009; Franklin, Moore, and Hopson 2008). SFBT works well in a school setting because of the emphasis on active listening and focusing on strengths, which facilitates collaboration with others involved with the student. The solution-focused approach encourages use of tools from other models if they are used thoughtfully to accommodate the student’s goals. Solution-focused therapists in a school setting collaborate with students, parents, and teachers in developing interventions. The therapist adopts the stance that there are many approaches that may result in solutions and respects the unique ideas, beliefs, and styles of students, parents, and teachers. The SFBT practice of defining small, concrete goals is also more realistic in a school situation in which those involved have limited time and resources (Bond et al. 2015).

Efficacy of Solution-Focused Therapy with Adolescents Research evidence supports the effectiveness of SFBT (Franklin 2015) and it is currently included in the Substance Abuse and Mental Health Ser vices Administration’s (SAMHSA) national registry for evidence-based practice. Research on the efficacy of SFBT with adolescents is growing and there are a number of studies that demonstrate its outcomes with adolescents in schools (Kelly, Kim, and Franklin 2008). A meta-analysis of studies on SFBT in schools indicates that the approach has small but positive treatment effects and has demonstrated greater improvements in internalizing behavior problems than alternative treatments (Kim and Franklin 2009). A more recent review of SFBT demonstrated the utility of SFBT in settings with youth and families where the ser vice providers have large and diverse caseloads, such as schools (Bond et al. 2015). Bond et al. (2015) found that SFBT addressed individual concerns of the adolescent clients while incorporating the family structure into the therapeutic process. The review also explored the various uses of SFBT among adolescents in need of crisis intervention and assistance with internalizing disor-

Involuntary Clients in Public Schools ders (Bond et al. 2015). Overall, SFBT was able to address the adolescents’ needs promptly through a strengths-based model and was found to be effective in early intervention. Evidence also supports the use of SFBT with ethnic populations, such as Latino and Chinese individuals (Gonzalez, Franklin, and Kim 2016; Liu et al. 2015). A recent meta-analysis that examined twenty-four outcome studies on SFBT group interventions in Chinese schools found, for example, that SFBT was effective with internalizing disorders like depression and with family and relationship problems (Gong and Hsu 2016). All of the studies were conducted in school settings and resulted in large effect sizes. It was concluded that SFBT may be an effective intervention for engaging Chinese clients who are sometimes reluctant to seek ser vices because of a desire to maintain a positive public image of the self and do not wish to speak about their past traumas or problems. The Gong and Hsu (2016) study and other outcome studies (e.g., Kim, Brook, and Akin 2016) on Chinese populations indicate that Chinese clients may be more willing to accept SFBT because it emphasizes the strengths of the client. The cross-cultural adaptability of SFBT makes it ideal for schools and other mental health agencies that serve diverse adolescent populations with a range of mental health needs who also may have difficulty seeking mental health ser vices (Liu 2015; Bond et al. 2015). Results from SFBT studies show positive outcomes for adolescents on selfesteem mea sures and coping mea sures (LaFountain, Garner, and Eliason 1996); a reduction in acting-out behaviors and other emotional and behavioral problems (Franklin et al. 2001; Corcoran and Stephenson 2000; Newsome 2004; Franklin and Hopson 2007); reaching goals (Newsome 2004; Littrell, Malia, and Vanderwood 1995; LaFountain, Garner, ad Eliason 1996); improved social skills (Newsome 2004); and improved grades and attendance in schools (Newsome 2004; Franklin et al. 2007). More research is needed to understand the efficacy of SFBT with externalizing behavioral disorders and substance use, and academic failure and dropout prevention. SFBT is being applied with these conditions, and some research exists that supports the efficacy of SFBT with externalizing problems (Bond et. al. 2013) but, overall, the findings are not as strong as with internalizing disorders (Gong and Hsu 2016; Kim and Franklin 2009).

Summary Evidence demonstrates that SFBT is an effective intervention to use with adolescents. SFBT can be particularly effective with adolescents who are perceived as resistant to receiving mental health ser vices because it is strengthensbased and goal-oriented. SFBT creates a space where adolescents can focus on the challenges at hand and create small achievable goals for themselves. Once adolescents begin SFBT they are quickly able to track their progress with the

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Practice Applications with Involuntary Problems and Settings use of scaling questions. This progress is then positively reinforced each session by a strong rapport with the service provider. The versatility of SFBT makes it a promising intervention for serving diverse populations of adolescents in settings such as schools. Additionally, the time commitment of SFBT is not overbearing for involuntary adolescent clients. During the session, the adolescent is empowered to identify the area of change, explore solutions, and set goals.

Case Study and Discussion Questions Eva is a sixteen-year-old girl referred to see the school social worker for aggressive behavior toward peers and teachers. Specifically, Eva slapped another female student during gym class and directed foul language toward her math teacher. Before meeting with Eva, the social worker spoke with teachers about Eva’s performance in school and known family life. Eva has no record of discipline referrals or aggression but several teachers were concerned with Eva’s recent tardiness and mood changes. Eva is well liked at school with small group of close, mostly female, friends. Eva’s academic performance has been fairly consistent, passing classes and turning in assignments on time. Upon meeting with Eva’s band instructor, the social worker learns that Eva’s mother was recently released from prison after serving a seven-year sentence. Eva had previously been living with extended family members but has now moved into an apartment with her mother. During the first session, Eva responds to the social worker but does not speak unless questioned. Her answers are brief and she often responds with “I don’t know.” When the social worker asks Eva why is there to see her, Eva says that she may be suspended for the aggressive behavior if she does not participate in counseling.

Questions for Discussion 1. How would you begin the session with Eva working from a strengths perspective? 2. Describe three techniques you would try and how you think Eva would respond. 3. How would you end the session with Eva?

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Practice Applications with Involuntary Problems and Settings Franklin, C., J. Biever, K. Moore, D. Clemons, and M. Scamardo. 2001. “The Effectiveness of Solution-Focused Therapy with Children in a School Setting.” Research on Social Work Practice 11 (4): 411–434. Franklin, C., and L. Hopson. 2007. “New Challenges in Research: Translating CommunityBased Practices Into Evidence-Based Practices.” Journal of Social Work Education 43 (3): 377–404. Franklin, C., K. Moore, and L. Hopson. 2008. “Effectiveness of Solution-Focused Brief Therapy in a School Setting.” Children and Schools 30 (1): 15–26. Franklin, C., C. L. Streeter, J. S. Kim, and S. J. Tripodi. 2007. “Using Concept Mapping to Examine School Dropouts: A Solution-Focused Alternative School Case Study.” Children and Schools 29 (3): 133–144. Froerer, A. S., and E. E. Connie. 2016. “Solution-Building, the Foundation of Solution-Focused Brief Therapy: A Qualitative Delphi Study.” Journal of Family Psychotherapy 27 (1): 20–34. Gingerich, W. J., and S. Eisengart. 2000. “Solution-Focused Brief Therapy: A Review of the Outcome Research.” Family Process 39 (4): 477–498. Gong, H., and W. Hsu. 2016. “The Effectiveness of Solution-Focused Group Therapy in EthnicChinese School Settings: A Meta-Analysis.” International Journal of Groups 67 (3): 383–409. González Suitt, K., C. Franklin, and J. Kim. 2016. “Solution-Focused Brief Therapy with Latinos: A Systematic Review.” Journal of Ethnic and Cultural Diversity in Social Work 25 (1): 50–67. Gulliver, A., K. M. Griffiths, and H. Christensen. 2010. “Perceived Barriers and Facilitators to Mental Health Help-Seeking in Young People: A Systematic Review.” BMC Psychiatry 10 (1): 1. Guo, S., H. Nguyen, B. Weiss, V. K. Ngo, and A. S. Lau. 2015. “Linkages Between Mental Health Need and Help-Seeking Behavior Among Adolescents: Moderating Role of Ethnicity and Cultural Values.” Journal of Counseling Psychology 62 (4): 682–693. Haack, L. M., T. L. Kapke, and A. C. Gerdes. 2016. “Rates, Associations, and Predictors of Psychopathology in a Convenience Sample of School-Aged Latino Youth: Identifying Areas for Mental Health Outreach.” Journal of Child and Family Studies 25 (7): 2315–2326. Han, S. S., and B. Weiss. 2005. “Sustainability of Teacher Implementation of School-Based Mental Health Programs.” Journal of Abnormal Child Psychology 33 (6): 665–679. Healey, A., M. Knapp, and D. P. Farrington. 2004. “Adult Labour Market Implications of Antisocial Behaviour in Childhood and Adolescence: Findings from a UK Longitudinal Study.” Applied Economics 36 (2): 93–105. Humphrey, N., and M. Wigelsworth. 2016. “Making the Case for Universal School-Based Mental Health Screening.” Emotional and Behavioural Difficulties 21 (1): 22–42. Iveson, C. 2002. “Solution-Focused Brief Therapy.” Advances in Psychiatric Treatment 8 (2): 149–156. Jobes, D. A., A. L. Berman, and C. E. Martin. 2000. “Adolescent Suicidality and Crisis Intervention.” In Crisis Intervention Handbook: Assessment, Treatment, and Research, ed. A. R. Roberts, 131–151. New York: Oxford University Press. Jordan, S. S., A. S. Froerer, and J. B. Bavelas. 2013. “Microanalysis of Positive and Negative Content in Solution-Focused Brief Therapy and Cognitive Behavioral Therapy Expert Sessions.” Journal of Systemic Therapies 32 (3): 46. Kelly, M., J. S. Kim, and C. Franklin. 2008. Solution-Focused Brief Therapy in Schools: A 360 Degree Review of Practice and Research. New York: Oxford University Press. Kim, J. S., J. Brook, and B. A. Akin. 2016. “Solution-Focused Brief Therapy with SubstanceUsing Individuals: A Randomized Controlled Trial Study.” Research on Social Work Practice. doi:1049731516650517.

Involuntary Clients in Public Schools Kim, J. S., and C. Franklin. 2009. “Solution-Focused Brief Therapy in Schools: A Review of the Outcome Literature.” Children and Youth Services Review 31 (4): 464–470. Kuhl, J., L. Jarkon-Horlick, and R. F. Morrissey. 1997. “Mea suring Barriers to Helpseeking Behavior in Adolescents.” Journal of Youth and Adolescence 26: 637–650. Iveson, C. 2002. “Solution-Focused Brief Therapy.” Advances in Psychiatric Treatment 8 (2): 149–156. LaFountain, R. M., N. E. Garner, and G. T. Eliason, G. T. 1996. “Solution-Focused Counseling Groups: A Key for School Counselors.” The School Counselor 43 (4): 256–267. Littrell, J. M., J. A. Malia, and M. Vanderwood. 1995. “Single-Session Brief Counseling in a High School.” Journal of Counseling and Development 73: 451–458. Liu, X., Y. P. Zhang, C. Franklin, Y. Qu, H. Chen, and J. S. Kim. 2015. “The Practice of Solution-Focused Brief Therapy in Mainland China.” Health and Social Work 40 (2): 84–90. Logan, D. E., and C. A. King. 2001. “Parental Facilitation of Adolescent Mental Health Service Utilization: A Conceptual and Empirical Review.” Clinical Psychology: Science and Practice 8 (3): 319–333. McFarland, D. 2001. “Student Re sistance: How the Formal and Informal Organ ization of Classrooms Facilitate Everyday Forms of Student Defiance.” American Journal of Sociology 107 (3): 612–678. Merikangas, K. R., J. P. He, M. Burstein, S. A. Swanson, S. Avenevoli, L. Cui, et al. 2010. “Lifetime Prevalence of Mental Disorders in US Adolescents: Results from The National Comorbidity Survey Replication— Adolescent Supplement (NCS-A).” Journal of the American Academy of Child and Adolescent Psychiatry 49 (10): 980–989. National Center for Education Statistics. 2015. Fast Facts. NCES. http://nces.ed.gov/fastfacts /display.asp?id=372. Newsome, S. 2004. “Solution-Focused Brief Therapy (SFBT) Groupwork with At-Risk Junior High School Students: Enhancing the Bottom-Line.” Research on Social Work Practice 14: 336–343. Nestor, B. A., S. M. Cheek, and R. T. Liu. 2016. “Ethnic and Racial Differences in Mental Health Ser vice Utilization for Suicidal Ideation and Behavior in A Nationally Representative Sample of Adolescents.” Journal of Affective Disorders 202: 197–202. Osborne, C. J. 1999. “Solution-Focused Strategies with Involuntary Clients: Practical Applications for the School and Clinical Setting.” Journal of Humanistic Education and Development 37 (3): 169–172. Power, A. K. 2015. “Focus on Transformation: A Public Health Model of Mental Health for the 21st Century.” Psychiatric Services 60 (5), 580–584. Reddy, P. D., A. Thirumoorthy, P. Vijayalakshmi, and M. A. Hamza. 2015. “Effectiveness of Solution-Focused Brief Therapy for an Adolescent Girl with Moderate Depression.” Indian Journal of Psychological Medicine 37 (1): 87. Smock, S. A., T. S. Trepper., J. L. Wetchler, E. E. McCollum, R. Ray, and K. Pierce. 2008. “Solution-Focused Group Therapy for Level 1 Substance Abusers.” Journal of Marital and Family Therapy 34 (1): 107–120. Streeter, C. L., and C. Franklin. 2002. “Standards for School Social Work in the 21st Century.” In Social Worker’s Desk Reference, eds. A. Roberts and G. Greene, 612–618. New York: Oxford University Press. Tatar, M. 2001. “Counsellors’ Perceptions of Adolescence.” British Journal of Guidance and Counseling 29 (2): 213–231. Weist, M. D., S. W. Evans, and N. Lever. 2003. Handbook of School Mental Health: Advancing Practice and Research. New York: Springer.

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Chapter 19

Work with Involuntary Clients in Child Welfare Settings

Rebecca Mirick, Julie Altman, and Debra Gohagan

In child welfare settings, nearly all clients are nonvoluntary clients. They become clients due to outside pressures from professionals such as school teachers, pediatricians, mental health practitioners, daycare workers, early intervention service providers or other people in their lives, such as friends, family members, or neighbors. Although parents can technically choose whether to participate in child welfare ser vices, the costs of refusing to participate can be high, including longer stays in foster care, loss of custody, and termination of parental rights (Choi et al. 2012; Harris 2012; Smith 2003). Therefore, parents feel strong external pressure to participate in ser vices, but they are not always eager or motivated to engage with the worker or fulfill the requirements on their treatment plans. Parents may not just be reluctant to engage. They also may be resistant to the problem definition, the ser vice plan, or attending ser vices. Within the United States, federal policy has emphasized the importance of connecting with and engaging families in an effective, timely manner. As a result, child welfare agencies have adopted a strengths-based approach for working with parents (Kemp et al. 2014) and have developed and implemented new practice models that focus on family engagement, including family group conferencing, differential response pathways, and safety orga nized practice models such as “Signs of Safety.” Using a strengths-based approach can be challenging in a context in which many parents enter ser vices feeling angry, afraid, and powerless (Ayon and Aisenberg 2010; Dumbrill 2006; Howe 2010). Child welfare workers must engage these involuntary clients in strengths-based

Work with Involuntary Clients in Child Welfare Settings work, while always needing to remain conscious of their authority and power and their mandate to follow policy and maintain child safety. The reality of these challenges is that a strengths-based approach is not always used effectively or consistently by child welfare workers (Oliver and Charles 2016; Rapp, Saleebey, and Sullivan 2005). In fact, many workers frequently use a confrontational approach with parents, particularly in response to perceived resistance or noncompliance (Dumbrill 2006; Forrester, McCambridge, Waissbein, and Rollnick 2012), or they use the power inherent in their role to push or coerce parents to change (Harris 2012; Klease 2008), ignoring the practice skills that are known to increase engagement. Noncompliance and resistance, which are common in child welfare work, are often interpreted as an indicator of risk. In this context, compliance with treatment mandates (e.g., treatment attendance, retention, and completion) is often used as an indicator of engagement. Resistance and noncompliance are seen as potential safety concerns (Mirick 2014a). Even parents who are open to ser vices can feel that ser vice plans are “hoops to jump through” instead of individualized plans to help them (Smith, 2008), which can increase resistance. Feelings of shame, guilt, and stigma also increase resistance and negatively impact engagement (Gibson 2014). Many parents may have had previous negative experiences with agencies, may distrust ser vice providers (Yatchmenoff 2005), or may find ser vices are not culturally responsive (Ayon and Aisenberg 2010). Others may be coping with significant mental health issues, poverty, substance use disorders, or trauma. This chapter examines the complex context of client nonvoluntariness within child welfare, where client resistance, safety issues, intense feelings and reactions, and individual challenges often create significant engagement challenges for child welfare workers. Systemic factors that impact child welfare ser vice delivery at various levels of intervention are highlighted, as is current research about best practices with involuntary clients. Models of child welfare ser vice delivery that focus on client strengths and enhancing resiliency are described, including family group conferencing, solution-focused treatment, trauma informed practice, and safety organized practice models. The chapter’s main concepts are illustrated with a case example drawn from one author’s research (Altman 2004).

A Child Welfare Case Example Ms. J. is a thirty-eight-year-old African American woman living in an impoverished urban community. Ms. J. spent time in foster care as a child. Her daughter, A., age seven, was removed from her care three months ago, after numerous substantiated reports of neglect. Ms. J. states that as the youngest of her three children and the only one she has attempted to raise on her own,

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Practice Applications with Involuntary Problems and Settings A. presented some challenges. She often refused to go to school and Ms. J. found supervision of her during nonschool hours difficult. Ms. J. had worked as a government employee for some time before A.’s removal, and is in a long-term relationship with the father of A., who works as a mechanic. Bouts of domestic violence, often fueled by alcohol, prompted Ms. J.’s arrest for assault on him recently, and the two have lived apart ever since. Ms. J. is making ends meet by going to a food pantry, though she worries about losing her subsidized housing. She comes to the child welfare helping encounter involuntarily, realizing that she must do what she has to in order to reunite her family. Efforts by the worker to work with Ms. J. have been uneven, as the worker has twenty-four cases, each one as difficult as the next. While Ms. J. believes the worker is trying her best, she worries that the worker’s inexperience and lack of clarity around expectations have hindered progress toward reunification. She also struggles with the worker’s lack of a sense of urgency: And I don’t want to say she don’t do her job because maybe she’s trying to do what she has to do but in my concern I think she need to followup more . . . we have a finite amount of time for me to get my child back . . . Just tell me what to do. She leave things vague . . . Who’s the name of this person you want me to see? What room she in? What floor? What’s her name? Come on; give me something to work with, you know? Further complicating their work together are differences in age, parental status, and ethnicity, and the perceived impact of those differences. Ms. J. reflects: . . . this is a f—ing heavy responsibility of a job. I’m surprised they got somebody that young working here. She is Puerto Rican and she’s probably . . . I don’t even know if she got kids . . . I don’t think she has no idea of what I’m going through. No idea whatsoever. Desiring more than just a friendly relationship with the worker, Ms. J. wants her to be effective. In her view, this means the worker needs to be honest and straight with her, “to say what she means, and mean what she says”: And she’s very nice and she’s, you know, she sits and stays with us and she joins in like a family, you know . . . but that ain’t helping me get her back . . . don’t tell me that you’re going to come to my house and don’t show up. Don’t tell me that you’re going to send me some mail and don’t send it. Don’t tell me that . . . that’s the worst thing you can do. You know ’cause I don’t know what to do and then I think I’m getting somewhere . . .

Work with Involuntary Clients in Child Welfare Settings Ms. J. emphasizes her desire to do “whatever it takes” to ensure that A. will be returned to her care, and yearns for clear direction on what exactly that entails: I’m ready to piss them a river. They keep accusing me and it’s not fair . . . you know, I don’t care, I’ll do it . . . whatever I’ve got to do. I really don’t mind. But tell me. Don’t just tell me the name of it, like anger management. Where can I go get some anger management? It’s not like I’m shopping for it at Home Depot, you know what I’m saying? She admits that she really wishes the worker had more time for her: I know she’s busy, you know, and she’s like she’s got a million things to do but . . . you know if I could catch her face-to-face then we could talk, you know . . . This is a very serious situation and I know I’m just another caseload to you but this is serious shit to me. I need my child back, you know, don’t just brush me off like that . . .

The Black Box of Treatment with Involuntary Clients in Child Welfare Precise understanding of what is inside the successful treatment black box for child welfare workers and the involuntary families they serve remains a challenge, though its dimensions have become increasingly clear (Staff and Fein 1994). Despite years of both process- and outcome-oriented research, clarity regarding the elements of best practice remains tantalizingly out of reach for parents, practitioners, and policy makers. In part, this is due to the complex nature of this work. Additionally, doing the kind of research that may yield empirical answers while dealing with the life and death real world challenges of making good decisions in child welfare practice is incredibly difficult (Howe 2010). Yet, in the past twenty years, research suggests areas of promising practice (Gilbert, Parton, and Skivenes 2011). Knowledge generation specific to the earliest and perhaps most difficult phase of treatment in the child welfare process— engagement—has made especially significant progress (Mallon 2011; Kemp et al. 2014; Mirick 2012; Platt 2012; Pennell et al. 2011; Child Welfare Information Gateway 2010). Building on the pioneering work of Yatchmenoff (2005) in conceptualizing engagement in child welfare ser vices as “positive involvement in the helping process,” research increasingly documents the central role that active participation plays in ser vices to improve outcomes for families (Lee and Ayon 2004; Ingoldsby 2010; Gopalan et al. 2010; Antle et al. 2008; Kemp et  al. 2009; King, Currie, and Peterson 2012). This chapter

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Practice Applications with Involuntary Problems and Settings contributes to that view by providing a review of the complex context and nature of the nonvoluntary helping transaction in child welfare, highlighting the areas that empirical research helps to advance. Anchoring the empirical with the pragmatic client perspective, we use the above case of Ms. J. to remind us of the humility required when working in such a raw and intimate domain of family life, and the importance of always incorporating the client’s point of view.

The Complex Context of Nonvoluntariness in Child Welfare This case of Ms. J. illustrates a number of contextual factors that significantly impact the capacity for parents and workers to engage in helpful, collaborative child welfare practice. These include the federal laws and policies discussed earlier and cultural and other differences between workers and those they serve, including issues of power and authority and the organizational context of the practice itself.

Differences between Clients and Workers Ms. J.’s story demonstrates how perceived differences between the worker and client often make the process of engaging parents complex. When clients perceive that their cultural values in parenting are at odds with that of the child welfare system, their resistance can be great (Healy and Darlington 2009; Mirick 2013, 2014a). Cultural and family values and childhood experiences powerfully reinforce that what one is doing is right; families may resent intervention and focus on ways to escape from child welfare scrutiny instead of engaging with ser vices. Work with immigrant families demonstrates this effect most powerfully (Kriz et al. 2012; Ayon, Aisenberg, and Erera 2010). Research suggests that child welfare settings require critical worker skills and effort to reduce the distance of differences. Most studies have concluded that child welfare professionals first have a responsibility to be aware of their own individual and cultural values and biases, attitudes, and beliefs (Ortega and Faller 2011). Then, it is necessary that the worker understand the client’s world view and know culturally relevant strategies (Ayon and Aisenberg 2010). In child welfare, it takes a skilled worker to work out compromises between client cultural values and legal standards of child and family caretaking. Cross-cultural collaboration with clients requires careful attention to traditional notions and impacts of empathy, mutuality, power and authority, use of self, and communication (Bundy-Fazioli, Briar-Lawson, and Hardiman 2009).

Work with Involuntary Clients in Child Welfare Settings Beyond race, ethnicity, or national origin, gender is increasingly being researched as a factor in the complex dynamic of child welfare ser vice delivery. Fathers have been historically under- or mis-served in the United States (Cowan et al. 2009; Fabiano 2007) and other countries (Featherstone 2009; Maxwell et al. 2012; Dominelli et al. 2011). Knowledge gained from intervention studies with fathers suggest gender bias in the design, delivery, and evaluation of ser vices have not served them well (Berlyn, Wise, and Soriano 2008), particularly as this relates to engaging them in ser vices. These and other empirical gains have translated recently into promising practice models for work with fathers (Bayley, Wallace, and Choudhry 2009).

Power and Authority Child welfare practice is fraught with inequalities of power and authority, making the collaborative ideal difficult to achieve and a trusting worker-client relationship unlikely (Shemmings, Shemmings, and Cook 2012). Research suggests that the more clients perceive power and authority as shared, the more likely they are to form a positive working relationship that leads to better outcomes (Maiter, Palmer, and Manji 2006). As workers became more competent, reducing the power imbalance through the use of empathy, care, and genuineness, parents’ perception of the helping relationship was strengthened. In child welfare work, effective collaboration depends on finding creative ways to develop and balance a sense of reciprocity, shared power, and responsibility (Fuller, Paceley, and Schreiber 2015).

Parents’ Responses to Involuntary Child Welfare Services Parents who are involved involuntarily with child welfare ser vices often experience stigma, shame, and anger as a result of their involvement (Bundy-Fazioli et al. 2009; Gibson 2014; Reich 2005). Unsurprisingly, many clients express resistance to ser vices, either because they do not recognize the problem identified by child welfare ser vices or they believe the intervention was not appropriate for the situation. Client resistance is often expressed through anger and frustration, often directed at the child welfare worker, or through passive resistance, when the client superficially agrees with the worker, but makes none of the promised changes. Resistant clients are often seen as unmotivated or unwilling to change. Resistance and noncompliance are linked to more negative outcomes for families (e.g., longer stays in foster care, higher rates of termination of parental rights), in part because compliance is an indicator of readiness to change and, therefore, a decrease in risk to the child. Reactance theory (Brehm 1966) can help us to understand parent resistance within child welfare ser vices (Mirick 2012). Reactance is seen as a normal,

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Practice Applications with Involuntary Problems and Settings expected response to a threat or loss of personal freedoms (Brehm 1976). Reactance will be stronger when the freedom is highly valued. The feeling of reactance is intolerable, and clients attempt to decrease this feeling and increase their own feelings of control over the situation by expressing anger at the person who took away the freedom, by trying to regain the freedom, either actively or by trying to find loopholes in the mandate (Brehm and Brehm 1981). Within child welfare ser vices, lost or threatened freedoms are common. They can include the removal of a child, a requirement to attend treatment ser vices, a mandate to cease using substances, or a request to obtain a restraining order for a violent boyfriend (Mirick 2012). Reactance theory suggests that expected responses to these kinds of mandates would include attempts to restore the parenting role that has been threatened, such as by trying to convince the child welfare worker there was no maltreatment in the home, by having another baby, or by secretly visiting a child in a family placement. Other attempts might include fulfilling the letter but not the spirit of the mandate, such as by attending counseling but not participating in it, or going to a parenting group but not using the strategies it teaches at home. Parental anger and frustration, especially directed toward the child welfare worker, is another typical response to the experience of reactance. According to reactance theory, these actions and decisions on the part of parents should not be pathologized, but instead should be interpreted as normal, expected responses to the significant loss of freedoms that accompany child welfare involvement. They should not be labeled as noncompliance or denial. These responses can be decreased when child welfare workers use reactance reducing strategies, such as clarifying limitations, identifying available choices, acknowledging the frustration and anger, and avoiding direct confrontation and the use of power or coercion with clients (Mirick 2012). Research on child welfare practices suggests that although efforts are being made to work more collaboratively with parents and families, workers continue to struggle with how to do this within the confines of child welfare practice (Oliver and Charles 2016) and often default to a confrontational, directive style with parents (Forrester et al. 2008). These types of interactions are much more likely to increase parent reactance and reduce compliance than increase parents’ buy-in and engagement in treatment ser vices (Karno and Longabaugh 2005).

Engagement as Collaborative Work One of the biggest changes that has occurred in the past twenty years has been recognition that collaborative work within the organizational context is the conceptual core of client engagement in child welfare ser vices. While specific

Work with Involuntary Clients in Child Welfare Settings knowledge, skills, and attitudes on the part of the child welfare worker are necessary, it is just as critical to have an understanding of what the client brings to the transaction as well as the contributions of the larger system and environment (Altman 2008b). International child welfare research has compellingly shifted the dominant discourse from parent engagement, with the burden of engagement resting on the parents, to one of shared, mutual, and even solely worker responsibility for client engagement (Parton 2009; Dominelli et al. 2011; Healy, Darlington, and Yellowlees 2011; Roose et al. 2013; Gallagher et  al. 2011). While conceptual work on what exactly is meant by engagement should be an ongoing priority (Merkel-Holguin et al. 2015), establishing the client-worker relationship remains an important first step in the change process (Kemp et al. 2009; Platt 2012; Gladstone et al. 2012). Barriers to the establishment of the client-worker relationship are plentiful and include clients’ expressions of outrage at the child welfare system and workers’ frustration or fatigue with the organizational demands of the agency. These can be so extreme that at times the relationship is imperiled before it gets a chance to develop into a working partnership (Ayon, Asienberg, and Erera 2010; Dumbrill 2006; Gockel, Russel, and Harris 2009; Hall and Slembrouchk 2009; Kriz et al. 2012). However, workers must remember that the stakes for families are high, and the realization that someone wields the power to remove children from their care or not return them is powerful, as was painfully illustrated in the case of Ms. J. and her daughter, A. Barriers to Engagement The lived experience of many families in child welfare is too often fraught with a lack of workers’ empathy, strengths orientation, or responsiveness (Alpert and Brittner 2005; Forrester, Westlake, and Glynn 2012; Estefan et al. 2012). Qualitative research suggests that parents experience child welfare interactions as judgmental (Dumbrill 2006), fear-inducing and intimidating (Buckley, Carr, and Whelan 2011), shaming (Schreiber, Fuller, and Paceley 2013), and adversarial (Healy, Darlington, and Yellowlees 2011). Some parents describe their workers’ help as superficial, failing to dig deeper to resolve the more complex challenges of families (Whittaker et al. 2014). Factors that exacerbate the risk that families will not engage in a positive, productive helping process include stigma (Mirick 2014b; Buckley, Carr, and Whelan 2011; Sykes 2011), economic and racial marginalization (Krumer-Nevo 2008; Forrester et al. 2008; Schreiber, Fuller, and Paceley 2013; Damashek et al. 2011; Jonson-Reid, Drake, and Kohl 2009), mothers’ own history with child welfare ser vices (Fusco 2015; Jackson, Beadnell, and Pecora 2015; Marshall, Huang, and Ryan 2011), and the presence of substance use disorders in the family (Smith 2008; Forrester et al. 2014).

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Practice Applications with Involuntary Problems and Settings Factors Related to Successful Engagement Workers’ attitudes toward child welfare clients, their capacity to remain nonjudgmental, and their capability for being supportive and empathic are all correlated with increased engagement (Northern California Training Academy 2009). In one comprehensive, qualitative study of parental perception of worker skills in child protective ser vices, the authors found worker competence, communication, and care to be the three elements that most facilitated client engagement (Schreiber, Fuller, and Paceley 2013). This finding is similar to that in earlier research in family preservation work (Gockel, Russell, and Harris 2008), early intervention and support (Humphries and Korfmacher 2012; Girvin, DePanfilis, and Daining 2007; Fileme et al. 2013; Howard and BrooksGunn 2009; Daro et al. 2003; Damashek et al. 2011), and other related fields (King, Currie, and Peterson 2012; Ingoldsby 2010), lending support for the notion of “common factors” to engagement across disciplines. Strengths-based approaches have been shown to be effective in what Staudt considers the “heart of engagement” (2007:189), obtaining parental “buy-in” to ser vices (Kemp et al. 2014). Strengths-based, family-centered practice is relational, occurs in the context of partnership formed between client parents and workers (Lietz 2011), is hopeful about the possibilities and solutions that parents bring to the encounter (Saleebey 1995; Rapp, Saleebey, and Sullivan 2005), and acknowledges the opportunity and ability of parents to rebound from adversity (Thomas, Chenot and Reifel 2005). These approaches empower parents by building on their strengths, emphasizing supportive, collaborative relationship building between worker and parent, believing in a family’s capacity to change, and providing hope (Lietz 2009; Kyte, Trocme, and Chamberland 2013; Turney 2012; Kisthardt 2009). While this approach shows promise, research demonstrates that wide-scale implementation of family-centered, strength-based practice in child welfare organizations continues to be rare, complicated, and often challenging for workers (Kemp et al. 2009; Michaloupoulos et al. 2012; Oliver and Charles 2016; Wells, Vanyukevych, and Levesque 2015). The challenges of the work are significant and child welfare professionals describe it as very demanding and stressful (Cameron et al. 2013). Research suggests the organizational context of child welfare practice as one of the contributing factors to this stress (Gallagher et al. 2011; Platt 2012; Dumbrill 2010; Glisson and Green 2006; Yoo, Brooks, and Patti 2007; Kemp et al. 2009; Cameron, Hazineh, and Frensch 2010). This context includes more work than time, the high pressure and time sensitive nature of the work, increasing demands of documentation, and often rote, impersonal, and imposed ser vice guidelines that often seem to serve bureaucratic, not the family’s, needs.

Work with Involuntary Clients in Child Welfare Settings

Past and Future Work on Client Engagement in Child Welfare Ser vices For too long, parents in the child welfare system have been under-heard, under-valued, and under-used as partners in building sound and effective child welfare practice (Alpert 2005; Altman 2008a). While this has begun to change with broad based adoption of initiatives like differential response, strengths-based practice, and family centered practice, efforts to engage them for research and program improvement have lagged. Voices of parents such as the mother whose experiences were shared earlier should increasingly be solicited to add to the richness of perspective as to what constitutes best practice. Recent data collected by one of the authors confirms what others have demonstrated for decades—that relationship is what matters most to many child welfare clients (Perlman 1979). In a retrospective study of the outcomes of child welfare ser vice delivery for parents twenty years post-intervention, the durability of the effect of human helping relationships was apparent. One parent, when asked what she recalled of the effectiveness of the family reunification program she was a part of said this: It was worthless. I hated the program. E. was the only one who cared. There was a lot of turnover— every time I turned around, there was a new worker and I had to get to know them. But E. believed in us. She knew that I was a good parent. I was constantly trying to prove myself. I wasn’t a crack addict or a whore. My family told me, “just go through the program, just to prove that you’re a good mom” so that’s what I planned to do, but instantly, we took to each other, it was like visiting my friend every day. That’s what it felt like. She did help me. She let me know that what I was doing was right. She re-instilled in me, she’d say, my confidence. She’d say things like, “You know what you’re doing, J.” She went up above and beyond her duty with me. She got the biggest the wings of any of ’em up there, I’ll tell you, when she gets to heaven, she will have the biggest wings of any of ’em. She really had patience with me. Like, unbelievable. She gave me the confidence I needed to be a good parent, as if I had a good mother to talk through things with. There were time I did question myself, and she helped me through it. Helped me to know I was doing the right thing. At the close of this interview, when asked what advice she might give to aspiring child welfare professionals, J. said: To be genuine, to be honest, to have that constant believing in the client—E. both believed me, and believed in me—that’s what’s important.

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Practice Applications with Involuntary Problems and Settings And don’t pretend. Believe that what they’re saying is true, believe that what clients are saying is true. E. really felt it. Her heart was in it. Further work is needed in developing a theory of engagement that includes the voices of clients like J., even though promising progress to that end is being made (Alpert and Britner 2009; Roose et al. 2013; Love et al. 2013; Mullins 2011). A new model of client engagement and problem solving is also needed for child welfare practice, one that is more direct and expeditious, that sees the parent of the child in placement as the primary client to engage in change efforts, that values a strengths-based orientation to this work, and that builds on relational, responsive, competency-oriented strategies. In recent years, some new programs and models that address the issues and challenges in engagement described here have been developed and brought into use.

Best Practices in Child Welfare Within the United States, the Adoption and Safe Families Act (ASFA; P.L. 105–89) has had a significant effect on worker-parent engagement in child welfare practice (ASFA 1997). It requires that decisions about termination of parental rights for children in foster care be made within a limited time frame, making the urgency with which families engage in change more salient than ever. The reduction in the time allowed for treatment adds to the stress the parents feel and no longer affords the system or the parents extended periods of time to establish worker-client relationships. This act and other similar policies in Europe, Canada, New Zealand, Australia, and other countries place engagement and subsequent treatment interventions on the fast track to an outcome of reunification or termination of parental rights (Damman 2014; Parton 2009; Gallagher et al. 2011; Dumbrill 2010). Workers need models for ser vice delivery that allow them to work more quickly within the constraints of such policies, and caretakers such as Ms. J. desperately want them as well. These policies have spurred the development of new frameworks and models for child welfare practice. Equally consequential is a movement toward the use of differential response (DR) systems in child welfare practice, which sets the stage for more constructive, voluntary helping relationships between worker and client by bridging the intent between mandate and support (Fluke, Merkel-Holguin, and Schene 2013; Fuller 2014; Cameron and Freymond 2015; Kyte et al. 2013; Merkel-Holguin et al. 2015). This approach has begun to change the child welfare service system in significant, important ways, including conceptualization of the development of worker-client relationships and service provision to involuntary child welfare clients.

Work with Involuntary Clients in Child Welfare Settings Differential Response Pathways Beginning in the early 1990s, the use of DR systems allowed workers to consider levels of risk and the nature of the concern, and then, for lower risk families, include family assessment as an alternative response model to that of traditional investigation ser vices. DR allowed workers to consider levels of risk and the nature of concern for families (Child Welfare Information Gateway 2014; Hughes et al. 2013). Families with a low to moderate risk level are referred for assessment and offered supportive ser vices. Family assessment models incorporate a strong emphasis on collaborative work, with participatory roles for family members. Collaborative work reduces reactance and increases family responsiveness to case planning and ser vice involvement. When a child has been harmed or families are screened as high risk, families are referred to traditional models of investigation. In states that are using this model, child welfare professionals are able to provide preventative and supportive family ser vices, avoiding the negative and often punitive traditional family investigation track (Lorbach et al. 2005). In several experimental designs, parents in a DR child welfare pathway felt more relieved, thankful, and comforted, and less stressed, disrespected, and discouraged on average compared to parents in a “ser vices as usual” (protective ser vice investigation) condition (Fuller, Nieto, and Zhang 2013; Loman and Siegel 2004; Loman et al. 2010; Snyder et al. 2012). One review of numerous published and unpublished evaluative studies deduced that parents experiencing DR are generally more satisfied with their experience compared to parents accessing traditional child welfare ser vices (Merkel-Holguin et al. 2015). Qualitative results from another study of a differential response model suggest that parents found a positive and emotionally supportive relationship with the caseworker key to a successful experience with child welfare ser vices (Fuller, Paceley, and Schreiber 2015). Future research should help us better understand whether DR pathways also lead to more positive family outcomes (Hughes et al. 2013). While the DR models are strengths-based and collaborative, recently, significant concerns have been raised about the use of these models (Loudenback 2016). These concerns include inconsistency in implementation of DR programs in many jurisdictions around the country and a lack of empirical research to support the efficacy of the DR pathway to adequately protect children. Hughes et al. (2013) reviewed the research and interviewed key informants in states with active DR programs. They found concerns in five areas: (a) inconsistent implementation methods, (b) methodological problems in research that limited confidence in positive outcomes, (c) insufficient data to confirm the safety of children, (d) possible diversion of limited resources from families in the investigative pathway to the families in the assessment pathway, and (e) literature that often represented traditional child welfare work

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Practice Applications with Involuntary Problems and Settings in a more negative light and DR in more positive language. Their report has sparked a widespread conversation about the need for empirical research to support the effectiveness of DR approaches and changes in implementation efforts as well as policy and funding models. Trauma-Informed Practice Trauma-informed practice has become one of the most significant theories to inform child welfare work in recent years. This practice approach offers new perspectives to professionals for understanding behavior (Perry 2009; SAMHSA 2014; Child Welfare Information Gateway 2015). A trauma-informed approach recognizes that there is a high prevalence of trauma, especially in mental health, substance abuse, and child welfare settings, understands the role that previous trauma has on current behaviors, and reframes many “problem behaviors” as coping skills that developed as adaptive responses to the trauma. This approach moves conversations from a more confrontational, reactive viewpoint (“What is wrong with you?”) to a concerned, nonjudgmental perspective (“What happened to you?”). Solution-Focused Brief Treatment (SFBT) SFBT has been used in many fields of practice including addictions, mental health, education, and juvenile justice (see for example, Corcoran 1997, 1998; Dielman and Franklin 1998; Eakes et al. 1997; Gingerich and Wabeke 2001; Kok and Leskela 1996; Linton 2005; McFarland 1995; Miller 2000; Nickerson 1995; Osborn 1999; Rowan and O’Hanlon 1999; Todd 2000). It has also been used within the field of child welfare practice (see Berg 1994; Corcoran and Franklin 1998; Corcoran and Stephenson 2000; Selekman 1999). The integration of SFBT into child welfare settings has brought renewed attention to the integration of the strengths perspective, resiliency theory, and empowerment practice models into child welfare practice with involuntary clients. The use of SFBT can shift child welfare practice from traditional deficitbased models, in which the child welfare professional is responsible for reducing symptoms and fixing problems, to a strengths-based perspective, in which the worker understands strengths, protective and risk factors, and promotes the competence and well-being of children and families (Antle et al. 2009, 2012; Flynn, Dudding, and Barber 2006; Masten 2011). Safety Organized Practice (SOP) Models Safety organized practice (SOP) models use these perspectives to work collaboratively with families, including parents as partners in the process. SOPs

Work with Involuntary Clients in Child Welfare Settings value the voices of family members and in some instances, see their voices as more important than the voice of the child welfare professional (Fox, Berrick, and Frasch 2008; Kemp et al. 2009; Pennell 2006). There is a focus on collaboration and partnership between the child welfare professional and the client. One of the hallmarks of this active collaboration is the child welfare professional’s responsibility to demonstrate respect for the family’s voice and cultural context (Alexander and Dore 1999; Berg and Kelly 2000; D’Andrade and Chambers 2012; Family Group Decision Making n.d.; Howard and Bruce 2008; Kemp et al. 2009; Pennell 2006; Turnell and Edwards 1999). Participatory, collaborative relationships are not only important with the immediate family, but also with the extended family, social support network, and other professionals who are involved with the family (Berg 1994; Herbert and HarperDorton 2002; Norman 2000; Pecora, Reed-Ashcraft, and Kirk 2001; Petr 1998; Walton, Sandau-Beckler, and Mannes 2001). SOP child welfare practice models integrate a strong commitment to the strengths perspective, resilience theory, and empowerment practice approaches (Antle et al. 2009, 2012; De Jong and Berg 2001; de Shazer et al. 1986; Masten 2011; Osborne 1999; Stalker, Levene, and Cody 1999; Rothe, Nelson-Dusek, and Skrypek 2013). This practice model is in direct contrast to the traditional problem-focused, pathology-based, deficits-driven approach to working with involuntary families in child welfare settings. It requires that workers reassess their personal and professional beliefs related to client capabilities and worthiness. Client problems are no longer labeled as pathological and client strengths are emphasized instead of deficits (Berg 1994; Cowger 1994; Saleeby 1996; Turnell and Edwards 1997). Core principles of these models are informed by the strengths perspective, which assumes that all clients have the resources and strengths to change and sees the clients as the experts on their lives and current challenges (Berg 1994; Saleeby 1996; Stalker, Levene, and Cody 1999). Herbert and HarperDorton suggest that the “worker’s responsibility is to see the cup as half full rather than half empty” (2002:257). The task of the child welfare professional is to find, amplify, reinforce, look for exceptions to, and help the client repeat any positive changes the client has already made. This focus on strengths allows clients to assume or resume control of their lives. Along with the strengths perspective, these models draw on resiliency theory, focusing on past and current protective factors used to identify signs of safety for families. There is a clear emphasis on both identifying safety and redefining safety specifically for each family, instead of applying a generic definition to all families (Fox, Berrick, and Frasch 2008; Pipkin et al. 2013; Rothe, Nelson-Dusek, and Skrypeck 2013; Turnell and Edwards 1997; Wheeler and Hogg 2011). Child welfare professionals identify each family’s past and current efforts to protect their child(ren) as well as specific behaviors that place the child(ren) at further risk (Berg 1994; Iannos and Antcliff 2013; Masten 2011;

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Practice Applications with Involuntary Problems and Settings Saleeby 1996). Protective factors at all system levels, and their role on present and future well-being, are emphasized (Iannos and Antcliff 2013; Mannes, Roehlkepartain, and Benson 2005; Masten 2011; Turnell 2012). Using SOP models, one of the child welfare professional’s primary tasks is to uncover forgotten problem-solving skills and help families adapt these skills to address current difficulties, encouraging parents to engage in future-oriented action. Child welfare professionals are trained to identify past harm and future concerns and to clearly define and focus on a child’s safety while identifying and supporting a family’s best efforts to protect their child. State child welfare programs using these models report more families entering the family assessment track and fewer families starting the family investigations track (Antle et al. 2009; 2012; Lorbach et al. 2005; Nelson-Dusek and Rothe 2015). One of the leading child welfare practice models is Signs of Safety, which was developed in the early 1990s by Andrew Turnell and Steve Edwards in western Australia (Turnell 2012; Western Australia Department of Child Protection 2011). This model has spread to many countries around the world including the United States, Canada, Japan, and the Netherlands (Rothe, Nelson-Dusek, and Skrypek 2013). Olmsted County in Minnesota adopted the Signs of Safety approach in 1999, followed by Carver County in 2005 (Koziolek 2007; Rothe, Nelson-Dusek, and Skrypek 2013). In 2009, the Minnesota Department of Human Ser vices in partnership with the Casey Family Program launched a Signs of Safety training that spread the use of this approach to eighteen counties. Components of this practice model have become the state’s preferred approach to child welfare service delivery (Skrypek, Idzelis, and Pecora 2012). Signs of Safety has fully integrated the use of solution focused treatment (SFT) questioning and scaling techniques (Berg 1994; de Jong and Berg 2000; de Shazer et al. 1986) in order to enhance the parent’s sense of competence and self-empowerment (de Shazer et al. 1986; Berg and De Jong 1996; De Jong and Berg 1998; De Jong and Miller 1995; Turnell 2007; Turnell and Edwards 1997; Turnell 2012; Westbrock 2006; Wheeler and Hogg 2011). These techniques are useful in looking at past and current behaviors to construct safety plans. To see how these questions could be applied to the case of Ms. J., see Table 19.1. One of the hallmarks of the Signs of Safety model is the SFT technique of scaling. Clients are asked to rank, on a scale of 1 to 10, where they or someone close to them would rank them on a particular behavior or concern. Child welfare professionals can adapt this approach to an unlimited number of scenarios in clients’ lives. Clients often respond positively as this approach both allows them to quantify their reaction and demonstrates the worker’s interest in their perspective (Kemp et al. 2009; Penell 2006; Skrypek, Idzelis, and Pecora 2012). In the case described earlier, the worker could have asked Ms. J. to rank herself in a variety of areas, such as, “How likely I am to make a decision

Work with Involuntary Clients in Child Welfare Settings Table 19.1 Solution Focused Treatment Question Types and Examples Question Type

Description

Example

Survival

Ask the client to explain how she survived under the circumstances.

Ms. J., how do you manage to work full time, raise a daughter, keep the bills paid, and have a relationship?

Coping

Ask the client to identify Ms. J., how did you cope when you how she is coping during were fighting with your boyfriend? difficult times. Or when you were worried about every thing? Or when you were feeling alone?

Support

Ask the client who helps her do this.

Ms. J., who helps you to make decisions about your life? Or about your daughter’s behavior?

Exception

Ask the client for exceptions, times when this behavior does not occur.

Ms. J., can you describe a day when you are not feeling overwhelmed? Or what is different about the days when your daughter, A., does attend school? Or can you describe a time when you and A. were both able to enjoy spending time together?

Possibility

Ask the client to imagine what it would take for a change in behavior or attitude to happen and how the client would know that this change had occurred.

What would it take for you to get back to work, Ms. J.? Or if you decided to return to work, what would that be like?

Esteem

Ask the client to imagine What would be different about you, what would be different Ms. J., if you were able to make if the change occurred. good decisions about your daughter and your life? Or if you were able to return to work?

to return to work?” or “How would I rank my efforts to have my daughter returned home?” The Signs of Safety model avoids describing client behavior that does not fit the expectations as resistance or noncompliance, and instead explains these, as Rooney (2009) suggests, as manifestations of reactance. Even when the client’s views and behaviors are different from the child welfare professional’s

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Practice Applications with Involuntary Problems and Settings expectations, they are considered valid. When confrontation is appropriate, the child welfare professionals use a curious tone of voice and avoid an accusatory approach. Clearly, successful transition for the child welfare professional to an SOP model such as Signs of Safety requires a change in the professional’s behavior away from advice giving, lecturing, confronting, or nagging involuntary clients who may have previously been labeled as difficult or resistant. It also requires understanding on the part of the worker as to when and how to use their authority and the power that comes with it. Several concerns have been raised about the SOP models. One is that a focus on family strengths may lead to the minimization of past harm, future risk, and statutory criteria and responsibilities. Another concern is that there is less emphasis on the use of the traditional treatment approaches and services such as addiction recovery programs, parenting classes, and financial support programs. In safety organized practice models, which are based on Turnell’s Signs of Safety, the primary focus is on safety regarding past harm or future danger, and treatment plans address steps the family and social network will take to ensure child safety. Problems that contribute to a parent’s difficulty in ensuring safety, such as limited parenting skills, addictions, and mental health concerns, are treated as complicating factors, not primary concerns. While ser vices addressing these concerns can be valuable to families, Andrew Turnell has criticized as simply requiring all ser vices possible for the client in the hope that something will work (Turnell and Edwards, 1999). Others refer to it as a “one size fits all” or “cookie cutter” approach of ser vice planning (D’Andrade and Chambers, 2012). In reality, too often referrals are not well-tailored to meet the family’s unique needs (D’Andrade and Chambers 2012). When this happens, the ser vices may not be effective and mandated multiple ser vices, especially those that are unnecessary, may increase reactance for parents (Mirick 2012). Researchers are beginning to examine the effectiveness of these SOP models, including solution focused approaches. As stated earlier, SFT models have been used and evaluated by researchers in a variety of fields of social work practice (Gingerich and Eisengart 2000; Kim et al. 2010). Gingerich and Peterson (2013) analyzed forty-three studies and found strong evidence that SFBT is an effective treatment for a wide variety of behavioral and psychological outcomes, and has the benefit of being briefer and less costly than alternative approaches. In a large, longitudinal study (N = 760 cases), Antle and colleagues (2009) found that when child welfare professionals engaged in solution focused casework, they experienced significantly fewer recidivism referrals than when traditional approaches were used. Another large study of public child welfare cases (N = 4559) examined the use of a solution based casework practice model on federal outcomes of safety, permanency, and well-being (Antle, Christensen, van Zyl, and Barbee 2012). This study found that when the child welfare professional maintained strong adherence to the solution focused case-

Work with Involuntary Clients in Child Welfare Settings work model, cases had significantly better outcomes in the areas of child safety, permanency, and well-being and exceeded federal standards in these areas. Cases for which child welfare professionals did not adhere to the model failed to meet federal standards. More research is needed to determine if SOP models positively impact client perceptions of child welfare professionals and programs. In a qualitative study with parents (N = 24) involved with child welfare ser vices, Skrypek, Idzelis, and Pecora (2012) found that two-thirds of parents (67 percent) reported their perceived experience either remained positive over the course of the relationship (29 percent) or improved over time (38 percent). More than half of the cases (58  percent) were considered positive by case closure. In the same study, (67 percent) reported that their work with their child protection worker had given them hope that things would get better for them in terms of keeping their child safe. Family Group Conferencing Family group conferencing (FGC), also sometimes referred to as family group decision making or family unity meetings, was one of the first more collaborative and participatory approaches to be adapted to child welfare practice. The use of family and extended social networks was originally developed to increase the cultural relevance of ser vices provided to ethnic populations in New Zealand (Fulcher 2000; Halsell 1996; Vance and Elofson 1999; Waites et al. 2004). In the United States, the approach was adopted in youth programs and police environments (Crow and Marsh 2000; McCold and Wachtel 1998) and child welfare agencies in the early 1990s (Doolan 2002; Fulcher 2000; Hassall 1996; Howard and Bruce 2008; Merkel-Holguin 1998; Pennell and Burford 2000) in response to the escalating number of children, disproportionately minorities, with negative outcomes, including higher rates of out-of-home placements, multiple placements, and longer time periods in out-of-home placements (Family Group Decision Making n.d.; Hudson, Sieppert, and Unrau 2000; Howard and Bruce 2008; Pennell 2006). FGC is characterized by attendance of family and extended family, social support network, and professionals from one or more agencies. When it is possible and appropriate, children also attend. These meetings are held in nonthreatening environments such as churches or community centers. FGC is a family-centered, family- and community-strengths oriented, culturally competent, and solution-focused model that encourages family and community empowerment. It is a nonadversarial process that provides families with the opportunity to make important decisions about managing their child’s safety. It recognizes that families have the most information about themselves to make well-informed decisions and that individuals can find security and a sense of

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Practice Applications with Involuntary Problems and Settings belonging within their families. It emphasizes that, first and foremost, families have the responsibility to not only care for, but also to provide a sense of identity for, their children. It encourages families to connect with their communities, and the communities to link with their families. In this model, families and other concerned individuals join with the child welfare worker to share in the responsibility for developing safety plans that protect and nurture children and prevent further abuse and neglect. It is typically implemented in stages, using group meetings in which a facilitator, whose level of presence and participation is negotiated at the beginning of the meeting, allows the FGC participants to negotiate a plan of action with and without the presence of the FGC coordinator and other professionals. In our earlier case scenario, Ms. J. would have been considered for FGC ser vices, given the strengths that appear to exist in her personal and family life (i.e., extended family connections, work history, etc.). Members of her family as well as other interested parties would be invited to participate in the development of a plan to care for Ms. J.’s daughter. Research on the use of FGC has demonstrated that FGC can be effectively used with a variety of family situations, does not increase risk, produces high levels of satisfaction in the families who participate, and has positive effects on child placement outcomes (Burford et al. 1996; Pennell 2006; Walton et al. 2004). These positive outcomes include fewer children living in out-of-home care, fewer court proceedings, more professional involvement with extended families, more children living with kin, more community involvement for nuclear family members, especially fathers, and lower levels of recidivism for juveniles engaging in violent crimes (Burford et al. 1996; Hudson, Sieppert, and Unrau 2000; Jackson and Morris 1999; McCold and Wachtel 1998;). Pennell (2006) evaluated the use of FGC by child welfare workers in North Carolina on factors related to conference participation, satisfaction, and decision-making processes. Multiple studies report high levels of satisfaction with the conference process and decisions and demonstrate similar results when used with culturally different groups (see Merkel-Holguin, Nixon, and Burford 2003; Pennell 2006). The use of FGC provides families with a strong voice in the treatment planning process, which makes it a natural fit with SOP practice models. Therefore, the FCG method has been adapted for use with these models. Signs of Safety has pioneered the use of safety networks or safety circles, which are used early in the assessment process. Parents are asked to identify family, friends, and other persons who may be concerned about their own safety or the child’s safety. Those identified are invited to participate in a family group meeting to assist in developing a safety plan and are asked to commit to maintaining a presence in the child and family’s life. They are asked to assume responsibility for particular aspects of the safety plan and are sometimes assigned spe-

Work with Involuntary Clients in Child Welfare Settings cific tasks so they can demonstrate over time that they can keep the child(ren) safe. Identifying naturally occurring extended networks in children’s and parent’s lives can break down the barriers and secrecy that often surround these families (Turnell and Edwards, 1999).

Conclusion Several promising strengths-based, collaborative models have been developed for child welfare ser vices. These models address issues of resistance, reactance, power, and differences between workers and clients, and replace traditional, deficit-focused child welfare work with a more collaborative, hopeful, strengths-focused perspective. The use of these models can change the tone and feeling of child welfare work. More work needs to be done to address the challenges and limitations of these models, as well as to increase their use across the United States and the world. Clients like Ms. J. are clearly seeking changes in how child welfare workers approach, engage, and work with families. Although families in the child welfare system are often there involuntarily, there are many opportunities to effectively engage with them. These newer models offer promising opportunities for more effective child welfare work in which child welfare professionals work in collaboration with parents. However, in order to fully reach their potential, structural barriers such as caseload size, worker turnover, and bureaucratic responsibilities such as increasing requirements for documentation must be for the child welfare workforce to have the time needed to engage in and fully incorporate these promising strengths-based collaborative models into their practice.

Discussion Questions 1. How can we adapt current social work education and training to allow for better ser vice delivery to involuntary clients in child welfare settings? 2. What are some of the critical elements of engaging families who are nonvoluntary and mandated to receive ser vices in child welfare settings? 3. How might we better envision our work toward more inclusive practice with the diverse families engaged in involuntary child welfare ser vices?

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Practice Applications with Involuntary Problems and Settings Love, S. M., M. R. Saunders,, C. W. Metzler, R. J. Prinz, and E. Z. Kast. 2013. “Enhancing Accessibility and Engagement in Evidence-Based Parenting Programs to Reduce Maltreatment: Conversations with Vulnerable Parents.” Journal of Public Child Welfare 7: 20–38. Maiter, S., S. Palmer, and S. Manji. 2006. “Strengthening Social Worker-Client Relationships in Child Protection Ser vices: Addressing Power Relationships and Ruptured Relationships.” Qualitative Social Work 5: 161–186. Mallon, G. P. 2011. “Meaningful Family Engagement.” Child Welfare 90: 5–7. Mannes, M., E. C. Roehlkepartain, and P. L. Benson. 2005. “Unleashing the Power of Community to Strengthen the Well-Being of Children, Youth, and Families: An Asset-Building Approach.” Child Welfare League of America 74 (2): 233–250. Marshall, J. M., H. Huang, and J. P. Ryan. 2011. “Intergenerational Families in Child Welfare: Assessing Needs and Estimating Permanency.” Children and Youth Services Review 33: 1024–1030. Masten, A. S. 2011. “Resilience in Children Threatened by Extreme Adversity: Frameworks for Research, Practice, and Transnational Synergy.” Development and Psychopathology 23: 493– 506. doi:10.1017/S0954579411000198. Maxwell, N., J. Scourfield, B. Featherston, S. Holland, and R. Tolman. 2012. “Engaging Fathers in Child Welfare Ser vices: A Narrative Review of Recent Research Evidence.” Child and Family Social Work 17: 160–169, McCold, P., and B. Wachtel. 1998. The Bethlehem Pennsylvania Police Family Group Conferencing Project. Pipersville, PA: Community Service Foundation. http://fp.enter.net/restorativepractices /BPD.pdf. McFarland, B. 1995. Brief Therapy and Eating Disorders: A Practical Guide to Solution-Focused Work with Clients. San Francisco: Jossey-Bass. Merkel-Holguin, L., ed. 1998. 1997 National Roundtable Series on Family Group Decision Making: Summary of Proceedings. Englewood, CO: American Humane Association. Merkel-Holgun, L., D. M. Hollinshead, A. E. Hahn, K. L. Casillas, and J. D. Fluke. 2015. “The Influence of Differential Response and Other Factors on Parent Perceptions of Child Protection Involvement.” Child Abuse and Neglect 39: 18–31. Merkel-Holguin, L., P. Nixon, and G. Burford. 2003. “Learning with Families: A Synopsis of FGDM Research and Evaluation in Child Welfare.” Protecting Children 18 (1–2): 2–11. Michaloupoulos, L., A. Haksoon, T. V. Shaw, and J. O’Connor. 2012. “Child Welfare Worker Perception of the Implementation of Family-Centered Practice.” Research on Social Work Practice 22: 656–664. Miller, S. 2000. “Description of the Solution-Focused Brief Therapy Approach to Problem Drinking.” In Approaches to Drug Abuse Counseling, ed. K. M. Carroll, 91–98. NIH Publication Number 00–4151. Washington, DC: National Institute on Drug Abuse. http://www .nida.nih.gov/ADAC/ADAC1.html. Mirick, R. G. 2012. “Reactance and the Child Welfare Client: Interpreting Parents’ Resistance to Ser vices through the Lens of Reactance Theory.” Families in Society 93: 165–172. Mirick, R. G. 2013. “An Unsuccessful Partnership: Behavioral Compliance and Strengths-Based Child Welfare Practice.” Families in Society 94: 227–234. Mirick, R. G. 2014a. “Engagement in Child Protective Ser vices: The Role of Substance Abuse, Intimate Partner Violence and Race.” Child and Adolescent Social Work Journal 31: 267–279. Mirick, R. G. 2014b. “The Relationship Between Reactance and Engagement in a Child Welfare Sample.” Child and Family Social Work 19: 333–342. Mullins, J. L. 2011. “A Framework for Cultivating and Increasing Child Welfare Workers’ Empathy Toward Parents.” Journal of Social Service Research 37: 242–253.

Work with Involuntary Clients in Child Welfare Settings Nelson-Dusek, S., and M. I. Rothe. 2015. “Does Safety Planning Endure After Case Closure? A Pilot Study on the Effectiveness of Signs of Safety in Four Minnesota Counties.” St. Paul, MN: Wilder Research. https://www.wilder.org / Wilder-Research /Publications/Studies /Signs%20of%20Safety/Does%20Safety%20Planning%20Endure%20After%20Case%20 Closure%20-%20A%20Pilot%20Study%20on%20the%20Effectiveness%20of%20Signs%20 of%20Safety%20in%20Four%20MN%20Counties.pdf. Nickerson, P. 1995. “Solution Focused Group Therapy.” Social Work 40: 132–133. Norman, E., Ed. 2000. Resiliency Enhancement: Putting the Strengths Perspective into Social Work Practice. New York: Columbia University Press. Northern California Training Academy. 2009. “The Importance of Engagement in Child Welfare Ser vices.” Retrieved from https://humanservices.ucdavis.edu /programs/northern -california-training-academy. Oliver, C., and G. Charles. 2016. “Enacting Firm, Fair, and Friendly Practice: A Model for Strengths-Based Child Protection Relationships.” British Journal of Social Work 46: 1009–1026. Ortega, R. M., and K. C. Faller. 2011. “Training Child Welfare Workers from an Intersectional Cultural Humility Perspective: A Paradigm Shift.” Child Welfare 90: 27–49. Osborn, C. J. 1999. “Solution-Focused Strategies with ‘Involuntary’ Clients: Practical Applications for the School and Clinical Setting.” Journal of Humanistic Education and Development 37: 169–181. Parton, N. 2009. “Challenges to Practice and Knowledge in Child Welfare Social Work from the ‘Social to the Informational’?” Children and Youth Services Review 31: 715–721. Pecora, P. J., K. R. Reed-Ashcraft, and R. S. Kirk. 2001. “Family-Centered Ser vices: A Typology, Brief History, and Overview of Current Program Implementation.” In Balancing Family Centered Services and Child Well-Being, eds., E. Walton, P. Sandau-Beckler, and M. Mannes, 1–33. New York: Columbia University Press. Pennell, J. 2006. “Restorative Practices and Child Welfare: Toward an Inclusive Civil Society.” Journal of Social Issues 62 (2): 259–279. Pennell, J., and G. Burford. 1995. Family Group Decision Making Project: Implementation report, Volume I. St. Johns, Newfoundland: Memorial University of Newfoundland. Promoting Alternative Thinking Strategies (PATHS) (1998): Blueprints for Violence Prevention Model Program, Retrieved from http://www. colorado. edu/cspv/blueprints/model /programs/PATHS. Pennell, J., and G. Burford. 2000. “Family Group Decision Making: Protecting Children and Women.” Child Welfare 79 (2): 131–158. Pennell, J., G. Burford, M. Connolly, and K. Morris. 2011. “Taking Child and Family Rights Seriously: Family Engagement and Its Evidence in Child Welfare.” Child Welfare 90: 9–16. Perlman, H. H. 1979. Relationship: The Heart of Helping People. Chicago: University of Chicago Press. Perry, B. D. 2009. “Examining Child Maltreatment Through a Neurodevelopmental Lens: Clinical Applications of the Neurosequential Model of Therapeutics.” Journal of Loss and Trauma 14 (4): 240–255. doi: 10.1080/15325020903004350. Petr, C. G. 1998. Social Work with Children and Their Families: Pragmatic Foundations. New York: Oxford University Press. Pipkin, S., E. M. Sterrett, B. Antle, and D. N. Christensen. 2013. “Washington State’s Adoption of a Child Welfare Practice Model: An Illustration of the Getting to Outcomes Implementation Framework.” Children and Youth Ser vices Review 35 (12): 1923–1932. doi: 10.1016/j.childyouth.2013.09.017.

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Practice Applications with Involuntary Problems and Settings Platt, D. 2012. “Understanding Parental Engagement with Child Welfare Ser vices: An Integrated Model.” Child and Family Social Work 17: 138–148. Rapp, C. A., D. Saleebey, and W. P. Sullivan. 2005. “The Future of Strengths-Based Social Work.” Advances in Social Work 6: 79–90. Reich, J. A. 2005. Fixing Families: Parents, Power, and the Child Welfare System. New York: Routledge. Rooney, R. 2009. Strategies for Work with Involuntary Clients. 2nd ed. New York: Columbia University Press. Roose, R., G. Roets, S. Van Houte, W. Vandenhole, and D. Reynaer. 2013. “From Parental Engagement to the Engagement of Social Work Ser vices: Discussing Reductionistic and Democratic Forms of Partnership with Families.” Child and Family Social Work 18: 449–457. Rothe, M. I., S. Nelson-Dusek, and M. Skrypek. 2013. Innovations in Child Protection Services in Minnesota: Research Chronicle of Carver and Olmsted Counties. St. Paul, MN: Wilder Research. Rowan, T., and B. O’Hanlon. 1999. Solution- Oriented Therapy for Chronic and Severe Mental Illness. New York: John Wiley. Saleebey, D. 1995. The Strengths Based Perspective in Social Work Practice: Extension and Cautions. Social Work 41: 296–305. Saleeby, D. 1996. “The Strengths Perspective in Social Work Practice: Extensions and Cautions.” Social Work 41 (3): 296–305. Schreiber, J. C., T. Fuller, and M. S. Paceley. 2013. “Engagement in Child Protective Ser vices: Parent Perceptions of Worker Skills.” Children and Youth Services Review 35: 707–715. Selekman, M. 1999. “The Solution-Oriented Parenting Group Revisited.” Journal of Systemic Therapies 18: 5–23. Shemmings, D., Y. Shemmings, and A. Cook. 2012. “Gaining the Trust of ‘Highly Resistant’ Families: Insights from Attachment Theory and Research.” Child and Family Social Work 17: 130–137. Skrypek, M., M. Idzelis, and P. J. Pecora. 2012. Signs of Safety in Minnesota: Parent Perceptions of a Signs of Safety Child Protection Experience. St. Paul, MN: Wilder Research. Smith, B. D. 2003. “How Parental Drug Use and Drug Treatment Compliance Relate to Family Reunification.” Child Welfare 82: 335–365. Smith, B. D. 2008. “Child Welfare Ser vice Plan Compliance: Perceptions of Parents and Caseworkers.” Families in Society 89: 521–532. Snyder, E. H., C. N. Lawrence, T. N. Weatherholt, and P. Nagy. 2012. “The Benefits of Motivational Interviewing and Coaching for Improving the Practice of Comprehensive Family Assessments in Child Welfare.” Child Welfare 91: 9–36. Staff, I., and E. Fein. 1994. “Inside the Black Box: An Exploration of Ser vice Delivery in a Family Reunification Program.” Child Welfare 73: 195–214. Stalker, C. A., J. E. Levene, and N. F. Cody. 1999. “Solution-Focused Brief Therapy— One Model Fits All?” Families in Society: The Journal of Contemporary Human Services 80 (5): 468–477. Staudt, M. 2007. “Treatment Engagement with Caregivers of At-Risk Children: Gaps in Research and Conceptualization.” Journal of Child and Family Studies 16: 183–196. Substance Abuse and Mental Health Ser vices Administration. 2014. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14–4884. Rockville, MD: SAMHSA. Sykes, J. 2011. “Negotiating Stigma: Understanding Mothers’ Responses to Accusations of Child Neglect.” Children and Youth Services Review 33: 448–456.

Work with Involuntary Clients in Child Welfare Settings Thomas, M., D. Chenot, and B. Reifel. 2005. “A Resilience-Based Model of Reunification and Reentry: Implications for Out-of-Home Care Ser vices.” Families in Society 86: 235–243. Todd, T. 2000. “An Essay for Practitioners— Solution Focused Strategic Parenting of Challenging Teens: A Class for Parents.” Family Relations 49 (2): 165–168. Turnell, A. 2007. Enacting the Interpretive Turn: Narrative Means Toward Transformational Practice in Child Protection Social Work.” PhD Thesis, Curtin University, Perth, Australia. Turnell, A. 2012. Signs of Safety. Briefing paper V2.3. Perth, AU: Perth Resolutions Consultancy. www.signsofsafety.net/products-page. Turnell, A., and S. Edwards. 1997. “Aspiring to Partnership. The Signs of Safety Approach to Child Protection.” Child Abuse Review 6 (3): 179–190. Turnell, A., and S. Edwards. 1999. Signs of Safety: A Solution and Safety Oriented Approach to Child Protection Casework. New York: W. W. Norton. Turney, D. 2012. “A Relationship-Based Approach to Engaging Involuntary Clients: The Contribution of Recognition Theory.” Child and Family Social Work 17: 149–159. Vance, J., and P. Elofson. 1999. Family Group Conferences: Implementation with Native American Families. Seattle, WA: Northwest Institute for Children and Families and Division of Children and Family Ser vices. Waites, C., M. J. Macgowan, J. Pennell, I. Carlton-LaNey, and M. Weil. 2004. “Increasing the Cultural Responsiveness of Family Group Conferencing.” Social Work 49 (2): 291–300. Walton, E., J. Roby, A. Frandsen, and R. Davidson. 2004. “Strengthening At-Risk Families by Involving the Extended Family.” Journal of Family Social Work 7 (1): 1–21. Walton, E., P. Sandau-Beckler, and M. Mannes, eds. 2001. Balancing Family- Centered Services and Child Well-Being. New York: Columbia University Press. Wells, M., A. Vanyukevych, and S. Levesque. 2015. “Engaging Parents: Assessing Child Welfare Agency Onsite Review Instrument Outcomes.” Families in Society 96: 211–219. Westbrock, S. 2006. Utilizing the Signs of Safety Framework to Create Effective Relationships with Child Protection Service Recipients. St. Paul, MN: University of St. Thomas, MSW Clinical Research. Wheeler, J., and V. Hogg. 2011. “Signs of Safety and the Child Protection Movement.” In Solution-Focused Brief Therapy: A Handbook of Evidence-Based Practice, eds., C. Franklin, T. Trepper, E. McCollum W. Gingerich. New York: Oxford University Press. Whittaker, K.A., P. Cox, N. Thomas, and K. Cocker. 2014. “A Qualitative Study of Parents’ Experiences Using Family Support Ser vices: Applying the Concept of Surface and Depth.” Health and Social Care in the Community 22: 479–487. Yatchmenoff, D. 2005. “Mea suring Client Engagement from the Client’s Perspective in Nonvoluntary Child Protective Ser vices.” Research on Social Work Practice 15: 84–96. Yoo, J., D. Brooks, and R. Patti. 2007. “Orga nizational Constructs as Predictors of Effectiveness in Child Welfare Interventions.” Child Welfare 86: 53–78.

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Chapter 20

Work with Involuntary Clients in Corrections

Chris Trotter

Professionals work with involuntary clients in corrections in a variety of settings. Professional workers employed by government departments who supervise offenders in the community are generally known as probation officers, parole officers, or community corrections officers. This chapter uses the term “probation officer” to describe them. Probation officers have a role in ensuring that the conditions of court orders are carried out and in helping those under supervision to stop offending. Probation officers may also work with courts undertaking assessments and providing advice regarding sentencing and treatment options. Other professionals, often employed by nongovernmental organizations, work with offenders in the community and have more specialized roles. They may be specialists, for example, in drug and alcohol treatment, in psychiatric or psychological treatment, in anger management, in dealing with domestic violence, in housing or emergency accommodation, in family support, or in financial counseling. In some cases the offenders who see these professionals may be on court orders that require them to attend appointments. In other cases the offenders may be referred by a probation officer for specialist treatment or assistance. Some offenders may seek out the treatment on the advice of a lawyer or another professional or they may seek assistance on a purely voluntary basis. Professionals also work in the field of corrections in residential settings. Prison social workers and prison psychologists may offer individual counseling to adults or juveniles in custody. They may also be involved with prisoners’

Work with Involuntary Clients in Corrections families. They may offer group counseling in a range of areas, such as substance abuse or anger management. Professionals working in halfway houses and in residential units also work with offenders to help them reestablish themselves in the community.

Involuntary Clients in Corrections For the most part, clients in the corrections system are involuntary. Clients on the whole attend interviews with a probation officer because they are required to do so by a court order. They go to anger management groups or substance abuse treatment because they are directed to do so, either by a court order or someone in authority such as a probation or parole officer. Involuntary clients can be described in terms of a continuum (Trotter 2015). On one end of the continuum the clients (or recipients of welfare or legal services) can be described as involuntary because they have not chosen to receive the services they are being given. In fact, the clients may be actively opposed to receiving the ser vice. They may believe that it is unnecessary and intrusive. The clients accept the ser vice offered only because of a court order or the threat of some other legal sanction. In some cases, however, clients who are on court orders are not entirely involuntary. For example, a dependent client who visits his probation officer without an appointment on a daily basis cannot be described as purely involuntary. What of the client who uses the problem-solving skills of a probation officer to work through problems? What of the depressed prisoner who asks for assistance from the prison psychologist or social worker? Most clients in the corrections system are involuntary inasmuch as they are required to attend interviews. For the most part, however, client worker interviews and interactions involve both voluntary and involuntary components. One way of looking at the involuntary/voluntary issue in corrections is to see it as having two elements. The client is involuntary in terms of having to comply with the condition of a court order, for example, attend interviews or undertake a prison sentence. The client then has a choice, however, to use or not use the helping ser vices that are offered by the professional worker.

Who Are Clients in Corrections? In talking about clients in corrections I am referring to adults, young people, and children who have been found guilty of a criminal offense and have been placed on a court order that involves some sort of supervision or intervention by a professional ser vice provider in the criminal justice system. The notion of “client” assumes that there is some sort of supervisory or treatment

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Practice Applications with Involuntary Problems and Settings relationship. This could be offered by a probation or parole officer or one of the many specialist treatment workers I have mentioned. It could also be offered by a youth justice worker in a residential setting. The term “client” would not be used, however, to describe the relationship between a police officer and an offender or a prison officer and a prisoner unless that prison officer had a designated treatment or casework role. In this chapter I limit my discussion to situations in which there is a worker and a client in some sort of a helping as well as supervisory or law enforcement relationship. Effectiveness of Work with Involuntary Clients in Corrections In the 1960s and 1970s practitioners and academics in the field of corrections often accepted the “nothing works” view in relation to interventions in corrections. An extensive literature review by Robert Martinson and his colleagues (1974) supported the view that casework and other interventions that aim to rehabilitate offenders seem to have little impact in terms of reducing reoffending rates. This view was supported by literature reviews about casework in general in the 1970s (e.g., Fischer 1973). During the 1980s and 1990s the “nothing works” view was increasingly challenged. It was argued that rather than having no impact, corrections interventions in fact does have an effect, but it can be either positive or negative. Some approaches or intervention methods lead to reductions in offending and some lead to increases in offending. More recently it has been argued that the more effective interventions can reduce reoffending by as much as 80 percent, with the average effective interventions resulting in 40 or 50  percent reductions in offending (Gendreau, Cullen, and Bonta 1998; Trotter 2013b). Since the early 1990s more and more publications have offered literature reviews and meta- analyses of the “what works” research. These reviews have argued on the basis of the research that corrections interventions can be successful in reducing reoffending (e.g., Andrews et al. 1990; Izzo and Ross 1990; McIvor 1990; McGuire 1995; Dowden and Andrews 1999; Hopkinson and Rex 2003; McNeill 2003; Wing Hong Chui 2003; Andrews and Bonta 2010; Trotter 2013b; Raynor, Ugwedike, and Vanstone 2014). The burgeoning “what works” literature has been accompanied by an increasing willingness in many places, in both community and residential corrections settings, to embrace rehabilitation alongside a law and order and punishment agenda. Correctional systems in Western countries seem to be increasingly punitive with rising numbers in incarceration, yet at the same time “what works” conferences and rehabilitation programs are increasingly part of the corrections landscape. What do the traditional literature reviews and the meta-analyses tell us about what works? In discussing this I focus primarily on what works in the one-to-one supervision of offenders in community settings. The principles

Work with Involuntary Clients in Corrections apply generally, however, to institutional work and to work with groups of offenders.

Pro-social Modeling and Reinforcement I have conducted two studies in corrections, one with juvenile offenders and another with adult offenders, each of which found that probation officers and community corrections officers who scored high on the California Personality Inventory (CPI) Socialization Scale had offenders with lower reoffending rates compared than those who scored low on the inventory (Trotter 1990, 1993). The socialization scale measures the extent to which people have prosocial or pro-criminal attitudes. My studies suggested that the more pro-social officers were more inclined than the less pro-social officers to model pro-social behaviors, to focus on the pro-social behaviors of their clients, and to appropriately challenge the pro-criminal comments of their clients. These practices were directly related to lower offending rates. Similar outcomes were found in a Canadian study in the 1970s, although that study suggested that it was also important for the probation officer to have high levels of empathy (Andrews et al. 1979). Pro-social modeling and reinforcement has been shown to be effective in a number of other studies and it is included as one of the key components of what works in most reviews (e.g., Gendreau, Cullen, and Bonta 1998; Andrews and Bonta 2010; McNeill 2003; Raynor 2003; Trotter 2013a). One illustration of the power of simple modeling processes is seen in a study I completed in child protection (Trotter 2004). When child protection clients indicated that their workers returned their phone calls, kept their appointments, and did the things they said they would do, the outcomes for the clients were much better than when the clients believed that their workers did not do these things. Client satisfaction was greater, worker estimates of client progress were greater, and cases were closed earlier. The results could not be explained by client risk levels or other factors. It seems that the principles of pro-social modeling may be important not only with corrections clients but with involuntary clients in general.

Problem Solving Effective interventions in corrections address the issues that have led offenders to become offenders. The literature reviews and meta-analyses often refer to the concept of criminogenic needs. Criminogenic needs are needs or problems that are related to offending but that it is possible to change. Obviously, age, gender, and prior criminal history relate to offending. They cannot, however, be changed. On the other hand, employment, family relationships, drug use,

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Practice Applications with Involuntary Problems and Settings peer group associations, housing, finances, and pro-criminal attitudes, may all relate to offending and can be changed. These are criminogenic needs. Gendreau, Cullen, and Bonta (1998) argue that criminogenic needs do not include intrapsychic issues such as anxiety, self-esteem, or depression, factors that cannot easily explain offending behavior. There seems to be little doubt that effective practice in work with offenders involves addressing the clients’ offense-related problems or needs. My research suggests that the problem-solving process will be more successful in reducing offending if the workers and the clients reach agreement on the problems to be addressed and what is hoped to be achieved (Trotter 1996, 2013a). The general counseling literature is replete with research studies that point to the importance of working with the client’s view of their problems (see, e.g., Hepworth et al. 2016 for further details on this issue). It may be perfectly clear to the worker that a par ticu lar young male client is persistently offending because of rejection by his family, because of drug use, or because of homelessness. However, until the client acknowledges that these are problems for him, it is very difficult to work through the issues. Effective work in corrections involves a collaborative approach that helps the client to acknowledge his or her offense-related problems. It is also important in work with offenders to canvass a range of potential offense-related problems. Andrews and Bonta (2010) found on the basis of their meta-analysis that greater reductions in reoffense rates occurred when as many as six problems were addressed in the intervention. I have argued elsewhere that holistic approaches work best with involuntary clients (Trotter 2015), and work in corrections is no exception to this.

Role Clarification Work with offenders involves what Rooney (1992) and Jones and Alcabes (1993) refer to as client socialization, or what I have referred to as role clarification (Trotter 2015), in other words, helping the client to accept that the worker can help with the client’s problems even though the worker has a social control role. This involves exploring the client’s expectations, helping the client to understand what is negotiable and what is not, the limits of confidentiality, and the nature of the worker’s authority. The stage is set for effective work once the client begins to accept that the worker can help and once the worker and client begin to reach agreement on the goals of the intervention.

A Balanced Approach: Social Control and Problem Solving The research consistently suggests that interventions that focus exclusively on punishment or scare tactics lead to increased offending (e.g., Gendreau,

Work with Involuntary Clients in Corrections Cullen, and Bonta 1998; Andrews and Bona 2010). Similarly, interventions that focus exclusively on developing insight or that focus exclusively on the client-worker relationship are unlikely to be helpful (Trotter 1990, 1996; Gendreau, Cullen, and Bonta 2010). This was also evident in my child protection study: when clients described their workers as both helpers and investigators the outcomes were substantially better than when they saw them as either a helper or an investigator (Trotter 2004). Again it seems that the principles of effective practice that apply to offenders may apply to work with other groups of involuntary clients. Focus on High Risk Much of the literature talks about the importance of focusing on high-risk offenders rather than low-risk offenders. It is argued that there is a relatively large group of offenders that is unlikely to reoffend and unlikely to benefit from intensive intervention, whereas there is a smaller group of medium- to high-risk offenders that more likely to reoffend and more likely to benefit from supervision (see, e.g., Gendreau, Cullen, and Bonta 1998). For this reason it is important to assess risk levels and to focus resources on medium- to high-risk offenders. The issue of risk assessment is complex and has its critics (see Trotter, McIvor, and McNeill 2016 for a discussion about the issues). The primary criticism is that risk levels are often used as part of a sentencing process and as part of a post-sentencing method to provide for varying levels of supervision. This can lead to offenders who are already disadvantaged getting harsher penalties. An offender who is homeless, without family support, with a drug or alcohol addiction, and without employment might receive a harsher sentence or intervention than someone else who does not have these problems but has committed a similar offense. Nevertheless it does seem to make sense to concentrate welfare or human ser vice resources on higher-risk individuals who are likely to reoffend. To this end a number of risk assessment profiles have been developed for use by corrections ser vices. One of the most popular ones is the Level of Supervision Inventory, Revised (LSIR), developed over many years by Don Andrews and James Bonta (2010). It is in use in probation and community corrections services in many English-speaking countries, including Canada, the United States, Australia, and the United Kingdom. In addition to providing a risk assessment, the LSIR helps to identify criminogenic needs that can inform the problem-solving process. Programs A meta-analysis by Don Andrews and his colleagues suggests that structured learning programs may have the most potential for reducing reoffending

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Practice Applications with Involuntary Problems and Settings (Andrews and Bonta, 2010). Community corrections ser vices around the world offer group and individual programs based on the “what works” principles. These programs “put together a series of planned and sequential learning opportunities into a cumulative sequence covering an appropriate curriculum of skills and allowing plenty of opportunity to reinforce learning through structured practice” (Raynor 2003:79). The effectiveness of these programs in practice has however been questioned (Heseltine, Day, and Sarre 2009) primarily due to implementation issues and deviation from “what works” principles. Other Factors This is not an exhaustive list of “what works” principles. The reviews refer to a number of other practices. For example, “multimodal” approaches, which rely on a range of intervention methods, are likely to be more effective than those that rely on only one method (Gendreau, Cullen, and Bonta 1998). This is supported by my study on probation, which found that reoffense rates among the clients of probation officers who used a range of skills, including modeling and reinforcing pro-social behaviors, role clarification, and problem solving were lower than in situations in which the workers made use of only one or two of the skills (Trotter 1996). There is also some support for working with families of young offenders (see Trotter 2013b for a review of the evidence) for intervention methods that are implemented as they were intended and for matching workers and clients according to learning style and personality (Gendreau, Cullen, and Bonta 1998; Wing Hong Chui 2003). Relationship skills are also referred to in some of the reviews (e.g., Gendreau, Cullen, and Bonta 1998). I have not identified this as a key skill or a key factor in effective practice because the evidence in relation to this area is somewhat equivocal. Studies I have undertaken in corrections with both juveniles and adults have found that probation officer empathy levels, for example, do not relate to reoffending rates (Trotter 1990, 1996). Don Andrews and his colleagues also found that high-empathy workers did better with their clients only if they made use of the other skills (Andrews et al. 1979). On the other hand, my study indicated that when workers made judgmental comments about their clients (e.g., lazy, no hoper) those clients were more likely to reoffend even after taking into account client risk levels. Certainly workers in corrections need to be able to listen to their clients and to model appropriate behavior.

Work with Involuntary Clients in Corrections

An Application of Best Practice The following two case studies present alternative ways of using a problemsolving approach. The first interview focuses on what the worker believes is the primary criminogenic need: the client’s drug use. The second interview focuses on working with the client’s view of the problem but working toward helping the client to accept that her drug use is an issue that needs to be addressed. In the second interview the worker demonstrates the skills of role clarification, pro-social modeling and reinforcement, and problem solving. The transcript is taken from a role-played video tape on working with involuntary clients produced at Monash University. In the first interview the worker is drawing on information about the client’s problems, which was written in the file at the time of the initial assessment undertaken for the court. The second interview reflects the way he usually works. Problem-Solving Interview 1* probation officer: Jennifer, thank you for coming back. You’ve been to correctional ser vices twice now, the first time when you came in they went through a number of forms, we explained to you what you had to, and when you have to come. When you saw me last time we talked about what my role will be and we started to look at implementing some of the conditions on your order. What I want to do today is speak to you about the problems you’ve got in your life and one of the things that you really need to address as a matter of urgency is the drug use because that will . . . jennifer: Yeah, but I mean I don’t think I’ve got a drug problem, I told you that when I first met you so, I mean I don’t think it’s necessary to go into that. probation officer: You committed offenses and you committed offenses in the past and they’re all drug related so I think you’ve got a problem that you need to deal with. jennifer: Well, why do you think they’re drug related? I mean, who told you that? probation officer: Well the information that was provided that you gave to the court was that it was drug related and we need to deal with that fairly quickly. So, what I want to do today is look at that and start dealing with that in terms of getting the counseling arranged and getting the testing done and so on. Some of the other things that relate to your offending, that * I wish to acknowledge the work of Michael Scheel who plays the probation officer and Anna Tasevska who plays the role of client in the interviews presented in this chapter. The script for the role play was developed by them.

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Practice Applications with Involuntary Problems and Settings you’ve got problems with are the accommodation difficulties that you mentioned. jennifer: Yeah, that’s right, yeah. probation officer: And the relationship with your boyfriend that you’ve had some difficulties with. jennifer: Yeah. probation officer: The other thing that was causing you difficulties was the relationship with your parents and you mentioned that you didn’t have enough money to pay rent. jennifer: Yeah, well I don’t because I don’t have a job. probation officer: Yeah and employment’s another one that we need to look at. So, what I want to do today is, maybe I’ll just write those few things down so that we don’t miss any of them and we’ll talk about it in order of priority. Remember last time we sort of made reference to the problem survey where we look at all of the things that are really causing difficulties in your life. jennifer: Yeah. probation officer: And what I want to do today is talk to you about how we’re going to do that and I’ve mentioned already that one of the more important ones is the drug use so I expect you to go to drug treatment. jennifer: Yeah, I know you keep bringing it up. It seems to me you’re calling me a drug user and you don’t even know me. So, to me personally I think that finding a job is more important to me then what you’re saying. probation officer: Yeah and I think that it’s great that accommodation and finding a job is important for you but while you’re using drugs you’re going to get in more difficulties and if you get into more difficulties . . . jennifer: Well you don’t know I’m using drugs. How do you know that? probation officer: I guess from the information that’s on file at the moment and the order that you’ve got requires you to do it so you just have to do it. And the testing will then identify whether you’re using or not and give me an indication anyhow. So once you’ve done a few tests we can see whether you’re still using or not. jennifer: What kinds of drugs do the tests show? probation officer: They’ll show up any drugs that you may be using. Prescribed medications, it might be cannabis, it can be alcohol, it can be heroin, speed, any of the drugs that are available out there at the moment. So, we’ll need to deal with that as a matter of priority because I don’t want you to get in further trouble with the law. And the other thing is the next one we’re going to look at is the money side of it because you mentioned earlier that you haven’t got enough money to pay for your rent. jennifer: Well that’s right. I don’t. probation officer: Yeah. So you mentioned you need to go to community work so you may have difficulties because you’ve got no money.

Work with Involuntary Clients in Corrections jennifer: Yeah, which will make it hard for me to complete this order anyway. probation officer: What do you think you can do about that? jennifer: About what? probation officer: With the money side of it. jennifer: Well I don’t know. Hopefully find a job. probation officer: Yeah, how would you go about doing that? jennifer: Well, I don’t know. I don’t have much skills. probation officer: Have you looked for jobs before? jennifer: I’ve had a few jobs. Yeah. I haven’t worked for a long time though. probation officer: Can you tell me how you went about doing that last time? jennifer: How to find a job? probation officer: Yeah. jennifer: Usually basically just people that I knew who already work there got me the job. probation officer: Yeah. And I understand you have to go to centerlink on a regular basis as well and part of that is you need to look for work. jennifer: Yeah. probation officer: So I expect you to continue that and keep looking for work that way. You might want to look through the paper as well. We’ve got the local paper at the front in the interview room. You might want to grab that and have a look at the employment section in that. jennifer: There’s not many jobs there though. probation officer: But if you don’t go out and look though you won’t find any. jennifer: I don’t think they’ll hire me anyway. probation officer: Why’s that? jennifer: I don’t have any skills. I’m on this order so they’re probably not going to want to hire a criminal even though I don’t consider myself a criminal anyway. I mean I’ve never harmed anyone before in my life and I don’t intend to. probation officer: It would have caused some harm doing the burglaries because there would have been some victims in the process. You went into somebody else’s house. The following interview represents a more collaborative approach to the problem-solving process. The probation officer is talking to the same client. Problem-Solving Interview 2 probation officer: Jennifer, thank you for coming in today. You actually made it on time. We appreciate that.

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Practice Applications with Involuntary Problems and Settings jennifer: I tried to, yeah. probation officer: That’s good to see Jennifer. Just a recap from the last two sessions, the first time you came to correctional ser vices was when I took you through the induction process, where you filled in a number of forms and got some clarification on what you need to do. And then you came back and saw me three days ago and we talked a bit about what my role is in terms of supervising you on your order and we talked about the two aspects of it. One part was that I supervised your order and made sure that you do the things you’re expected to do and the other part that we talked about was that I’m also there to help you identify what issues are in your life and how you want to work through those. Do you remember that? jennifer: Yeah. probation officer: OK then. Jennifer what do you see are some of the issues that are impacting on your life at the moment? jennifer: I guess a lot has changed in the last couple of months. My boyfriend’s been put in jail. I think he’ll be there for the next six or seven years. probation officer: How do you feel about that? jennifer: Well, quite upset about that actually. I mean I don’t think he deserves such a harsh penalty for what he did. probation officer: It was a serious offense, wasn’t it? jennifer: Well, I mean he shot the people whose house we burgled but he didn’t kill them. I mean other people have murdered people and they’ve gone to jail for as long as him. I don’t think that’s the same thing. probation officer: Still it’s a very serious offense, isn’t it? jennifer: I don’t think he meant to, you know, I don’t think he wanted to kill them. probation officer: That’s probably reflected in the sentence as well. Because had the person died it would have been a lot more serious. jennifer: Yeah, well it’s just made it hard because I’m on this order and they won’t let me see him at all and we’ve been living with these friends of his and ever since he’s gone to jail I just don’t feel comfortable living there any more but I don’t really have much of a chance to leave because I don’t have any money. probation officer: So Jennifer, one of the things you’ve mentioned is not being able to get in touch with your boyfriend at the moment. Is that OK if I write that down? jennifer: Yeah. probation officer: Just so that we don’t lose them all. We’ll deal with all of the things that are worrying you. We’ll write it down and identify what all of the issues are and so we don’t forget any of them. OK what are some of the other things? jennifer: Well, as I was saying I don’t really want to live where I’m living right now but I don’t have any money to find another place to live because

Work with Involuntary Clients in Corrections it’s for free but ever since my boyfriend went to jail I just feel like I’m not wanted any more because they’re actually friends with my boyfriend. I just met them through him so I wouldn’t mind finding somewhere else to live. probation officer: Where have you lived in the past Jennifer? jennifer: Well, I left home when I was about fourteen probation officer: OK. That’s about four years ago now. jennifer: Yeah and I went to live with a friend of mine and her family for a couple of months after that and then after that I sort of had an argument with her and I had to leave there and I lived on the streets for a while and then I met my boyfriend and he was living with these people and I moved in with them and that’s where I’ve been ever since. probation officer: And you need to look at some new place to live now, do you? jennifer: Yeah, well I’d like to. probation officer: So, we’ll put that accommodation down as an issue that we might need to work on? jennifer: Yeah. probation officer: OK. What are some of the other things that are worrying you at the moment? jennifer: Well I don’t have a job so I guess that’s the only way I can really get some money to find a place to live. probation officer: Have you been employed in the past Jennifer? jennifer: I have but I haven’t had really good jobs they’ve just been, you know, working in a milkbar and waitressing and stuff like that. probation officer: Yeah, but you have been able to get a number of jobs? jennifer: Yeah, but they’ve never really lasted very long, only a couple of months. probation officer: Is there any reason for that? jennifer: Well, the first job when I was working in the milkbar, they thought that I was giving away free food and stuff like that and the second job as a waitress, they thought that I was stealing everyone else’s tips which is not true but they fired me for that. probation officer: So, we can say that at this point we’ve got three issues. The first one is in relation to your boyfriend, the other one was the accommodation and then you need to look at employment, finding a job possibly—Anything else that’s affecting you at the moment Jennifer? jennifer: No, not really, no. probation officer: In relation to the court order, there’s some suggestions about drug treatment and the offenses seem to have some relationship to drug use. What do you think about that? jennifer: Well, when we were arrested apparently they found that I was under the influence of alcohol and drugs. probation officer: What sort of drugs?

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Practice Applications with Involuntary Problems and Settings jennifer: Heroin. probation officer: OK. And the offenses were they committed to purchase more drugs? That your boyfriend was involved in? jennifer: Well, yeah. And to buy clothes and food.

Key Issues in Working with Involuntary Clients in Corrections Perhaps the biggest issue for direct practice workers in corrections relates to the worldwide trend toward tougher penalties. Prison populations are increasing all over the world. At the same time more and more people are being placed on community-based corrections orders. This has led to increasing caseloads and increasing numbers of relatively low-risk clients finding their way into the criminal justice system. This in turn has fueled the development of risk assessment as a method of dealing with the increasing numbers and as a method of rationalizing scarce resources. Yet at the same time, as I mentioned earlier, there appears to be increasing acceptance at least in some places that treatment and rehabilitation programs are important. The public may want tougher penalties but they also seem to want something done to prevent offenders from reoffending. There is also a trend in many parts of the world toward case management. Therapeutic work that was once done by probation and parole officers is now contracted out to specialist workers. Individual offenders might be involved with numerous treatment agencies and workers. For example, they might be required as part of a court order to attend for anger management, for drug treatment, for psychiatric treatment, and for programs such as reasoning and rehabilitation. In addition to this, they may be referred to other agencies for housing, for family support, for literacy, or for assistance with employment. In some instances even risk assessment is contracted out. This process can lead probation and parole officer to see themselves as simply referral agents and agents of social control. It provides limited opportunity for the holistic and balanced approach to social control and helping that the research suggests is so important to effective outcomes. Similarly it is difficult for the specialist worker who has a treatment rather than a social control role to maintain a holistic and balanced approach. Holistic and balanced interventions work best. Systems that facilitate this also are likely to work best. Unfortunately the organizational systems in many places mitigate against, rather than for, holistic and balanced approaches. In the meantime those who work within these systems will do better if they are aware of the “what works” principles and if they try to adopt a balanced approach to the work when they can.

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Contributions of Work with Involuntary Clients in Corrections to Knowledge About Involuntary Clients There are similarities in the issues that face those who work with involuntary clients, whether in child protection, mental health, or substance abuse. The growth of risk assessment and the development of case management systems, for example, are not limited to corrections settings. Child protection, for example, has seen burgeoning numbers of referrals in the last ten years, and, like corrections, is increasingly concerned with risk assessment, often, it is argued, at the expense of treatment or helping interventions (Krane and Davies 2000; Parton and O’Byrne 2000; Trotter 2015). Case management is criticized in child protection circles for the same reasons it is criticized in corrections (Hood 1997; Turner 2010). Interest in evidence-based practice and concern about outcomes is common across work with a range of involuntary clients. It is perhaps an area in which corrections has led the way. Outcome measures are complex in child protection or mental health or work in schools. In corrections, however, the recidivism outcome measures are more straightforward. As I mentioned earlier, the technique of meta-analysis has provided information about which particular approaches or intervention methods have the greatest impact on recidivism (e.g., Andrews and Bonta 2010). Recidivism research has shown, for example, that pro-social modeling and reinforcement is an important factor in corrections interventions. Pro-social modeling and reinforcement, however, has had little application in research with other groups of involuntary clients other than my work in child protection (Trotter 2004). I referred earlier to simple modeling practices by workers having a substantial influence on child protection outcomes. It could also be that structured learning programs that have proved successful in corrections could be adopted with similar success in work with other groups of involuntary clients. Another area in which corrections may be leading the way in research with involuntary clients relates to the concept of “program integrity.” In other words, are programs or intervention methods or risk assessment profiles being implemented as they were intended or is there a drift away from the theory or model on which they are based? It is argued that program integrity is an important factor in achieving positive outcomes (Gendreau, Cullen, and Bonta 1998).

Discussion Questions 1. To what extent do the effective corrections practice principles apply to work with involuntary clients in other fields?

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Practice Applications with Involuntary Problems and Settings 2. Look again at the two case study scenarios and discuss which approach is likely to lead to the better outcomes. Discuss the reasons for this. 3. Can you identify examples of role clarification or client socialization in the two scenarios? 4. Can you identify examples of pro-social modeling or reinforcement in the scenarios? 5. What is the difference between the way the problem survey or problem assessment is undertaken in the two scenarios? References Andrews, D. A., and J. Bonta. 2010. The Psychology of Criminal Conduct. Cincinnati, OH: Anderson. Andrews, D. A., J. J. Keissling, R. J. Russell, and B. A. Grant. 1979. Volunteers and the One-toOne Supervision of Adult Probationers. Toronto, ON: Ministry of Correctional Ser vices. Andrews, D. A., I. Zinger, R. Hoge, J. Bonta, P. Gendreau, and F. Cullen. 1990. “Does Correctional Treatment Work? A Clinically Relevant and Psychologically Informed Meta-Analysis.” Criminology 28 (3): 369–401. Dowden, C., and D. A. Andrews. 1999. “What Works for Female Offenders: A Meta-Analytic Review.” NCCD News 45 (4): 438-452. Fischer, J. 1973. “Is Casework Effective? A Review.” Social Work 19 (1): 5–20. Gendreau, P., F. Cullen, and J. Bonta. 1998. “Intensive Rehabilitation Supervision: The Next Generation in Community Corrections.” In Community Corrections Probation Parole and Intermediate Sanctions, ed. J. Petersilia. New York: Oxford University Press. Hepworth, D. H., Rooney, R. H., Rooney, G. D., & Strom- Gottfried, K. 2016. Empowerment Series: Direct Social Work Practice: Theory and Skills. Nelson Education. Heseltine, K., A. Day, and R. Sarre. 2009. Prison Based Correctional Offender Rehabilitation Programs. Canberra: Australian Institute of Criminology. Hood, S. 1997. “The Purchaser/Provider Separation in Child and Family Social Work: Implications for Ser vice Delivery and for the Role of The Social Worker.” Child and Family Social Work 2: 25–35. Hopkinson, J., and S. Rex. 2003. “Essential Skills in Working with Offenders.” In Moving Probation Forward: Evidence Argument and Practice, eds. Wing Hou Chui and M. Nellis. Essex, UK: Pearson Longman. Izzo, R. L., and R. R. Ross. 1990. “Meta-Analysis of Rehabilitation Programs for Juvenile Delinquents: A Brief Report.” Criminal Justice and Behavior 17 (1): 134–142. Jones, J., and A. Alcabes. 1993. Client Socialization: The Achillles’ Heel of the Helping Professions. Westport, CT: Auburn House. Krane, J., and L. Davies. 2000. “Mothering and Child Protection Practice: Rethinking Risk Assessment.” Child and Family Social Work 5 (1): 35–45. Martinson, R. 1974. “What Works? Questions and Answers About Prison Reform.” The Public Interest 35: 22–54. McGuire, J.E. 1995. What Works: Reducing Reoffending: Guidelines from Research and Practice. Hoboken, NJ: John Wiley & Sons. McIvor, G., 1990. Sanctions for Serious or Persistent Offenders: A Review of the Literature. Glasgow: Social Work Research Centre, University of Stirling.

Work with Involuntary Clients in Corrections McNeill, F. 2003. “Resistance Focused Probation Practice.” In Moving Probation Forward: Evidence Arguments and Practice, eds. Wing Hong Chui and M. Nellis, 146–162. Essex, UK: Pearson Longman. Parton, N., and P. O’Byrne. 2000. Constructive Social Work: Towards a New Practice. London: Macmillan. Raynor, P. 1978. “Compulsory Persuasion: A Problem for Correctional Social Work.” British Journal of Social Work 8 (4): 411–424. Raynor, P. 2003. “Research in Probation: From Nothing Works to ‘What Works.’ ” In Moving Probation Forward Evidence Arguments and Practice, eds. W. H. Chui and M. Nellis, 74–91. Essex, UK: Pearson Longman. Raynor, P., P. Ugwedike, and M. Vanstone. 2014. “The Impact of Skills in Probation Work: A Reconviction Study.” Criminology and Criminal Justice 14 (2): 239–239 Rooney, R. H. 1992. Strategies for Work with Involuntary Clients. New York: Columbia University Press. Trotter, C. 1990. “Probation Can Work: A Research Study Using Volunteers.” Australian Journal of Social Work 43 (2): 13–18. Trotter, C. 1993. “The Effective Supervision of Offenders.” Unpublished PhD thesis, La Trobe University, Melbourne. Trotter, C. 1996. “The Impact of Different Supervision Practices in Community Corrections.” Australian and New Zealand Journal of Criminology 29 (1): 29–46. Trotter, C. 2004. Helping Abused Children and Their Families: Towards an Evidence-Based Practice Model. Sydney: Allen Unwin. Trotter, C. 2013a. Collaborative Family Work— A Practical Model for Working with Families in the Human Services. Sydney: Allen Unwin. Trotter C. 2013b. “Reducing Recidivism through Probation Supervision—What We Know and Don’t Know from Four Decades of Research.” Federal Probation 77 (2): 9–14. Trotter, C. 2015. Working with Involuntary Clients: A Guide to Practice. 3rd ed. New York: Routledge. Trotter, C., G. McIvor, and F. McNeill. 2016. Beyond the Risk Paradigm in Criminal Justice. London: Palgrave. Turner, S. 2010. “Case Management in Corrections: Evidence Issues and Challenges.” In Offender Supervision, eds. F. McNeill, P. Raynor, and C. Trotter. Abingdon, UK: Willan. Wing Hong Chui. 2003. “What Works in Reducing Re-offending: Programs and Principles.” In Moving Probation Forward: Evidence, Arguments and Practice, eds. Wing Hong Chui and M. Nellis. Essex, UK: Pearson Longman.

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Chapter 21

Applying the Involuntary Perspective to Management and Supervision

Carol Jud and Tony Bibus

This chapter applies strategies for work with involuntary clients to social work supervision. Since supervisors often have administrative and especially middle management responsibilities, applications of the involuntary perspective to management and administration are also considered. Based on the authors’ experience and on published evidence of effectiveness in supervision, the chapter offers managers, supervisors, supervisees, and students guidelines for administrative, educational, and supportive functions in supervisory practice. Lawmakers’ reliance on mandates, sanctions, time limits, and other forms of pressure or coercion to enforce compliance has increased the proportion of involuntary clients in public social ser vice settings (Bibus 2009; Bibus, Link, and O’Neal 2005; Billings, Moore, and McDonald 2003; McGowan and Walsh, 2000; McPhee and Bronstein 2003; Pecora et al. 2000; Salus 2004). Similarly, the movement to managed care and the crisis in financing health care have led to restrictions in treatment options and length of ser vice available for practitioners and clients in both nonprofit and for-profit agencies (Kadushin and Harkness 2014; Munson 1995; Strom-Gottfried and Corcoran 1998). Mental health practitioners in a variety of settings more frequently face situations that require involuntary treatment or court-ordered interventions (Taylor and Bentley 2005). Hence, clients are often “captives” of the agency, and managers and supervisors need to act assertively to ensure that involuntary clients are treated with respect and sensitivity: “The fact that the client’s use of the agency is often compulsory means that greater provision needs to be made to protect the client than would be the case in situations in which

Applying the Involuntary Perspective to Management and Supervision the client could choose to withdraw if dissatisfied with the ser vice” (Kadushin and Harkness 2014:23). To this point, licensing regulations increasingly accent the call for enforceable standards of supervision and practice (Bibus and Boutté-Queen 2011). As leaders in their organizations, managers and supervisors play a pivotal role in monitoring whether clients who did not request help still receive effective and ethical ser vices. Since many practitioners have been trained under models of practice that presume their clients will be voluntary, supervisors and supervisees must together develop competencies in work with involuntary clients. Clients who feel forced under legal mandates or in other ways pressured to have contact with social workers are vulnerable to premature termination of ser vices or exploitation of their low-power status for the purposes of social control. Given attentive, responsive, and expert supervision, practitioners can recognize these vulnerabilities and work to transcend adversarial dynamics, to reach past clients’ initial hostility or apparent indifference, and to develop at least tentative agreements and working relationships with involuntary clients. Drawing from public social ser vice and child welfare settings, the case examples in this chapter illustrate how managers and supervisors can work to improve social work ser vices in involuntary contexts. These strategies are resources for dealing with a stressful work climate and coercive policy environment and for pursuing social work’s mission with a greater possibility of success.

Supervisory and Management Strategies for Work with Involuntary Clients Four conceptual tools are especially useful in managing and supervising in an involuntary context. Supervisors should encourage workers to: (1) plan for reactance, (2) use contracting to link clients’ concerns with agency mandates, (3) address performance difficulties, and (4) apply the legal-ethical matrix in making decisions. We begin with examples of how supervisors and managers can also use these tools in their own practice with staff. Later in the chapter, we will discuss how managers and supervisors can address involuntary dynamics by mediating with other human ser vices professionals and by working to improve organizational climate, cultural competence, and safety.

Reactance The concept of reactance highlights predictable strategies that people turn to when valued freedoms are threatened (Mirick 2012). Managers and supervisors

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Practice Applications with Involuntary Problems and Settings should keep reactance in mind in their work with supervisees as well as with clients. For staff in public social ser vice agencies, which are often subject to tumultuous turmoil and cascading crises, one valued freedom is some remnant of personal control over the routine of record keeping. Preserving this degree of predictability when so many other demands dictated by external pressures are being made on one’s time and attention is often perceived as vital. In many social ser vice settings, though, change is a constant, and some changes challenge practitioners’ skills, philosophies, and abilities. The following example shows how understanding reactance helps predict and respond effectively to the inevitable periodic spasms of change or reorganization. In 1999, the state of Minnesota required all county agencies to adopt a new statewide social ser vice information system (SSIS). Social workers were required to enter all client contacts on the computer system. Handwritten notes were no longer allowed. In addition, tasks previously done with pen and paper were now done on the computer. One of the authors (Jud) was involved in implementing SSIS, working with both information technology staff and social workers toward a smooth transition. In this role, I encountered reactance. Some staff had never used computers except for e-mail and had no desire to learn. Others could not imagine how they could keep up with case notes if they had to put them all into the computer. They could foresee having to sit at a computer all day and having no time to visit clients. Staff responded in several ways. Some attempted to take freedom back directly. They would simply refuse to use the new system and made comments like “What are they going to do? Fire me? Well, let them!” Other workers tried to find the loophole. They would enter the minimum needed in SSIS and then do every thing else the old way. Some workers began to value the prohibited behavior more than ever. They wanted the option to write notes by hand, stating they could never compose on the computer and still see clients. A few workers responded with hostility or aggression. Many people complained about the new system, and some workers were outright hostile, as if I had made the decision that they had to use SSIS. One social worker told me he was going to unplug his computer and destroy the whole system! (Clearly his understanding of computers was rather limited.) A few workers tried to incite others to restore freedom by telling other workers: “We should all just refuse to use SSIS and see what they do. What will management do if we all refuse to use it?” Some workers dealt with their feeling of losing control by watching others attempt to restore freedom. These people enjoyed watching others complain and refuse to use

Applying the Involuntary Perspective to Management and Supervision the system or attend training, and they hoped their coworkers’ efforts would be successful. The system was introduced and now is used without question. During the entire process of learning the new system, it was important for supervisors and managers to understand that the responses social workers had were normal, and these workers should not be labeled “resistant to change” or “problem employees” because they were slow to adjust to the changes. Change is difficult for everyone, and some people just have a harder time adjusting. This characteristic does not make them “bad” social workers. The supervisor helped staff identify how the changes had the potential to ease their workload and serve clients more efficiently as well as hold the agency accountable to its mission, to which they had devoted their careers. The new information system thus became an agreeable (or at least tolerable) mandate.

Managers will also find the concept of reactance valuable when implementing organizational changes. For example, social ser vice agencies periodically move from locating all staff in one central office to distributing staff into several neighborhood offices. Even though managers, supervisors, and social workers may agree that decentralization promises improvements for client services and other outcomes congruent with the agency’s mission, managers will likely face volatile responses from staff. Many of these responses can be understood as normal and natural reactions to potential loss of valued freedoms. A few years ago, one county social ser vice department (Jud’s) began opening regional offices to provide residents with multiple ser vices in community locations. Staff who had always been housed with others who did the same kind of work were now working alongside staff who provided different types of ser vices. This change to a more holistic ser vice model allowed county residents to receive more than one type of ser vice in a single location on a single visit. In addition to the change in the model of ser vice delivery, the regional locations were different than the previous offices, in that there were no assigned workspaces. Instead social workers were assigned lockers. Managers should anticipate multiple forms of reactance to such changes. Highlighting the overall purpose of the decentralizing move and linking it to values shared across the agency (such as partnership with community residents or organizations and outreach to vulnerable populations) will be helpful in setting the stage for motivational congruence between managers, supervisors, and social workers. Identifying what is required of staff (e.g., to move!) and what is negotiable (e.g., timing of the move and perhaps choice in location), and encouraging staff to find some elements of the mandate that fit their own

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Practice Applications with Involuntary Problems and Settings goals may reduce the likelihood of extreme negative reactions. Timely communication about the upcoming changes is critical, letting staff know what will be happening, when it will be happening, and how it will have an impact on their work. Training, orientation, and support related to changes in work expectations should be provided prior to the change and throughout the change as needed. For instance, Jud’s staff went through quite an adjustment when they moved to “open work space” in which they had a locker and no assigned desk or work area. They were now able to use any desk that was available but needed to leave the space clean after they were done using it. The transition to this new way of working was facilitated by offering training in utilizing the new office equipment and using electronic methods to store documents and by having those who had already made the transition talk about what made it easier for them. Highlighting the positive effects of the change can also help staff with the adjustment (e.g., the work area is much cleaner, and staff can move if they do not want to sit by someone who is loud or distracting). Coordination with unions and employee representatives as well as community advisors will be critical as well. Managers should assume that staff members want to do a good job and secure as many resources as possible for staff to use in accomplishing job tasks. While the move is in process and as staff settle in to their new locations, positions, or working conditions, managers should frequently ask how people are doing, what adjustments need to be made, and how better to achieve the intended objectives of the organizational changes. And they should act responsively on feasible suggestions or explain if suggestions are not implementable. With the potential for reactance recognized, managers, supervisors, staff, and clients are ready to attend to other difficulties or barriers to effective and ethical practice, such as lack of clarity about goals and purpose.

Contracting Principles Clarity about the purpose of supervision and the supervisor and supervisee’s mutual understanding and commitment to this purpose are keys to successful supervision. The importance of establishing an agreement or contract for work between supervisors and supervisees informs most models of supervision, including the influential one developed by the Yale Program on Supervision: “A major premise of this model is that many supervisory relationships go awry because of the failure to develop a shared understanding about the nature of this working relationship at its inception” (Hoge et al. 2014:176; emphasis in the original). Lawrence Shulman, a leading scholar in supervision, agrees that “as in work with clients, the lack of a clear contract will frustrate efforts at almost every turn” (1993:43). Accordingly, the National Association

Applying the Involuntary Perspective to Management and Supervision of Social Work (NASW) and the Association of Social Work Boards (ASWB) include in their standards for high quality supervision that there should be a written and signed “contractual agreement among the social worker, the supervisor, and the employing agency” (2013:14). When consulting with supervisors on problematic situations involving supervisees, we recommend that they “begin again” with crafting a contracting statement of the purpose of supervision to share with their supervisees. Asking the question: “What will you and I be working on in supervision?” can also be fruitful. And in a parallel to work with involuntary clients, supervisors are thus modeling that supervisees should take a similar approach in developing a clear working contract with clients. It is important to specify what is required and what is negotiable. Focusing on clients’ goals as well as mandated ser vices is also essential; some research suggests that when attention is focused on clients’ issues in supervision, “there is a greater likelihood of better client outcomes” (O’Donoghue and Tsui 2015:626). Other supervisory questions that are empirically associated with effective ser vices include: • What do clients understand to be the purpose of your work with them? • What have you done to reach agreement with your clients about purpose? • How will you know if your clients are successful in achieving their objectives? • Do you have a contract? • What positive actions by clients have you supported or recognized? • What actions or inactions by clients have you confronted? • Do your clients believe you are helping? (Harkness and Hensley 1991; Trotter 1999:148–149) Practitioners familiar with the body of knowledge regarding power differences within involuntary transactions are less likely to ignore clients’ concerns that are not requirements or to approve unnecessarily coercive measures to resolve problems that their agency is required to address (Hasenfeld 2010). When clients express feelings of being invaded, trapped, or humiliated (Lengyel 2001; McPhee and Bronstein 2003), supervisors can guide staff to expect these normal reactions to being involuntary and avoid prematurely labeling clients as uncooperative or resistant. Faced with adversarial interactions, supervisors and supervisees who use negotiating and mediating models encourage cooperation and expand the range of choices within mandates (Center for Advanced Studies in Child Welfare 2002). Once practitioners are skilled in engaging involuntary clients and negotiating successful service agreements, their supervisors should continue to support

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Practice Applications with Involuntary Problems and Settings and assist staff in maintaining competence (NASW and ASWB 2013). Moreover, supervision includes demand for work, holding supervisees’ accountable for effective and ethical client ser vices. The strategies developed for work in involuntary transactions can be particularly useful when confronting staff when their performance falls below standards. Performance Issues There are two distinct strategies that a supervisor can choose in dealing with performance issues. Just as managers might dictate to their program staff how to solve a problem (instead of involving the program staff in designing a solution), a supervisor can tell a supervisee what the practitioner needs to do to solve a performance problem; or, instead, the supervisor can involve the supervisee in the process. As we will see in the following scenarios, the latter strategy is more likely to be successful. High quality supervision combines concrete suggestions for improving performance with respectful listening for the supervisees’ point of view (Westbrook, Ellis, and Ellett 2006). Scenario 1 supervisor: Hi Mary. I called you into my office today to discuss some concerns I have about your work. mary: Concerns? What kind of concerns? Has someone been complaining about me? supervisor: I’ve received several phone calls from clients and collaterals who say they can’t get a hold of you because your voice mail is full, and you do not return pages. I have tried to page you on numerous occasions and have not heard back. My second concern is that your paperwork is several months behind, and workers on coverage are not able to answer questions about your cases because your case notes are not up to date. Also, we have discussed you closing four cases on your caseload and they have not yet been closed. mary: I’ve been busy! I have fifteen cases and there is no way I can stay up to date with that many cases! supervisor: I’d like you to take the next five days to catch up on all of your paperwork. I want all four cases closed and on my desk by Friday. Also, you need to clear your voice mail three times a day so clients can get a hold of you. I expect you to be up-to-date by next week. OK? mary: I guess so, but I don’t know where I’m going to find the time to do any of this! I’ll do what I can.

Applying the Involuntary Perspective to Management and Supervision Scenario 2 supervisor: Hi Mary. Thanks for coming in to talk with me. You’ve seemed really overwhelmed lately, and I’m concerned. Are you feeling as overwhelmed as you look? mary: Yes! I am totally overwhelmed. I don’t know what to do! I have fifteen cases, and I’m so behind on paperwork I don’t know how I’m going to get caught up! I’m trying to see clients, but am having trouble keeping up to date with that! And every time I’m gone from my phone, the voice mail fills up. I just can’t return all the calls I’m getting! supervisor: Have you had a chance to close those four cases we talked about closing? mary: No. I’ve been spending my time dealing with crises, and haven’t had a chance. supervisor: Well, I think our first priority should be getting you caught up so you’re not feeling so overwhelmed. How does that sound to you? mary: That would be great! But how? supervisor: What do you think it would take to get caught up on your paperwork and close those four cases? I think if you could close the four cases, you’d feel a lot better since your caseload would be down to eleven. mary: If I could spend three days working only on paperwork and not have to see clients or answer the phone, I think I could get caught up. But how am I going to do that? supervisor: How about if you take off three days next week, say Monday through Wednesday, just to do paperwork. Put a message on your voice mail that you will not be available on those days. If anyone needs anything, the coverage worker can contact me. Unplug your phone so you don’t hear it ring. Reschedule any appointments you have on those days, and if an emergency comes up, I will take care of it. How does that sound? mary: That would be great! Would it be OK if I took a laptop home and worked at home for those three days? Then I wouldn’t be so distracted by coworkers. supervisor: Fine with me. Then, next week we can brainstorm some ways you could use to stay caught up. So, by Friday of next week, what do you think you can have done? mary: I’ll have the four cases closed and on your desk. I will also be within two weeks of being caught up on the case notes for all my cases. supervisor: Are you sure you can get all of that done in just three days? mary: Yes, I’m sure. I just need some time to do the work. supervisor: O.K. So by Friday, I will expect the four cases to close on my desk, and your case notes to be within two weeks of being caught up. I’m writing this down so I remember, and I’ll make a copy for you as well. Then,

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Practice Applications with Involuntary Problems and Settings let’s meet on the following Monday at 10:00 a.m. to talk about how things are going. O.K., Mary? Mary: OK I’ll see you next Monday. The two scenarios above show different ways to address per formance. In the first scenario, the supervisor tells Mary what the problems are and what the solution is. Mary really doesn’t have any say and isn’t asked for input. In the second scenario, the supervisor focuses on concerns that Mary is overwhelmed. Mary then readily admits to being overwhelmed and defines the problem herself, asking for help. The supervisor reaches for motivational congruence so she and Mary are working together on a solution for the performance problems. Mary may be able to catch up, and then she and the supervisor can work on ways for her to stay caught up. In the second scenario, Mary could feel more supported by her supervisor and be less likely to react as if she had done something wrong or was “in trouble.” She will be more open to her supervisor’s helpful suggestions. The two scenarios also use different ways to talk with the social worker about the work that needs to be done. In the first scenario, the supervisor just tells Mary what needs to be done and when the work must be completed. In the second scenario, the supervisor utilizes contracting with Mary by asking for her input in what tasks need to be done and what she can do by the following Friday. She uses a task-centered approach, specifically asking Mary what she thinks she can complete and then writing these tasks down so there are no misunderstandings (Caspi and Reid 2002). The supervisor then sets a follow-up meeting. Of the two scenarios, the first one is much less time-consuming for the supervisor. However, the second scenario may be more successful and also models techniques in working with involuntary clients. Sometimes per formance problems are chronic. In such situations, other concepts for working with involuntary clients can be used. For instance, if after several meetings Mary continues to be behind in court reports, case notes, and client contacts, the supervisor should become more directive. A first step would be to identify what is negotiable and what is mandated, and the next step could be to expand choices. The following scenario illustrates how a supervisor might use this technique. Scenario 3 supervisor: Mary, I continue to be concerned about how behind you are in your work. We’ve discussed these issues several times, and have tried some different techniques to help you catch up. However, you are still behind in your court reports, case notes, and client contacts.

Applying the Involuntary Perspective to Management and Supervision mary: I know. I just can’t seem to get caught up. There are just too many reports to write and too many requirements! supervisor: Well, I know this job has a lot of paperwork associated with it. However, completing court reports and case notes is a required part of the job. Seeing clients is also required and extremely important, as you know. Child protection workers are responsible for assessing risk to children on an ongoing basis— and we need to make sure you’re seeing the families on your caseload regularly. mary: I know. I just don’t have enough time! Can’t I just see clients and not worry about the paperwork so much? supervisor: Well, the paperwork that needs to be done is not negotiable. However, how you structure your time to get it done is up to you. We have discussed some different ways you could structure your time—has that been helpful? mary: Yes, I guess. I’m still working on figuring out a system to get my paperwork done. I just haven’t figured anything out yet. supervisor: Mary, I guess I’m not quite sure what is keeping you from getting caught up in your work. We’ve tried having you work for three days on paperwork at home, but I still haven’t received the case closings I requested two months ago. You asked me to not assign you a case so you could catch up, and I did this. However, you still have not caught up. I guess I’m not sure what the problem is, and why you haven’t been able to catch up. What do you think is keeping you from getting caught up? mary: I just have too much to do. It’s impossible to do this job with so many cases. I want to get caught up, but just haven’t been able to do so. supervisor: I agree this job is difficult with so many cases. I have suggested trying to get your caseload down so that you have a more manageable caseload, and we have tried a few different ways to give you time to close the four cases that need to be closed. I still haven’t seen these cases on my desk. What do you think it is going to take to get these cases closed? mary: I just need to finish catching up on the paperwork for the cases before I close them. I just need more time. Maybe if I work on Saturday I can get these cases closed. supervisor: OK. I need to let you know that if you continue to be so behind, I will have to start looking at disciplinary measures. I’d like to avoid this, and I know you would also. But I do have a responsibility to the clients we serve, and you have been consistently behind on your work for several months now, and none of the ideas we’ve tried has seemed to work. The bottom line is that you need to be seeing clients and staying caught up in your paperwork. I’m willing to have you work on Saturday to get caught up, but am wondering what will be different this time from the other times you’ve taken time to do paperwork.

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Practice Applications with Involuntary Problems and Settings mary: I know I’ll be able to do this Saturday. Every thing that’s due will be on your desk Monday morning. In the above dialogue, the supervisor let Mary know that paperwork is required, clearly identifying what is negotiable and what is mandated in the job. Mary continues to be behind on her paperwork despite previous interventions by the supervisor. In the next step, the supervisor tries to find out what Mary’s view of the problem is and what are her goals. Mary asserts that she has too many cases, and her goal is to get caught up. Accepting her view of the problem is an important aspect of addressing the performance concerns. The supervisor has already joined with Mary to address these issues. However, these efforts have not been successful in solving the performance problems. The supervisor is ultimately responsible for clients’ receiving the ser vices they need and therefore must continue to address the performance problem. In the dialogue above, the supervisor tries again with Mary, responding to her view of the problem. She then reframes the problem as a winwin situation. Finally, using informed consent, the supervisor addresses with Mary the consequences of noncompliance in getting caught up in her work. Mary’s performance problems have reached the point of possible disciplinary action, and the supervisor has the legal and ethical obligation to confront Mary forthrightly.

Legal-Ethical Matrix The legal-ethical matrix facilitates making ethical decisions in involuntary settings (see chapter 2 in this volume). Social workers often have a sense that something doesn’t feel right, but they may have difficulty verbalizing what exactly is bothering them or on what basis to proceed in a specific direction. The legal-ethical matrix provides supervisees, supervisors, and managers with a tool for discussing such situations, as the following scenario illustrates.

Scenario 4 Ron, a child protection social worker, comes into the supervisor’s office to talk, following an earlier discussion in which the supervisor advised him to close the Teresa Wells case. ron: I’d like to talk to you about the Teresa Wells case. I know we talked about me closing the case in supervision, but I just don’t feel right about it. supervisor: Do you know what’s bothering you about closing the case?

Applying the Involuntary Perspective to Management and Supervision ron: It just doesn’t feel right. I know we consulted with the county attorney’s office, and they said we did not have enough to file a petition, but I still don’t feel it’s a good idea to close the case. supervisor: Well, Teresa Wells is refusing to work with you and has not taken advantage of any of the ser vices you’ve offered her. Correct? ron: Yes, that’s true. I don’t even know where she is half of the time. supervisor: How are the children doing? ron: They’re fine. Their grandparents are caring for them most of the time and making sure they have enough to eat, and they are all making it to school on time. The grandparents are really committed to these children and are making sure they get proper care even when Mom’s not around. supervisor: So the children are receiving adequate care, Ms. Wells is refusing to work with us, and we do not have any evidence of maltreatment on her part that would enable us to go to court to have her ordered to work with us. Is that right? ron: That’s correct. But it just doesn’t seem right that mom is out using cocaine all the time, and we can’t do anything about it. I think the children would be better off if Mom transfers custody to the grandparents, or if she would get the help she needs to stop using drugs. supervisor: True. Ethically, it makes sense to intervene in this family’s life. You have tried to work with Mom, and she’s not interested in working with you. Legally, we do not have grounds to intervene by removing the children or taking Mom into court. Therefore, since she’s not working with you, we need to close the case. The children are being cared for adequately, and the mother is not cooperative with ser vices. ron: It still doesn’t feel right, although I understand what you’re saying. The grandparents don’t want us to close either. supervisor: I think your gut feeling that ethically the community and social ser vices should be intervening more with this family is right on target. However, the agency doesn’t have the legal right to continue our intervention, even though we’d like to. Mom has a right to refuse services, and as long as her children are doing OK, we can’t legally do anything. I know it’s frustrating, but that’s part of this job. You could talk to the grandparents and let them know that if they stop bailing out Ms. Wells every time she goes out to use cocaine, there will be a maltreatment finding based on abandonment, and we would have a legal basis to intervene—but as long as the grandparents keep caring for the children when Mom takes off, we can’t do anything about it. ron: OK—I’ll talk to the grandparents before I close the case, and explain to them what you’ve explained to me. Thanks for your help in clarifying this for me. At least now I know why I’m feeling so uncomfortable with closing the case.

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Practice Applications with Involuntary Problems and Settings In the above scenario, the situation with the Wells family fits into Cell 3 of the legal-ethical matrix: intrusion is ethical but not legally based. Looking at the situation in terms of the legal-ethical matrix helped Ron understand why he felt bad about closing the case, but also why he still needed to end ser vices. In other situations, such as in the following example, social workers may feel uncomfortable because an action on a case may be legal but not ethical.

Serena comes into the supervisor’s office to discuss some concerns she is having with a new case she just received. Ms. Byers is nine months pregnant, and the case was opened due to prenatal exposure of the child to chemicals. Ms. Byers had several toxicology screens while pregnant that were positive for cocaine. She is currently committed to inpatient treatment until she has the baby. Ms. Byers has been doing well in treatment and plans to enter a halfway house with the baby after the child is born. Her parental rights to one other child were terminated two years ago due to her illegal drug use, and she is determined to keep this baby. The child protection investigating social worker has filed a petition in juvenile court, an order for immediate custody of the child is in effect, and the child is to be placed in foster care as soon as it is born. Ms. Byers has no knowledge that the agency is planning to take her child when it is born, and the investigating social worker did not want her to be told. Serena expresses concerns with the decision not to tell the mother of the plans to remove her child when it is born. While this plan is legal, in that there is no obligation to tell the mother anything, it still did not feel right. We discuss the case and whether it would be ethical to deceive Ms. Byers about the plan for the baby. If Serena didn’t tell Ms. Byers, and then removed her baby from her, Ms. Byers might never trust a social worker again. If she did tell Ms. Byers, there was a risk that Ms. Byers would leave the hospital or treatment with the baby against advice, although based on her stated commitment to this unborn child and her sobriety, Serena judges that Ms. Byers would stay. After discussing the case situation, we ultimately decide to tell Ms. Byers about the order for immediate custody, and then work with her to get the child returned to her safely as soon as possible. Serena states that she feels a lot better about this course of action, and she predicts it will lead to a more successful working relationship with Ms. Byers.

Applying the Involuntary Perspective to Management and Supervision In the above example, Serena was not comfortable with a plan made by another social worker because she did not feel it was ethical. This situation falls into Cell 2 of the legal-ethical matrix: intrusion is legal but not ethically based. Discussing the case in terms of this framework helped clarify why the other worker was legally able to support the decision to remove the baby after birth without telling mom and why Serena had an ethical rationale to object to a deceitful plan. This example also illustrates the influence that involuntary transactions can have on the work and ser vice environment, a context that can be particularly stressful and conducive to unethical and abusive practices. Consequently, moral courage along with other virtues will be required to take ethical action (Bibus 2015; Strom-Gottfried 2015). The following section suggests supervisory strategies for effectively and ethically managing this context.

The Involuntary Context Managers, supervisors, and supervisees need to understand the challenges of working in an involuntary context and to recognize ways social workers might handle their frustrations. In social ser vice agencies today, difficulties such as those described earlier are commonplace. In the United States, society typically focuses on an individual pathology in addressing social issues. For instance, people tend to view family members who neglect their elders as “the problem.” The societal factors that may have led to the neglect, such as fragmented and dysfunctional health care policies, are often overlooked. Other examples of structural factors built into today’s society that tend to foster involuntary contact with social workers include poverty, discrimination, biases in policy, disparities in opportunity, commercial encouragement of drug and alcohol abuse, neighborhood dangers, and lack of affordable childcare, housing, or health care. People of color are disproportionately subject to coercive and punitive rather than supportive or preventative interventions. Welfare-to-work programs use punishments to gain compliance, such as sanctions if clients miss meetings. They may not consider how poverty limits access to transportation or how difficult it is to carry several children onto the bus to get to a required appointment. Managed care policies may only fund short-term therapy for clients who would be better served by longer-term therapy. Often, it seems as if agencies are more concerned with processing people than meeting their needs. For example, some public social ser vice agencies have adopted outcome-based programs to measure success. While there are advantages to such a focus, sometimes outcome statistics become ends in themselves, eclipsing clients’ needs. Some scholars in public administration have suggested transcending this trend emphasizing efficiency in achieving outcomes and are calling instead

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Practice Applications with Involuntary Problems and Settings for an administrative process that invites clients and other citizens as partners in setting the course and delivery of ser vices (Bibus and Carlsen 2017). Denhardt and Denhardt’s (2011) analysis identifies effective and ethical administrative strategies that can be used to limit involuntary dynamics and nurture more voluntary working relationships between clients and agency staff. Their new public service approach aims at building coalitions of public, nonprofit, and private agencies, involving people to meet mutually agreed upon needs and goals. In this way, clients are seen and treated as citizens with rights and responsibilities (Toft and Bibus 2014). For example, a manager or supervisor in a hospital social work department could arrange for former patients, some of whom had been involuntarily committed to the locked psychiatric care unit, to be invited to join an advisory committee charged with reviewing and recommending improvements in the admission process. In another example, social work managers, supervisors, and staff could lead the way with community agencies to advocate for extension of voting privileges to former prison inmates and set up voter registration outreach. (See Bibus 2009 for more examples of such advocacy with involuntary clients.) Studies have shown that clients will make longer lasting changes when they have self-attribution, that is, when they feel they made changes for themselves. However, heavy caseloads may not allow the social worker enough time to work with clients to gain self-attribution. According to Sherman and Wenocur (1983), social workers may cope in several different ways. They describe the capitulator response as resolving conflict by identifying with the organization. Using this strategy, social workers comply to minimal expectations, accept the current level of resources, and without guilt refrain from making any additional effort beyond routine ser vices. Often they will stop advocating for change, shut down their empathy, and shuffle papers. The noncapitulator response, on the other hand, rejects complacency. Using this strategy, social workers will identify with clients’ anger rather than powerlessness and may become isolated. Other practitioners may fall into the response of self-victimization or martyrdom. Finding a niche, such as a work unit whose supervisor is adept at buffering dispiriting stressors (Westbrook, Ellis, and Ellett 2006), usually works better. Withdrawing or leaving the agency is an option, though opportunities to learn how to make successful system changes may then be lost. The functional noncapitulator strategy is a most promising response to frustration with the organization. Conflict is managed by acting responsibly to influence the organization. Using this strategy, practitioners form a supportive work group, pick their battles, and decide when to take calculated risks in negotiating the conditions of work. Managers and supervisors should watch for signs of all of these responses in staff. If any of the less functional strategies are evident, supervisors and supervisees should talk, identify specifically the pattern they noticed, and then

Applying the Involuntary Perspective to Management and Supervision work together to find more effective ways to deal with stress. The following scenario illustrates this work: Scenario 5 supervisor: Hi Greg. I’d like to talk to you about some concerns I’ve had recently. Have a seat. greg: Thanks. What kind of concerns are you talking about? supervisor: Well, you know we’ve been working together a long time, and I’ve always considered your work to be excellent. greg: Yes, I know you’ve told me that several times. Has something changed? supervisor: Well, I’m not sure. I’ve noticed recently that you seem to be connecting less and less with clients, which isn’t typical for you. You’re always up-to-date in your paperwork . . . that’s still true, but there is something different in how you talk about clients in supervision. greg: What exactly do you mean by “something different?” supervisor: Well, you used to relate little anecdotes about each of your clients as you were talking with me about cases, and I got to know the clients through you as individuals. Lately, it seems as if you just group all the clients together, focus purely on what they have or haven’t done, and your sense of hope seems to be diminished somehow. Does that make sense? greg: Actually, it does. I have been feeling really burned out lately. I’ve been really angry since management refused to give us the additional staff we asked for, and I’ve been overwhelmed by the number of cases I’ve had. I guess I figured that if management doesn’t care about the clients and maintaining a decent caseload size for workers, I don’t need to care either. I told myself I’d just do the paperwork, which is what management seems to want, and try not to care so much about the clients. I don’t think it’s fair to them that I can’t work with them the way I want to, so I guess I’m sort of just going through the motions. supervisor: How does that feel to you? greg: Lousy! It’s like part of me has shut down in doing the job, and I don’t enjoy the work as much as I used to. I’m so angry still at management, because it seems that they don’t care as much as I do, and that’s frustrating. supervisor: So you’re not going to care either? greg: I guess. supervisor: Greg, I know you well enough to know that you’re not going to last in this job doing it the way you’ve started to do it lately. You won’t be happy with yourself, and your clients won’t be getting as good ser vice as they should. Would you be willing to talk with me about some other ways to deal with your anger towards management, so you can be happier in your job and clients can get the ser vice they deserve.

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Practice Applications with Involuntary Problems and Settings Greg: Yes, I would like to talk about that. I’m glad you brought it up—I know the way I’m dealing with this isn’t working, so maybe we can figure something else out. In this scenario, Greg was frustrated with management and had begun to assume the role of capitulator. With this issue out in the open, Greg is able to articulate how he feels about management’s decision not to approve new staff for the department as well as how he’s been coping with this anger. The supervisor and Greg can now talk about alternative coping strategies. By bringing the issue up early, the supervisor is also showing she values Greg’s work and wants him to be happy in his job, as well as effective in his work with clients. The potential positive function of supervision in work with involuntary clients becomes evident in these examples and is also substantiated to an extent in research findings, as reviewed in the next section.

Functions of Management and Supervision in Involuntary Contexts Following the long tradition of social work scholarship devoted to supervision (Kadushin and Harkness 2014; Munson 2002; Shulman 2010; Tsui 2005), we think of supervisors as serving three primary functions: administrative, educational, and supportive. These functions interrelate to meet the primary goal of delivering ser vices to clients effectively and ethically. Exercising their administrative function, supervisors manage and direct supervisees’ work, oversee the daily operations and productivity of their units or work teams, and carry out the agency’s mission. The administrative function requires sophisticated competencies in gathering data and information, communicating, assigning cases, prioritizing, team building and leading, problem solving, managing conflict and crises effectively and diplomatically, networking within the professional community and at large, and using other outwardly oriented strategic skills (Preston 2004). It also demands an increasingly high proportion of social work supervisors’ time and attention as they take on tasks previously assigned to upper management (Collins- Camargo 2003; Hoge et al. 2014; Strand and Badger 2007). In some settings, such as those serving people facing difficulties with drugs or alcohol, supervisors may also carry a caseload, which while potentially valuable further limits their time for supervisory functions (Joseph 2006). In contrast to administrative duties, supervisors often cite the educational function as more rewarding because they can focus on teaching supervisees and fostering their professional development. These teaching opportunities span the spectrum from informal orientation and on-the-job training to

Applying the Involuntary Perspective to Management and Supervision formal presentations modeling and demonstrating practice competencies (Caspi and Reid 2002). From research on the effectiveness of supervision we know that the educational instruction and task assistance which supervisees’ perceive to be helpfully provided by their supervisors are strongly associated with beneficial outcomes for workers and their practice (Mor Barak et al. 2009). Modeling strengths-based approaches in supervision appears to lead to clients’ fuller and more authentic participation in ser vices that supervisees provide (Collins-Carmargo and Millar 2010:183). Moreover, supervisors’ attention to supervisees’ competency development and quality of their client outcomes can increase workers’ self-efficacy (Julien-Chinn and Lietz 2016). But as supervisors’ attention is absorbed in administrative duties, they report having less time for teaching (Westbrook, Ellis, and Ellett 2006). Similarly, supervisors value but are often diverted from their support function. Ideally, in addition to instruction and education, social work supervisors should support supervisees individually and as a group, thus cultivating both a nurturing work climate and high quality, reliable ser vice (see for example: Borders 2014; Clark and Giordano 2013; Kadushin and Harkness; Mor Barak et al. 2009; and Yoo and Brooks 2005). “Regarding worker outcomes, there is a clear theme across several studies that the provision of emotional support by supervisors within a trusting relationship mitigates the effects of work stress and is positively related to job satisfaction” (O’Donoghue and Tsui 2015:626). Lawrence Shulman has extensively researched and elaborated upon the support function. Supervisees tend to rate their satisfaction with their supervisors as positive if their supervisor has created an “emotional atmosphere in which I feel free to discuss my mistakes and failures, as well as my successes” (1993:137). Shulman’s research over three decades in a variety of settings indicates that effective supervisors take advantage of a parallel process wherein their support of supervisees, including their demands for work, encourages support for clients, which in turn leads to positive case outcomes. Likewise, other scholars (e.g., Bednar 2003; Latting et al. 2004) have found that the success of supervisees’ practice with clients is influenced by the quality of supervisory support: “If the supervisor works to empower and support the worker, so too will this be reflected in work with clients” (Kane 1991:20). Following a review of the empirical research on social work supervision by Ming-sum Tsui (1997), Bruce and Austin note that supervisees find the greatest satisfaction “(1) when the agency provides a supportive and clearly understood work environment; (2) when supervisors exercise leadership and authority based on competence and position; and (3) when workers feel supported by their supervisors” (2000:87). Reviewing research on supervision, Kadushin and Harkness conclude “that supervision makes a significant contribution to worker’s job satisfaction and that agency administration operates more effectively as a result of the availability of supervision” (2014:23). In a study of the

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Practice Applications with Involuntary Problems and Settings factors leading to retention of competent social workers in child welfare, respondents described their most valuable managers “as being supportive and caring, trusting and trusted, and interested in the professional development of their employees” (Westbrook, Ellis, and Ellett 2006:52). In the absence of supervisory support, practitioners are likely to experience dissatisfaction with their work (Joseph 2006). However, most of what we know about the effectiveness of supervision is dependent on the perceptions of supervisors or supervisees, so these research findings must be interpreted with caution. Few studies have been able to link supervisory activities with client outcomes, and more empirical study is needed to confirm whether there are parallel processes between good work done in supervision and effective practice with clients (Bibus 1993; Kadushin and Harkness 2014; O’Donoghue and Tsui 2015; Tsui 1997). For his 2006 integrative review of the effects that managers and supervisors have on client outcomes, Poertner found just eleven studies, six focused on supervisory behavior and the rest on organizational climate, use of teams, and program impacts. Still, he concluded that “this body of research, while not experimental, provides evidence that supervisory behavior makes a difference to consumers. . . . Supervisors who are proactive, problem solvers who use effective interpersonal skills tend to have work units that produce more positive outcomes for consumers” (2006:17–18). Because supervisees may have been trained in practice models that presume clients have voluntarily sought their help, managers and supervisors will need to offer supportive and educational supervision that is informed by models developed for involuntary transactions. Yet supervisors as well as managers must now attend primarily to administrative duties responding to additional mandates, such as those imposed by welfare reform, and hence may not have time to provide direct support to staff. Anticipating trends that further focus social work supervisors’ attention on external demands rather than internal relationships, Bruce and Austin write, “Supervising staff under these new realities places increased emphasis on skills related to assessing outcomes, monitoring systems, and managing resources. . . . Welfare reform has shifted the focus from client dependency to client self sufficiency, placing new pressures on workers and supervisors to use interventions which empower clients to assume increased responsibility for their lives. Supervising staff in the welfare reform environment that is increasingly community-focused involves greater understanding of interdisciplinary and community practice” (2000:102). Thus, social ser vice settings today present uniquely complex and challenging environments for social workers and their supervisors and managers. A variety of outside forces will continue to have an impact upon the focus of practice. Practitioners will continue to encounter radical shifts in their job descriptions based on legislative changes, media coverage, public opinion, internal policy changes, and budget cuts. Dominated by political pressures and

Applying the Involuntary Perspective to Management and Supervision interests, this practice arena often will be emotionally charged. Special interest groups may lobby for changes in policy, and social workers may face significant pressures to change their practice accordingly. Media coverage is another area that can be frustrating. Managers and supervisors must become savvy in use of media so that supervisees’ judgment and accountability can be appraised fairly. Another challenge of practice in the public sector and in many private agency settings is the court system. In addition to the adversarial nature of the court process, judges and attorneys may disregard the opinions of social workers despite the fact that many are master’s level clinicians. Also, judges may blame practitioners if the clients are not following the case plan. A cycle of coercion and blame often develops, as in the following case example:

Rebecca, a child protection social worker, is working with the Jansen family. The court ordered Camilla Jansen, the mother of two young children, to undergo an assessment for substance abuse and follow all recommendations. Rebecca has worked hard with Ms. Jansen to set up appointments for the assessment. Ms. Jansen has missed several appointments, and always has an excuse why she could not attend. Rebecca has provided her with a bus card to get to the appointment, but Ms. Jansen said she lost it. Rebecca offered to drive Ms. Jansen to the appointment, and Ms. Jansen refused the offer, stating she could find her own ride. Then Ms. Jansen missed the appointment, claiming Rebecca told her a different time. Rebecca provided Ms. Jansen with phone numbers and addresses of several places where she could participate in an assessment of her dependency on alcohol, but Ms. Jansen has not followed through, stating it’s too difficult to get to any with her two young children. At court, Ms. Jansen claims her social worker hasn’t helped her enough, and that’s why she hasn’t completed the assessment. Rebecca’s court report outlines the efforts made to work with Ms. Jansen. The judge is clearly upset that her orders were not followed and believes the social worker is to blame. She therefore orders the social worker to schedule another appointment and take the client to the appointment. Rebecca is extremely frustrated because her hard work has gone unnoticed, and she appears to be blamed for the client’s failure. In addition, she feels the judge has undermined her attempts to have clients assume appropriate responsibility. This frustration affects her relationship to Ms. Jansen, whom Rebecca blames for not getting to the appointment.

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Practice Applications with Involuntary Problems and Settings After the court hearing, Rebecca confers with her supervisor and recounts her frustration. The supervisor must be able to validate the supervisee’s perceptions of events while at the same time help the supervisee think through effective next steps. For example, it can be helpful to suggest how the powerlessness that the social worker is experiencing in the court system may mirror the client’s experiences with the agency.

Practicing in this conflicted, stressful, and pressured context, supervisors must develop expertise in administrative and community-based approaches based on evidence for effective supervision (Bogo and McKnight 2005; Borders 2014; Bunker and Wijnberg 1988; Harkness and Kadushin 2104; Hoge et al. 2014; Milne et al. 2008; Milne and Dunkerley 2010; Mor Barak et al. 2009; Munson 2002; O’Donoghue and Tsui 2015; Pecora et al. 2010; Poertner 2006; Shulman 1993, 1995, 2010; Taibbi 2013; Tsui 1997; Westbrook, Ellis, and Ellett 2006). Their position in their agencies mediating the boundaries between line staff and upper administration and between their work units and the community (resource agencies, courts, the general public) provides both a challenge and an opportunity to effect positive change. The following sections offer examples of and suggestions for managers’ and supervisors’ use of skills such as mediating, buffering or amplifying the dynamics of the ser vice system, offering case consultation, building cultural competence, and attending to safety. Mediating One area in which successful managers and supervisors develop competence is in mediation skills. When there are differences of opinions between social workers and other professionals, a sequence of strategies is typically employed. First, the supervisor or manager needs to encourage the practitioner to deal with the problem directly with the other professional. When this strategy is not effective, supervisory intervention may be warranted. The supervisor can call a meeting between the supervisee, the supervisor, the other professional and that person’s supervisor. The purposes of the meeting are to air each party’s opinions and positions and to reach for consensus or compromise. Since social workers typically believe they are advocating for a client’s welfare, their positions are heartfelt; supervisors should be ready to affirm the strength with which opinions are held without necessarily agreeing with their content. If a meeting at the supervisory level does not solve the problem, the supervisor should invite managers to help address the dispute.

Applying the Involuntary Perspective to Management and Supervision Mediating also may be utilized with a practitioner and a client. Involuntary clients frequently complain that their assigned social worker does not understand them and is not adequately listening to or serving them (e.g., Lengyel 2001:147). “As is not uncommon in typically involuntary ser vices, families often contact supervisors to complain about the ser vices they are receiving or the worker assigned to them” (Collins- Camargo and Groeber 2003:181). The following case example illustrates use of mediating skills with clients and supervisees. As a supervisor, I (Jud) received a call from Ms. Johnson, a client of Rachel, one of my supervisees. Ms. Johnson was in tears, and requested a new worker because she couldn’t work with Rachel anymore. She said Rachel wouldn’t listen to her, and Ms. Johnson always ended up very upset after their meetings. When I checked this out with Rachel, she said she was never able to discuss the case plan and other pertinent issues with Ms. Johnson because Ms. Johnson would keep focusing on unrelated issues, become upset, and then start screaming at Rachel until Rachel would leave. I offered to meet with Rachel and Ms. Johnson to discuss their concerns and determine how they could better work together. Rachel made a written list of all of the things she wanted to tell Ms. Johnson but never was able to because Ms. Johnson would start yelling at her. I began the meeting by asking each what they would like to discuss, and made a list. I assured them both we would get to all the concerns, but that I also might move the meeting along in the interest of time. Ms. Johnson began by talking about her concerns that Rachel didn’t listen to her and wasn’t on her side. She talked about how frustrating it was with her child in foster care and Rachel in control of when the child would return. Rachel then explained that the court ultimately made the decisions regarding the return of the child, and Rachel provided the court with reports from the ser vice providers. Therefore, if Rachel and Ms. Johnson could work together to make sure Ms. Johnson was successfully participating in programs such as her treatment, domestic abuse counseling and parenting classes, Rachel would have positive reports to provide to the court. Rachel gave Ms. Johnson a sheet explaining in writing what she needed to do and how Rachel could help her. Ms. Johnson was given time to read the list and ask questions. She finally understood more about how Rachel could help her. Rachel had the opportunity to listen to Ms. Johnson and learned that when she was yelling and crying, she

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Practice Applications with Involuntary Problems and Settings was expressing anxiety and sadness about her predicament and how frustrated and trapped she felt. At the end of the meeting, Ms. Johnson decided she would continue to work with Rachel, now that she understood Rachel’s role better and felt that Rachel heard her concerns. Rachel was also better able to work with Ms. Johnson now that she understood her anxiety and how putting items and tasks in writing worked well to keep their meetings on track.

Buffering or Amplifying Dynamics Rather than regretting that they are often caught in the middle, supervisors (and other middle managers) can take advantage of their powerful mediating position “in the middle,” ideally able to influence both “above” and “below,” either “buffering” or “amplifying” the messages and influence attempts of administrators or constituencies external to the work unit (Bunker and Wijnberg 1988; see also Westbrook, Ellis, and Ellett 2006:53, who refer to this skill as “running interference”). In actively buffering the work unit from pressures that threaten an empowering climate, supervisors assertively represent the needs of their workers to upper management while carefully and rationally interpreting the rules and requirements for their units, keeping focused on ser vices in the best interests of vulnerable clients. For example, a supervisor or manager can buffer fault-finding dynamics and focus instead on the supervisees’ strengths in learning from mistakes. Westbrook and colleagues found that supervisors and managers play another important role as they buffer the effects of negative publicity that may arise from a tragic incident or scandal “by establishing and sustaining positive relations with local media and by championing media coverage of local successes” (2006:56, italics in the original). Conversely, the supervisor or manager can amplify dynamics that are more positive, such as interest in serving customers, being responsive to clients, creating a work climate that honors caring for clients as a priority, and enhancing the prestige of the agency by showcasing successful innovations or cost savings or by recognizing veteran staff. However, supervisors may also inadvertently amplify the cycle of coercion by uncritically passing through to staff coercive messages from upper management. And supervisors might excessively buffer messages from upper management (such as those meant to make services more culturally competent) to such an extent that staff members do not realize the full import of new expectations.

Applying the Involuntary Perspective to Management and Supervision Building Cultural Competence With the increasing diversity of communities that social workers serve and given the persistent disparities in outcomes for people of color and other oppressed groups (Rodenborg 2004), supervisees must build cultural competence; this is a “life long process” of learning and subject to “daily supervision” (NASW 2015:15–16). The managers’ and supervisors’ role in holding themselves, their agency, and their supervisees to standards of cultural competence is key. If an agency has been successful in recruiting a multicultural staff, supervisors also will encounter the challenges inherent in cross-cultural supervision (Kaiser et al. 2000). Differences in cultural background and in degree of cultural competence can exacerbate the power imbalance between supervisors and supervisees. In work with involuntary clients, if the supervisor does not address this potential difference in power as well as possible cultural differences explicitly and directly, inadvertent abuse of power can spill over and endanger both staff and clients (see the chapter  5, on oppression and involuntary status). Additionally, when a supervisor explores with supervisees the possibility that clients’ actions may be signs of reactance, the supervisees’ capacity to use critical thinking skills grows as they generate explanations for clients’ behavior that are plausible alternatives to those that first might come to mind from the supervisees’ cultural perspective (Deal 2003). Attending to Safety Increasingly, social workers practice in settings where there is a palpable risk for violence (Spencer and Munch 2003). Whether in the public sector or in so called “voluntary” private sector, social ser vice agency staff can be perceived as agents who are withholding desperately needed benefits and assistance or as investigators who are interfering with or spying upon citizens. Research in work with involuntary clients indicates that practitioners should be vigilant; even though they see themselves as well-intentioned helpers, clients may view them as threats to valued freedoms. Reactions ranging from intimidation and staring or stalking, to verbal attacks and destruction of property and even physical assaults are possible. Supervision is critical for assessing the potential for violence both interpersonally and in the environment; this is especially important when staff are visiting with clients in their homes (Newbill and Hagan 2016). Setting up teams for home visits and supplying cellular or mobile phones as well as having supervisors and support staff “on call” to respond to distress calls can reduce the risk for harm to staff and clients. “Training during the initial orientation, periodic in-service programs, and ongoing staff meetings should address risk factors [such as] . . . mandated treatment” (Spencer and Munch

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Practice Applications with Involuntary Problems and Settings 2003:537). Westbrook and colleagues observed that “when a worker is sent out on a difficult case, a ‘good supervisor’ doesn’t leave the office until the worker has returned safe and unharmed” (2006:53). Supervisors and managers also should take the lead in developing agency policies and procedures that increase safety for staff and clients (Newbill and Hagan 2016; O’Neill 2004; Weinger 2001). If an attack on a supervisee occurs, managers and supervisors must be ready to provide support personally “and ensure staff access to a full range of agency support, including their direct coworkers and agency administrators” (Spencer and Munch 2003:540). In addition, Spencer and Munch remind supervisors and managers themselves to cultivate a support system to tap if they are called upon to manage an incident of violence toward a staff member.

Practice Guidelines The examples in this chapter have been drawn directly from the authors’ practice as supervisors and managers in social ser vice agencies serving involuntary clients. We try to engage employees in making decisions and solving problems. When a unit is overwhelmed due to high caseloads, we will take this issue to agency managers or governing board, and we also ask staff to brainstorm ways they can make their workload more manageable. We do not promise to solve the problem—we do what we can (talk to management, rearrange workload, etc.), and supervisees do what they can (block off time to do paperwork, spend less time with lower risk clients, etc.). For managers and supervisors, cultivating working relationships with both staff and upper management or boards is a key to effective leadership. After reviewing research thus far on effective supervision and management, Poertner concluded that “managers who have more interaction with those in authority apparently acquire more resources and have units with ser vices with more scope and sufficiency” (2006:19). The manager’s and supervisor’s primary goal is helpful ser vice to clients, and the usual means of achieving that goal is fostering the development of staff members as professional practitioners. In a process parallel to effective and ethical direct practice, managers and supervisors are most successful when they create a supportive atmosphere, based on trust in staff and building on strengths. They set clear expectations and don’t check up on staff members unless their performance warrants. However, supervisors must always be ready to override considerations of supervisees’ interests or needs in order to direct activities or attention to clients’ interests and needs. Scholars in social work supervision have noted that “there is a dearth of literature on the nature and effectiveness of supervisory practice” (Bruce and Austin 2000:86), and very few studies link supervisory interventions to effects

Applying the Involuntary Perspective to Management and Supervision that benefit clients. Nonetheless, evidence from training supervisors and supervisees in work with involuntary clients supports the following guidelines (Bibus 1993:19): 1. Be honest, direct, and clear about your expectations of your staff, your own role, and what is required or what is negotiable in supervision; in case consultations identify mandates and what’s negotiable in case plans. 2. Help supervisees generate solutions to problems in collaboration with you rather than telling them what to do. 3. Ask questions about clients’ goals and keep the focus of case discussions on including the client’s version in ser vice plans along with agency mandates; look for any areas to explore potential motivational congruence. 4. Within limitations imposed by increasing administrative demands, be available to assist or direct staff with difficult case situations, encourage staff to build competence in use of supervision, and facilitate consultation and support groups. 5. Compare your views of the problems faced by supervisees to their views and seek partnership with staff in setting goals and tasks. 6. Expect staff and clients to have reactions when valued freedoms are threatened. May you be undaunted in the realization of the vital importance of the manager’s and supervisor’s role in work with involuntary clients!

Practical Exercises and Discussion Questions 1. Give an example of how involuntary clients are vulnerable to exploitation of their lower-power status. 2. Practitioners in nonmandated settings may approach all of their clients as if they were completely voluntary, missing some of the nonvoluntary pressures and nonmandated expectations that result in clients being only semivoluntary or entirely involuntary. Think of a nonmandated client situation that you are familiar with. What strategies would you use as a supervisor or supervisee to raise awareness during initial assessment of where clients might be on the continuum from voluntary to involuntary? 3. From your experience, give a specific example for each of the kinds of pressures below as managers, supervisors, and supervisees might experience them:

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Practice Applications with Involuntary Problems and Settings a) legal pressures b) media pressures c) court pressures 4. What are some of the most stressful aspects of social work practice in adversarial settings common in work with involuntary clients? Under what circumstances might a practitioner have exhausted appropriate internal avenues to reduce or buffer stress factors and then might consider leaving the post or agency? 5. What are some of the advantages of the supervisor’s position “in the middle”? What are some of the disadvantages of the supervisor’s position “in the middle”? 6. Give an example of one of the forms of reactance that you have observed as a supervisor or manager. How can you best address this reactance in the role of supervisor? How can you address it in the role of manager? 7. How can effective supervision increase motivational congruence during performance reviews? 8. What ethical dilemmas have you faced? How did you handle them? In the light of this chapter, would you handle them differently? If so, in what way? How might you have used supervision in your decision making? 9. How can managers or supervisors most successfully support a group of functional noncapitulators? 10. Give a specific example from your practice of the administrative function of supervision; try to describe in detail what you did or what you observed others do, how actions and statements were received, what happened, and how successful you or others were. 11. Give a specific example from your practice of the educational function of supervision; try to describe in detail what you did or what you observed others do, how actions and statements were received, what happened, and how successful you or others were. 12. Give a specific example from your practice of the supportive function of supervision; try to describe in detail what you did or what you observed others do, how actions and statements were received, what happened, and how successful you or others were. 13. What is the missing link in research on the effectiveness of social work supervision? How could it be best addressed? 14. What do you predict will be a major future trend in supervision and management in settings where there are involuntary clients? 15. What might you do as a supervisor or manager in an agency with which you are familiar when you notice that a particular client or

Applying the Involuntary Perspective to Management and Supervision group is being stigmatized, marginalized, or in other ways not being served appropriately? 16. Read each of the standards of cultural competence developed by NASW and assess your level of competence so far related to each. What specifically can you do to maintain or reach the highest level of competence? How can you use supervision to grow in cultural competence? 17. Pick one of the practice guidelines at the end of the chapter and set up an action plan to implement that guideline in your own practice as manager, supervisor, or supervisee. Contract with a colleague to check in on your progress. 18. Think about a time when you experienced or implemented a major change in your organization. How did people react to the change, both before and after it was implemented? As a supervisor or manager, what could you have done differently that may have helped the change go more smoothly or successfully? References Bednar, S. G. 2003. “Elements of Satisfying Orga nizational Climates in Child Welfare Agencies.” Families in Society 84 (1): 7–12. Bibus, A. A. 1993. “In Pursuit of a Missing Link: The Influence of Supervision on Social Workers’ Practice with Involuntary Clients.” The Clinical Supervisor 11 (2): 7–22. Bibus, A. A. 2015. “Supererogation in Social Work: Deciding Whether to Go Beyond the Call of Duty.” Journal of Social Work Values and Ethics 12 (2): 27–40. Bibus, A. A., and N. Boutté-Queen. 2011. Regulating Social Work: A Primer on Licensing Practice. Chicago: Lyceum Books. Bibus, A. A., and M. Carlsen. 2017. “Ethics and Social Policy.” In The Global Encyclopedia of Public Administration, Public Policy, and Governance, ed. A. Farazmand. Cham, Switzerland: Springer International Publishing. Bibus, A. A., R. J. Link, and M. O’Neal. 2005. “The Impact of U.S. Welfare Reform on Children’s Well Being: Minnesota Focus.” In Safeguarding and Promoting the Well-Being of Children, Families and Communities, eds. J. Scott and H. Ward, 59–74. London: Jessica Kingsley. Bibus, T. 2009. “Involuntary Clients and Work in the Era of Welfare Reform.” In Strategies for Work with Involuntary Clients, 2nd ed., ed. R. H. Rooney, 402–422. New York: Columbia University Press. Billings, P., T. D. Moore, and T. P. McDonald. 2003. “What Do We Know About the Relationship Between Public Welfare and Child Welfare.” Child and Youth Services Review 25 (8): 633–650. Bogo, M., and K. McKnight. 2005. “Clinical Supervision in Social Work: A Review of the Literature.” The Clinical Supervisor 24 (1/2): 49–67. Borders, D. 2014. “Best Practices in Clinical Supervision: Another Step in Delineating Effective Supervision Practice.” American Journal of Psychotherapy 68 (2): 151–162. Bruce, E. J., and M. Austin. 2000. “Social Work Supervision: Assessing the Past and Mapping the Future.” Clinical Supervisor 19 (2): 85–107.

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Practice Applications with Involuntary Problems and Settings Bunker, D. R., and M. H. Wijnberg. 1988. Supervision and Performance: Managing Professional Work in Human Service Organizations. San Francisco: Jossey-Bass. Caspi, J., and W. J. Reid. 2002. Educational Supervision in Social Work: A Task- Centered Model for Field Instruction and Staff Development. New York: Columbia University Press. Center for Advanced Studies in Child Welfare. 2002. “Mediation Skills for Child Welfare.” Practice Notes, Issue No. 11. St. Paul, MN: CASCW. Clark, P. B., and A. L. Giordano. 2013. “The Motivational Supervisor: Motivational Interviewing as a Clinical Supervision Approach.” Clinical Supervisor 32: 244–259. Collins-Camargo, C., and C. Groeber. 2003. “Adventures in Partnership: Using Learning Laboratories to Enhance Frontline Supervision in Child Welfare.” Professional Development 6 (1–2): 17–31. Collins- Carmargo, C., and K. Millar. 2010. “The Potential for a More Clinical Approach to Child Welfare Supervision to Promote Practice and Case Outcomes: A Qualitative Study in Four States.” The Clinical Supervisor 29 (2): 164–187. Deal, K. H. 2003. “The Relationship Between Critical Thinking and Interpersonal Skills: Guidelines for Clinical Supervision.” Clinical Supervisor 22 (2): 3–19. Denhardt, J. V., and R. B. Denhardt. 2011. The New Public Service: Serving, Not Steering. 3rd ed. New York: M. E. Sharpe. Harkness, D., and H. Hensley. 1991. “Changing the Focus of Social Work Supervision: Effects on Client Satisfaction and Generalized Contentment.” Social Work 36: 506–512. Hasenfeld, Y., ed. 2010. Human Services as Complex Organizations. 2nd ed. Newbury Park, CA: Sage. Hoge, M. A., Migdole, S., Cannata, E., and Powell, D. J. 2014. “Strengthening Supervision in Systems of Care: Exemplary Practices in Empirically Supported Treatments.” Clinical Social Work Journal 42: 171–181. Joseph, M. A. 2006. Supervisory Effectiveness in Chemical De pen dency Settings: The Impact of Organizational Conditions, Job Strain and Job Dissatisfaction. Unpublished PhD diss., Columbia University, New York. Julien-Chinn, F. J., and C. A. Lietz. 2016. “Permanency-Focused Supervision and Workers’ Self-Efficacy: Exploring the Link.” Social Work 61 (1): 37–44. Kadushin, A. and D. Harkness. 2014. Supervision in Social Work. 5th ed. New York: Columbia University Press. Kaiser, T. L., C. F. Kuechler, and A. Barretta-Herman. 2000. Challenges in Cross- cultural Supervision. St. Paul, MN: College of St. Catherine/University of St. Thomas. Kane, D. 1991. Strategies and Dilemmas in Child Welfare Supervision: A Case Study. Unpublished PhD diss., City University of New York. Latting, J. K., M. H. Beck, K. J. Slack, L. E. Tetrick, A. P. Jones, J. M. Etchegaryay, and N. D. Silva. 2004. “Promoting Ser vice Quality and Client Adherence to the Ser vice Plan: The Role of Top Management’s Support for Innovation and Learning.” Administration in Social Work 28 (2): 29–48. Lengyel, T. E., ed. 2001. Faces of Change: Personal Experiences of Welfare Reform in America. Milwaukee, WI: Alliance for Children and Families. McGowan, B. G., and E. M. Walsh. 2000. “Policy Challenges for Child Welfare in the New Century.” Child Welfare 79 (1): 11–27. McPhee, D. M., and L. R. Bronstein. 2003. “The Journey from Welfare to Work: Learning from Women Living in Poverty.” Affilia 18 (1): 34–48. Milne, D., H. Aylot, H. Fitzpatrick, and M. V. Ellis. 2008. “How Does Clinical Supervision Work? Using a “Best Evidence Synthesis” Approach to Construct a Basic Model of Supervision.” Clinical Supervisor 27 (2): 170–190.

Applying the Involuntary Perspective to Management and Supervision Milne, D., and C. Dunkerley. 2010. “Towards Evidence-Based Clinical Supervision: The Development and Evaluation of Four GBT Guidelines.” Cognitive Behaviour Therapist 3: 43–57. Mirick, R. G. 2012. “Reactance and the Child Welfare Client: Interpreting Parents’ Resistance to Ser vices through the Lens of Reactance Theory.” Families in Society 93 (3): 165–172. Mor Barak, M. E., D. J. Travis, H. Pyun, and B. Xie. 2009. “The Impact of Supervision on Worker Outcomes: A Meta-Analysis.” Social Service Review 83 (1): 3–32. Munson, C. E. 1995. “Loss of Control in the Delivery of Mental Health Ser vices.” Clinical Supervisor 13 (1): 1–6. Munson, C. E. 2002. Clinical Social Work Supervision. 3rd ed. New York: Hayworth Press. National Association of Social Workers and Association of Social Work Boards (NASW and ASWB). 2013. Best Practice Standards in Social Work Supervision. Washington, DC: NASW and ASWB. National Association of Social Workers (NASW). 2015. Standards and Indicators for Cultural Competence in Social Work Practice. Washington, DC: NASW. Newbill, C. E., and L. P. Hagan. 2016. “Violence in Social Work Practice.” NASW Specialty Practice Section Connection for Administration/Supervision (Spring/Summer). Washington, DC: NASW. O’Donoghue, K., and M. S. Tsui. 2015. “Social Work Supervision Research (1970–2010): The Way We Were and the Way Ahead.” British Journal of Social Work 45: 616–633. O’Neill, J. V. 2004. “Tragedies Spark Worker-Safety Awareness.” NASW News 49 (4): 9. Pecora, P. J., D. Cherin, E. Bruce, and T. de Jesus Arguello. 2010. Strategic Supervision: A Brief Guide for Managing Social Service Organizations. Los Angeles: Sage. Pecora, P., J. Whittaker, A. Maluccio, R. P. Barth, and R. D. Plotnick. 2000. The Child Welfare Challenge: Policy, Practice, and Research 2nd ed. New York: Aldine de Gruyter. Poertner, J. 2006. “Social Administration and Outcomes for Consumers: What Do We Know?” Administration in Social Work 30 (2): 11–24. Preston, M. S. 2004. “Mandatory Management Training for Newly Hired Child Welfare Supervisors: A Divergence Between Management Research and Training Practice?” Administration in Social Work 28 (2): 81–97. Rodenborg, N. A. 2004. “Ser vices to African American Children in Poverty: Institutional Discrimination in Child Welfare?” Journal of Poverty: Innovations on Social, Political and Economic Inequalities 8 (3): 109–130. Salus, M. 2004. Supervising Child Protective Services Caseworkers. Washington DC: U.S. Department of Health and Human Ser vices. Sherman, W. R., and S. Wenocur. 1983. “Empowering Public Welfare Workers through Mutual Support.” Social Work 28: 375–379. Shulman, L. 1993. Interactional Supervision. Washington, DC: National Association of Social Workers. Shulman, L. 1995. “Supervision and Consultation.” In Encyclopedia of Social Work, 19th ed., ed. R. L. Edwards2373–2379. Washington, DC: National Association of Social Workers. Shulman, L. 2010. Interactional Supervision 3rd ed. Washington, DC: National Association of Social Workers. Spencer, P. C., and S. Munch. 2003. “Client Violence Toward Social Workers: The Role of Management in Community Mental Health Programs.” Social Work 48 (4): 532–544. Strand, V. C., and L. Badger. 2007. “A Clinical Consultation Model for Child Welfare Supervisors.” Child Welfare 86 (1): 79–98. Strom- Gottfried, K. 2015. Straight Talk about Professional Ethics. 2nd ed. Chicago: Lyceum Books.

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Practice Applications with Involuntary Problems and Settings Strom- Gottfried, K., and K. Corcoran. 1998. “Confronting Ethical Dilemmas in Managed Care: Guidelines for Students and Faculty.” Journal of Social Work Education 34 (1): 109–119. Taibbi, R. 2013. Clinical Social Work Supervision: Practice and Process. Upper Saddle River, NJ: Pearson. Taylor, M. F., and K. J. Bentley. 2005. “Professional Dissonance: Colliding Values and Job Tasks in Mental Health Practice.” Community Mental Health Journal 41 (4): 469–480. Toft, J., and A. A. Bibus. 2014. “Citizen- Centered Administration for Child Welfare.” In Governance, Development and Social Work, eds. C. S. Ramanathan and S. Dutta, 46–77. New York: Routledge. Trotter, C. 1999. Working with Involuntary Clients. London: Sage. Tsui, M.-S. 1997. “Empirical Research on Social Work Supervision: The State of the Art 1970– 1995.” Journal of Social Services Research 23 (2): 39–54. Tsui, M.-S. 2005. Social Work Supervision: Contexts and Concepts. Thousand Oaks, CA: Sage. Weinger, S. 2001. Security Risk: Preventing Client Violence Against Social Workers. Washington, DC: National Association of Social Workers. Westbrook, T. M., J. Ellis, and A. J. Ellett. 2006. “Improving Retention Among Public Child Welfare Workers: What Can We Learn from The Insights and Experiences of Committed Survivors?” Administration in Social Work 30 (4): 37–62. Yoo, J., and D. Brooks. 2005. “The Role of Orga nizational Variables in Predicting Ser vice Effectiveness: An Analy sis of a Multilevel Model.” Research on Social Work Practice 15 (4): 267–277.

Chapter 22

The Nonvoluntary Practitioner and the System

Ronald Rooney

The preceding chapters have applied concepts for working with involuntary clients to varied problems, populations, and settings. This final chapter focuses on the nonvoluntary practitioner across problems, populations, and settings. It suggests guidelines for reducing work-related stress and improving agency ser vice conditions. Finally, a research and practice agenda for further development of strategies for work with involuntary clients and agencies is suggested.

Nonvoluntary Practitioners Nonvoluntary practitioners are helping professionals serving involuntary clients who are themselves nonvoluntary. There is a parallel to nonvoluntary clients, as such practitioners consider themselves disadvantaged because desirable alternatives are believed to be available elsewhere or they feel forced to remain in their current positions because the cost of leaving would be too high. Nonvoluntary practitioners make constrained choices to continue such work because of the threatened loss of other benefits such as income, pension plans, and convenience. Some public agency practitioners speak of well-paid work with involuntary clients as “golden handcuffs,” since they might prefer working elsewhere but fear that they would have to do so for lower pay. Hence, their motivation to remain in their jobs may be more influenced by extrinsic rewards than by the intrinsic valuing of the work.

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Practice Applications with Involuntary Problems and Settings Nonvoluntary practitioners often feel a lack of motivational congruence with the system. Many of the intervention guidelines suggested in this book are not currently compatible with the policies of organizations employing nonvoluntary practitioners. Hence, reading this book may in fact stimulate cognitive dissonance. Practitioners may come to doubt the legality, ethics, or effectiveness of the ser vices provided in their settings. They may believe that an overemphasis on punitive options and a lack of choices and inducements might act to maintain behavior that comes to be labeled as reluctant, disgruntled, hard-to-reach, and resistant in involuntary clients. They may experience dissonance when their settings have beliefs that focus on client pathology and ignore situational explanations for client responses to involuntary circumstances. Cognitive dissonance theory suggests that if practitioners cannot change their behavior to fit their values, they may reduce dissonance by changing those values (Draycott and Dabbs 1998). Practitioners may respond to nonvoluntary situations in ways that are similar to patterns described for clients in nonvoluntary situations. For example, practitioners experiencing nonvoluntary pressure from persons perceived to have more power may use self-presentation strategies such as self-promotion, exemplification, and ingratiation when that higher-power person controls access to needed resources (Kelly 2000). Similarly, practitioners may experience reactance when valued freedoms are threatened. In such circumstances, practitioners often report procrastinating or “finding the loophole” in an unwelcome task by carrying out the required task in a narrow way while undercutting the purpose of the task (Brehm 1976). Of particular concern is the pattern suggested in reactance theory that repeated failed attempts to reassert valued freedoms may result in learned helplessness (Baum, Fleming, and Reddy 1986). Hence, practitioners who seek to be resourceful and empowering in work with their clients may find obstacles if their own agency experience is not empowering.

Job Stress, Burnout, and Compassion Fatigue There is high turnover in many of the settings in which involuntary clients are encountered. For example, turnover rates in child welfare often run above 30 percent (Johnco et al. 2014; Shier et al. 2012). Also, working conditions can be hazardous and job satisfaction lacking. Despite diligent efforts by practitioners, tangible positive results may be scarce with clients who have little commitment to goals set by agencies for them (Tam and Mong 2005). Practitioners also self-select and are selected for such settings in part because they can empathize with clients. However, such capacities can also lead to risk for experiencing compassion fatigue or an emotional burden experienced by helping professionals from overexposure to client traumatic events

The Nonvoluntary Practitioner and the System (Finzi-Dottan and Berckovitch Kormosh 2016; Figley 2002; Adams, Boscarino, and Figley 2006; Strom-Gottfried and Mowbray 2006). Staff in such settings need to be able to assess their own signs of stress and then to develop and apply their own coping skills. Debriefing and mourning or memorial rituals can be helpful for workers suffering from secondary trauma related to client losses or death (Strom-Gottfried and Mowbray 2006). Practitioners experiencing compassion fatigue also at times experience compassion satisfaction or appreciation of their efforts that can mitigate burnout or compassion fatigue (Conrad and Kellar-Guenther 2006). In addition to stress and compassion fatigue, a kind of practitioner disempowerment has been purported to occur in overloaded public welfare agencies (Sherman and Wenocur 1983). Agencies hard pressed to meet overwhelming demands are inclined to defensive, protective practice that focuses on avoiding lawsuits rather than proactively attaining client goals (Turnell 2006). Sherman and Wenocur (1983) suggest that probationary staff in such organizations often start with a skill and routine mastery stage in which they become oriented to the job in the context of limited caseloads and access to frequent supervision, somewhat like internships and field placements in professional education programs. Such protected practice can enhance skill and confidence that efforts with clients can be successful. However, in times in which resources are increasingly limited, this protected entry is often foregone in the interest of immediately reducing the caseloads and pressures on highly stressed staff members. So, if the protected period occurs, this “honeymoon” period is often followed by a social integration stage in which the protections are removed: caseloads increase and access to supervision decreases. Practitioners may come to realize that no matter how hard and skillfully they work, the agency lacks sufficient resources for them to carry out their jobs as described. This realization is purported to lead to a moral outrage stage in which workers become angry and confront their supervisors with the incongruity of resources and demands. Too often, this complaint may be met with a double-bind response from supervisors: “Your frustration shows us that you are the kind of conscientious person we thought you were when we hired you; we are confident that you will find the resources to cope.” Sherman and Wenocur (1983) suggest that this outrage is followed by feelings of guilt, frustration, repressed anger, and depression. Similarly, clients frustrated by the lack of resources project anger on the practitioner held responsible for the lack of resources. Sherman and Wenocur suggest six ways of coping with this conflict between job descriptions and lack of resources. The capitulator resolves the conflict by identifying with the organization: do what is possible without guilt, stop advocating, shut down empathy, and shuffle papers. In contrast, the noncapitulator continues to fight by rejecting the values of the organization. Such practitioners identify with client anger rather than powerlessness.

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Practice Applications with Involuntary Problems and Settings According to the authors, they also often become isolated, identified as mavericks and house radicals, such that they come to resign, are counseled out, or are fired. A third response is niche finding, in which practitioners find a special position such as training director in which they can use their skills outside of the line of fire of high client contact and low resources. This solution can last as long as the person holds the position. A fourth response is withdrawal, in which practitioners leave the job in hopes of finding a less constrained environment. Other forms of withdrawal can include psychological withdrawal or detachment, emotional distancing from clients, or a physical withdrawal. The latter can occur when practitioners have the opportunity to remove themselves, at least temporarily, from the pressure through long commutes or spending a day on paperwork. Sherman and Wenocur suggest that frustrations may recur within similarly constrained positions unless conflict management skills are learned. Self-victimization or martyrdom occurs when the practitioner identifies with the powerless client and tries to overcome the guilt over ineffectiveness by overworking. Such practitioners may work evenings and weekends, accumulating overtime, often at the risk of alienating persons in their own personal lives and support systems. It should be noted that policies requiring extensive access of clients to practitioners through beepers may also produce this stress on personal support systems. Practitioners with high skills and client commitment may be particularly prone to this martyrdom. While each of these five responses are understandable styles of coping with the dissonance over conflicting job descriptions and limited resources, Sherman and Wenocur describe a functional noncapitulator response as more functional. In this response, conflict is managed by acting responsibly to influence the organization. Functional noncapitulators pick their battles, deciding when to capitulate and when to take calculated risks in negotiating the conditions of work. This response also models a form of empowerment that enables them to negotiate with their clients within boundaries. With the exception of the functional noncapitulator role, most of the remaining coping styles have negative connotations. Practitioners with experience in such overloaded settings have suggested that selective use of responses such as withdrawal into paperwork for a day or looking forward to a long drive after a client visit can be productive coping methods. Other styles noted by such experienced practitioners include the scrapper, who models being pragmatic and making the best of bad situations, and the cheerleader, who praises peers and arranges for staff treats and lunches as a way of maintaining staff morale. The pragmatist emphasizes not getting deeply emotionally involved in situations but rather focusing on what the practitioner is required to do and the currently available choices rather than seeking to extend them. High focus on individual styles of coping runs the risk of implying that individual practitioners can and should be able to regulate their own stress

The Nonvoluntary Practitioner and the System and their response to it through appropriate use of individual coping techniques. In fact, the working conditions in many involuntary settings are such that emotional exhaustion could be considered a normative response to extraordinarily adverse conditions. Work stress increases for staff when clients suffer from a lack of resources (Lewandowski 2003). In addition to stress management and mindfulness training, organizational interventions such as increased worker autonomy and organizational support are needed (Crowder and Sears 2017; Mor Barak, Nissly, and Levin 2001). If clients are to be assisted in experiencing more power and influence to improve their circumstances, then the workers who serve them also need to feel as if they also have an impact on their environment (Gutierrez, GlenMaye, and De Lois 1995; Kondrat 1995; Cohen 2002). Assessment of organizational performance should include input from staff members and recipients of service. Encouraging staff members to advocate for ser vice improvements and with explicit commitment of top administrators to the work of staff are among the characteristics of empowering organizations (Hardina 2005). Organizations have a variety of internal and external methods that can assist in making workers feel valued and empowered in their employment. The organization can regularly solicit and utilize staff feedback, publicly express respect and appreciation for workers, promote a learning environment, include worker participation in planning of change efforts, and provide access to professional development (Turner and Shera 2005). Outside the organization, leadership can focus on acquiring increased resources for the population or domain of the agency and sponsor positive public campaigns about the importance of the work. They can also support legislative initiatives that promote greater social justice for users and collaborate in community research initiatives to enhance knowledge about effectiveness (ibid.). For such organizational support to occur, a transformational leadership style is recommended that provides intellectual stimulation and inspirational motivation and is not characterized by a reactive or laissez faire style of leadership (Mary 2005).

Flow Antithetical to burnout and stress is the experience of flow, or the mental state in which a person is fully immersed in what he or she is doing. Csikszentmihalyi originally studied artists to discover what allowed them to persist in the absence of significant external rewards (Csikszentmihalyi 1975). He found that the artistic experience was intrinsically rewarding for them, and later found that this sense of intense involvement was also experienced by persons across professions and cultures (Csikszentmihalyi 1991). Further, the components of flow experiences include clear goals, such that the goals are attainable and

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Practice Applications with Involuntary Problems and Settings expectations are understandable. A person in flow is able to concentrate and focus by paying attention to key activities and avoiding distractions. While in flow, a person is not self-conscious. That is, the person is so deeply immersed in the activity that he or she is not thinking about or worried about others’ perceptions of them. While in flow, there is a distorted sense of time. For example, extended periods can seem to pass quickly because the person is so immersed in the activity. On the other hand, a person can be so engrossed in an immediate event that he or she can get a large amount of information out of it. For example, some helping professionals can become so engrossed in a crisis situation that they can describe in detail events that transpired in a brief period. Flow activities are usually characterized by direct and immediate feedback such that individuals can tell how successful they have been and alter course if need be. Flow occurs when there is a balance between ability level and challenge. So, for instance, when challenge is too high and you are overloaded, you experience frustration. On the other hand, if ability is higher than challenge, you experience boredom. Hence a person should seek a balance such that the challenge is formidable, attainable, but not too high and out of reach. Hence, the process of assisting clients in an empowering fashion to enhance skills should incorporate seeking such a balance by raising expectations to a level that is attainable but not easy. Persons in the state of flow have a sense of personal control over their actions such that they are focused on what they can do and not distracted by what is out of their control. The flow experience is intrinsically rewarding in that the action appears effortless. Finally, focus while in flow is absorbed in the activity, which is referred to as action awareness merging (Csikszentmihalyi 1975; Nakamura and Csikszentmihalyi, 2009). The linkage between flow and working conditions with involuntary clients can be summarized in the following way. Persons who become involuntary may experience a kind of psychological entropy in which their energy feels useless and they feel out of control, unfocused, and overloaded. Similarly, hardpressed practitioners facing excessive expectations may experience a similar entropy (Csikszentmihalyi 1991). Trying to reduce entropy suggests seeking to establish conditions that foster flow. Hence, practitioners might seek to develop clear, attainable goals with clients with ready feedback. They would seek to support enjoyable activities. Similarly, the practitioner would seek to focus on attainable goals and establish working conditions that support concentration, for example, finding ways to not be disturbed while concentrating on writing a report. Finally, a supervisor wanting to support flow-like conditions would seek to support the above principles by establishing clear attainable goals, providing ready feedback, and attempting to match skill with demand level.

The Nonvoluntary Practitioner and the System

Change Efforts with Involuntary Clients Change efforts can occur at many levels in work with involuntary clients. Individual practitioners can utilize guidelines from this book to enhance their work with individuals, families, and groups. They can reduce stress and enhance flow by concentrating on specific goals. For example, they might be alert to mandated and nonvoluntary circumstances, empathize with reactance responses to unwanted pressure, utilize ethical persuasion, and contract with clients utilizing motivational congruence to pursue goals that are meaningful to clients. In so doing, they can seek to enhance meaningful choices. They can assist clients in making choices about which problems to explore first and which to table and make further choices in deciding which kinds of efforts and ser vices to employ in seeking the goals. They can pursue pro-social modeling and clarify roles including bound aries between helping and protection roles. Such efforts should enhance working relationships with involuntary clients and reduce time spent on trying to out-manipulate clients who are attempting to manipulate them. Hence some stress reduction and flow enhancement is within the capacity of individual practitioners. The solitary practitioner, however, works in an environment that operates under laws, policies, resources, and philosophies. Frequently such policies are engaged not in pursuing meaningful engagement with clients and seeking mutually defined success but rather in carrying out the letter of the law and demonstrating reasonable, reimbursable efforts. Hence the organizational climate is critical in enhancing the efforts of individual practitioners. Sending practitioners to training and bringing training in-house can be the early stage of an effort to develop a supportive agency environment. Frequently, however, such efforts are planned top-down with agency administrators determining what is in the agency’s best interest, paralleling an involuntary ser vice agreement approach with clients that is unlikely to engage practitioners as active participants. Polling practitioners and working with a planning group of practitioners and supervisors is more likely to produce initiatives that will engage practitioners beyond the agency’s capacity to reward and punish. Developing initiatives with clearly defined goals and markers for measuring progress including supporting norms of not merely studying compliance but rather assessing together what is working and examining obstacles impeding goals (Turnell 2006). Instead of focusing exclusively on problems that are occurring, identifying and studying promising exemplars of practice can assist in empowering the organization to succeed more than focusing exclusively on reducing errors (Ferguson 2001, 2003). Hence identifying models of practice that appear to be done well can guide further initiatives (Ferguson 2001). For example, the senior author of this book conducted training in the methods described in this book with a group of urban child welfare workers. After the training concluded he met with each team of practitioners attending the

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Practice Applications with Involuntary Problems and Settings training and asked them to bring one case each that they wished to consult about and one case whose success they were pleased with. In this fashion, the often-extensive focus on failure that occurs during consultations was avoided by devoting equal time to successes (Greene, Lee, and Hoffpauir 2005). Further, this identification of successes then led to the development of training videotapes in which agency practitioners were able to demonstrate promising models of practice. Hence, further training need not focus on what is wrong with agency practice but rather on how to increase successful practice (Rooney and De Jong 2012).

A Research Agenda for Work with Involuntary Clients Beyond individual and agency efforts, further studies of intervention with involuntary clients are needed. The areas in which further knowledge are particularly needed are delineation of ethical, effective practice; studies of influence and engagement; studies of practice with members of oppressed groups; studies of variation of influence methods across problems, groups, regions, and nations; studies of interventions such as motivational interviewing and solutionfocused brief treatment; and exemplars of best practices at the individual practitioner and organizational levels. 1. Ethical practice. This book has advocated that involuntary practice needs to be both ethical and effective. Practitioners need guidance about balancing responsibilities to involuntary clients, agencies, and social control. That is, they need to know how to include client goals and clarify limits and duties regarding privileged communication, confidentiality, informed consent, and social control responsibilities (Reamer 2005; Taylor and Bentley 2005; Burman 2004). Practitioners need guidelines for including clients in decision making (Adams and Drake 2006). 2. Effective practice. Practice must also be designed to be effective. That goal must consider a lens of evidence-based practice (EBP) in determining guidelines for practice. EBP refers to consulting appropriate research literature and explicitly and judiciously using that evidence in making intervention decisions (Sackett et al. 1996). The evidence-based practitioner formulates questions that can be answered with data, assesses the reliability and validity of that data, and shares the conclusions with clients as part of informed decision making (Gambrill 2006; Gibbs 2007). Such descriptions of EBP explicitly support collaborative practice and involving clients centrally in decision making. As mentioned in chapter 3, those descriptions appear to assume that clients are voluntary and hence can be the final judges over interventions to be used with them. Decisions are made guiding practice with involuntary clients as well, and consulting empirical data is no less impor tant. For example, so-called

The Nonvoluntary Practitioner and the System scared straight programs were developed as an intervention designed to prevent juvenile delinquency by exposing youth to incarcerated criminals (Petrosino, Turbin-Petrosino, and Buechler 2004). Later studies questioned the effectiveness of this method (ibid.). However, fields of practice such as child welfare often have a limited number of studies in which clients were randomly assigned to conditions (Thomlison 2003; Whiting-Blome and Stieb 2004; Kessler, Gira, and Poertner 2005). Consequently, practitioners and agencies need to consider the best available knowledge in their areas of practice when determining practice guidelines. 3. Studies of influence and engagement with involuntary clients are needed. Interventions that are coercive or exert a powerful source of influence require additional scrutiny in the decision to use them (Scheyett 2006). Hence, guidance for work with involuntary clients should include information about the ethical, effective use of influence to achieve individual and societal gains. In this regard, studies of the effectiveness of drug courts and other controls of drug use are important (Rempel and Depies-Di Stefano 2001; Brecht, Anglin, and Dylan 2005; Klag, O’Callaghan, and Creed 2005;). Such studies also examine the extent to which coercion has similar effects across nations (Stevens et al. 2005). In other arenas in which coercion is used, such as outpatient treatment of persons with serious and persistent mental illness, studies need to examine the quality of life of such patients (Swanson et al. 2003; Brophy and Ring 2004). Of particular interest are studies of the interaction between practitioners and patients living in the community in which efforts to utilize persuasion are featured (Floersch 2002; Angell, Mahoney, and Martinez 2006). Finally, since the first step in influence is engagement, studies of ethical, effective engagement are needed (Littell, Alexander, and Reynolds 2001; Yatchmenoff 2005). 4. Studies of involuntary practice with members of oppressed groups. We need to continue to study the disproportionate representation of members of oppressed groups among the ranks of involuntary clients (see chapter 5 by Dewberry Rooney and Blakey in this volume). For example, we need to know the extent to which race is a factor in the use of coercive means to control drug usage (Beckerman and Fontana 2001) and use of groups to control domestic violence (Buttell and Carney 2005). Guidelines for ethical, effective practice with involuntary clients who are members of oppressed groups are needed. 5. Study variation in ethical, effective practice with involuntary clients across problem areas, populations, and countries. In addition to focus on members of oppressed groups, studies are needed on the variation of effectiveness across problems, populations, and countries. For example, studies of drug courts with substance abusers need to consider variation in the substances used (Brecht, Anglin, and Dylan 2005). Studies on the variation in the engagement of women as clients are needed (Barlow et al. 2005; Clark et al. 2005). Finally, the incidence of involuntary status and variation in methods used are needed across

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Practice Applications with Involuntary Problems and Settings nations (Ho and Chui 2001; Billinger 2005; Stevens et al. 2005; Chui and Ho 2006). 6. Studies of the adaptation of interventions such as motivational interviewing and solution-focused brief treatment to work with involuntary clients. As demonstrated in part 3  in the chapters by Van Wormer and Parker (chapter  15), Hohman, Kleinpeter and Strohauer (chapter 17), and Chovanec (chapter 12), motivational interviewing and stages of change offer promising perspectives for engaging involuntary clients at their own stage of development. Similarly, Franklin, Hopson, and Guz (chapter 18) and Mirick, Altman, and Gohagan (chapter 19) have demonstrated the utility of solution-focused methods in pursuing co-constructed goals and focusing on positive outcomes. Simplistic applications that ignore power differentials and the authority of mandated workers to operate under laws does not serve public agency workers. Hence, applications to the role of mandated worker are needed. 7. Exemplars of best practices at individual practitioner and organizational levels are needed. Beyond broad guidelines for practice, profiles of best practice under difficult circumstances are needed. Models of what such practice look like are needed to guide practitioners (Ferguson 2001, 2003; Turnell 2006). Guidelines for implementation at organizational levels (Whittaker et al. 2006) are needed including incorporation of the voice of practitioners and clients about identifying key ingredients of quality ser vices (Dale 2004). Studies are needed of how to construct a climate of appreciative inquiry in which practitioners, clients, and agencies can explore together to find best practices (Turnell 2006; Wilson and Tiles 2006).

Discussion Questions 1. How do you see job stress as interacting in work with involuntary clients? What is the responsibility of the practitioner to protect against burnout? How can the agency support practitioners at risk of compassion fatigue? 2. How do practitioners in your agency cope with client and organizational pressures? How can they be replenished and at least occasionally experience flow in their work? 3. What are the assumptions in your agency about how and why involuntary clients change? Are they considered to be motivated primarily to avoid punishments and gain rewards? To what extent are their personal goals validated? 4. What is the value of cross-fertilization in research on involuntary clients? That is, what is the value of examining processes and outcomes with other involuntary audiences outside your own arena?

The Nonvoluntary Practitioner and the System 5. What do we know about the power of coercion to induce change? What assumptions are made in your setting about this? 6. How can your organization create a climate of appreciative inquiry that seeks to improve practice through incorporating the voices of clients and practitioners?

References Adams, J., and R. Drake. 2006. “Shared Decision Making and Evidence-Based Practice.” Community Mental Health Journal 42 (1): 87–105. Adams, R. E., J. A. Boscarino, and C. R. Figley. 2006. “Compassion Fatigue and Psychological Distress Among Social Workers: A Validation Study.” American Journal of Orthopsychiatry 76 (1): 103–108. Angell, B., C. Mahoney, and N. Martinez. 2006. “Promoting Treatment Adherence in Assertive Community Treatment.” Social Service Review 80: 485–526. Barlow, J., S. Kirkpatrick, D. Stewart-Brown, and H. Davis. 2005. “Hard-to-Reach or Out-ofReach: Reasons Why Women Refuse to Take Part in Early Interventions.” Children and Society 19 (5): 199–210. Baum, A., R. Fleming, and D. Reddy. 1986. “Unemployment Stress: Loss of Control, Reactance and Learned Helplessness.” Social Science and Medicine 22: 509–516. Beckerman, A., and L. Fontana. 2001. “Issues of Race and Gender in Court Ordered Substance Abuse Treatment.” In Drug Courts in Operation: Current Research, 45–61. New York: Haworth Press. Billinger, K. 2005. “A Focus Group Investigation of Care-Provider Perspectives in Swedish Institutions for the Coercive Care of Substance Abusers.” International Journal of Social Welfare 14: 55–64. Brecht, M., M. Anglin, and M. Dylan. 2005. “Coerced Treatment for Methamphetamine Abuse: Differential Patient Characteristics and Outcomes.” American Journal of Drug and Alcohol Abuse 31: 337–356. Brehm, J. 1976. A Theory of Psychological Reactance. 2nd ed. New York: Academic Press. Brophy, L., and D. Ring. 2004. “The Efficacy of Involuntary Treatment in the Community: Consumer and Ser vice Provider Perspectives.” Social Work in Mental Health 2 (2/3): 157–174. Burman, S. 2004. “Revisiting the Agent of Social Control Role: Implications for Substance Abuse Treatment.” Journal of Social Work Practice 18 (2): 197–210. Buttell, F., and M. Carney. 2005. “A Large Sample Evaluation of a Court Mandated Batterer Intervention Program: Investigating Differential Program Effect for African American and Caucasian Men.” Research on Social Work Practice 16 (2): 121–131. Chui, W., and K. Ho. 2006. “Working with Involuntary Clients: Perceptions and Experiences of Outreach Social Workers in Hong Kong.” Journal of Social Work Practice 20 (2): 205–222 Clark, C., M. Becker, J. Giard, R. Mazelis, A. Savage, and W. Vogel. 2005. “The Role of Coercion in the Treatment of Women with Co-Occuring Disorders and Histories of Abuse.” Journal of Behavioral Health Services and Research 32 (2): 167–181. Cohen, M. 2002. “Pushing the Boundaries in Empowerment-Oriented Social Work Practice.” In Pathways to Power: Readings in Contextual Social Work Practice, eds. M. O’Melia and K. Miley, 143–155. Boston: Allyn and Bacon.

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Practice Applications with Involuntary Problems and Settings Conrad, D., and Y. Kellar-Guenther. 2006. “Compassion Fatigue, Burnout, and Compassion Satisfaction Among Colorado Child Protection Workers.” Child Abuse and Neglect 30: 1071–1080. Crowder, R., and A. Sears. 2017. “Building Resilience in Social Workers: An Exploratory Study on the Impacts of a Mindfulness-based Intervention.” Australian Social Work 70 (1): 17–29. Csikszentmihalyi, M. 1975. Beyond Boredom and Anxiety. San Francisco: Jossey-Bass. Csikszentmihalyi, M. 1991. Flow: The Psychology of Optimal Experience. New York: Harper and Row. Dale, P. 2004. “Like Fish in a Bowl: Parents’ Perceptions of Child Protective Ser vices.” Child Abuse Review 13: 137–157. Draycott, S., and A. Dabbs. 1998. “Cognitive Dissonance 2: A Theoretical Grounding of Motivational Interviewing.” British Journal of Clinical Psychology 37: 355–364. Ferguson, H. 2001. “Promoting Child Protection, Welfare and Healing: The Case for Developing Best Practice.” Child and Family Social Work 6: 1–12 Ferguson, H. 2003. “Outline of a Critical Best Practice Perspective for Social Work and Social Care.” British Journal of Social Work 33: 1005–1024. Figley, C. R. 2002. “Compassion Fatigue: Psychotherapists’ Chronic Lack of Self-Care.” Psychotherapy in Practice 58: 1433–1441. Floersch, J. 2002. Meds, Money and Manners: The Case Management of Severe Mental Illness. New York: Columbia University Press. Gambrill, E. 2006. “Evidence-Based Practice and Policy: Choices Ahead.” Research on Social Work Practice 16 (3): 338–357. Gibbs, L. 2007. “Applying Research to Making Life-Affecting Judgements and Decisions.” Research on Social Work Practice 17 (1): 143–150. Greene, G., M. Y. Lee, and S. Hoffpauir. 2005. “The Languages of Empowerment and Strengths in Clinical Social Work: A Constructivist Perspective.” Families in Society 86 (2): 267–277. Gutierrez, L., L. GlenMaye, and K. DeLois. 1995. “The Orga nizational Context of Empowerment Practice: Implications for Social Work Administration.” Social Work 40 (2): 249–258. Hardina, D. 2005. “Ten Characteristics of Empowerment- Oriented Social Ser vice Organizations.” Administration in Social Work 29 (3): 23–42. Ho, K., and W. Chui. 2001. “Client Resistance in Outreaching Social Work in Hong Kong.” Asia Pacific Journal of Social Work 11 (1): 114–130. Johnco, C., A. Salloum, K. Olson, and L. Edwards 2014. “Child Welfare Workers’ Perspectives on Contributing Factors to Retention and Turnover: Recommendations for Improvement.” Children and Youth Services Review 47: 397–407. Littell, J., L. Alexander, and W. Reynolds. 2001. “Client Participation and Outcomes of Intensive Family Preservation Ser vices.” Social Work Research 25 (2): 103–114. Kelly, A. 2000. “Helping Construct Desirable Identities: A Self-Presentational View of Psychotherapy.” Psychological Bulletin 126: 475–494. Kessler, M. L., E. Gira, and J. Poertner. 2005. “Moving Best Practice to Evidence-Based Practice in Child Welfare.” Families in Society 86 (2): 244–250. Klag, S., F. O’Callaghan, and P. Creed. 2005. “The Use of Legal Coercion in the Treatment of Substance Abusers: An Overview and Critical Analysis of Thirty Years of Research.” Substance Abuse 40: 1777–1795. Kondrat, M. 1995. “Concept, Act and Interest in Professional Practice: Implications of an Empowerment Perspective.” Social Service Review 69: 405–428. Lewandowski, C. 2003. “Organizational Factors Contributing to Worker Frustration: The Precursor to Burnout.” Journal of Sociology and Social Welfare 30 (4): 175–185.

The Nonvoluntary Practitioner and the System Mary, N. 2005. “Transformational Leadership in Human Ser vice Organizations.” Administration in Social Work 29 (2): 103–118. Mor Barak, M., J. Nissly, and A. Levin. 2001. “Antecedents to Retention and Turnover Among Child Welfare, Social Work and Other Human Ser vice Employees: What Can We Learn from Past Research? A Review and Meta-analysis.” Social Service Review 75 (4): 625–661. Nakamura, J., and M. Csikszentmihalyi. 2009. “The Concept of Flow.” In Handbook of Positive Psychology, eds. S. Lopez and C. Snyder, 89–105. New York: Oxford University Press. Petrosino, A., C. Turbin-Petrosino, and J. Buechler. 2004. “Scared Straight and Other Juvenile Awareness Programs for Preventing Juvenile Delinquency.” The Cochrane Library issue 2. Chichester, UK: John Wiley. Reamer, F. G. 2005. “Ethical and Legal Standards in Social Work: Consistency and Conflict.” Families in Society 86 (2): 163–169. Rempel, M., and C. Depies-Di Stefano. 2001. “Predictors of Engagement in Court-Mandated Treatment: Findings at the Brooklyn Treatment Court, 1996–2000.” In Drug Courts in Operation: Current Research, 87–124. New York: Haworth Press. Rooney, R. H., and M. de Jong. 2012. “From Focusing on Deficits to Appreciative Inquiry: Work with Teen Parents Uncovering Promising Practices.” In Task- Centered Social Work to Evidence-Based and Integrative Practice, eds. T. Rzepnicki, S. McCracken, and H. Briggs, 200–218. Chicago: Lyceum. Sackett, D. L., W. Rosenberg, J. Muir-Gray, R. Haynes, W. Richardson. 1996. “Evidence Based Medicine: What It Is and What It Isn’t.” British Medical Journal 312: 71–72. Scheyett, A. 2006. “Danger and Opportunity: Challenges in Teaching Evidence-Based Practice in the Social Work Curriculum.” Journal of Teaching in Social Work 26 (1/2): 19–29. Sherman, W. R., and S. Wenocur. 1983. “Empowering Public Welfare Workers Through Mutual Support.” Social Work 28: 375–379. Shier, M., J. Graham, E. Fukuda, K. Brownlee, T. Kline, S. Walji, and N. Novik. 2012.” Social Workers and Satisfaction with Child Welfare Work: Aspects of Work, Profession and Personal Life That Contribute to Turnover.” Child Welfare 91 (5): 117–138. Stevens, A., D. Burto, W. Heckmann, V. Kerschl, K. Oeuvray, M. Van Ooyen, E. Steffan, and A. Uchtenhagen. 2005. “Quasi-Compulsory Treatment of Drug Dependent Offenders: An International Literature Review.” Substance Abuse and Misuse 40: 269–283. Strom-Gottfried, K., and N. Mowbray. 2006. “Who Heals the Helper? Facilitating the Social Worker’s Grief.” Families in Society 87 (1): 9–15. Swanson, J., M. Swartz, E. Elbogen, R. Wagner, and B. Burns. 2003. “Effects of Involuntary Outpatient Commitment on Subjective Quality of Life in Persons with Severe Mental Illness.” Behavioral Sciences and the Law 21: 473–491. Tam, T., and L. Mong. 2005. “Job Stress, Perceived Inequity and Burnout Among School Social Workers in Hong Kong.” International Social Work 48 (4): 467–483. Taylor, M. F., and K. J. Bentley. 2005. “Professional Dissonance: Colliding Values and Job Tasks in Mental Health Practice.” Community Mental Health Journal 41 (4): 469–480. Thomlison, B. 2003. “Characteristics of Evidence-Based Child Maltreatment Interventions.” Child Welfare 82: 541–569. Turnell, A. 2006. “Constructive Child Protection Practice: An Oxymoron or News of Difference?” Journal of Systemic Therapies 25 (2): 3–12. Turner, L., and W. Shera. 2005. “Empowerment of Human Ser vice Workers: Beyond IntraOrganizational Strategies.” Administration in Social Work 29 (3): 79–94. Whiting-Blome, W., and S. Stieb. 2004. “Whatever the Problem, the Answer Is ‘Evidence Based Practice’— Or Is It?” Child Welfare 83 (6): 611–615.

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Practice Applications with Involuntary Problems and Settings Whittaker, J., K. Greene, R. Blum, K. Blum, K. Scott, and R. Roy. 2006. “Integrating EvidenceBased Practice in the Child Mental Health Agency: A Template for Clinical and Organizational Change.” American Journal of Orthopsychiatry 76 (2): 194–201. Wilson, S., and C. Tiles. 2006. “Mentoring the Statutory Child Protection Manager— A Strategy for Promoting Proactive Outcome Focused Management.” Social Work Education 25 (2): 177–188. Yatchmenoff, D. 2005. “Mea suring Client Engagement from the Client’s Perspective.” Research on Social Work Practice 15 (2): 84–96.

Appendix

Training Videotapes on Strategies for Work with Involuntary Clients

Selections from several videotapes were used to illustrate intervention methods in chapters 4 and 7 to 10. Three tapes are available from Alexander Street at https://alexanderstreet.com/. 1. Task-Centered Case Management. Jane Macy-Lewis. 22 minutes. This tape depicts a recontracting session between a case manager for an adult, disabled, and mentally ill caseload in a small rural county and Mike, her actual client, who is unhappy in his current group home placement. Macy-Lewis specifies the problem, reviews options, and helps Mike make plans about future living arrangements in a clear model of commitment to client self-determination and normalization inherent in the task-centered approach (see chapter 9). 2. Contracting for Home-Based Services. Ron Rooney and Betty Woodland. 52 minutes. Family-centered, home-based ser vices are a form of in-home assistance that is usually aimed at preventing out-of-home placement for children. This tape depicts contracting with a mother and daughter to reduce the problems that caused the mother to seek out-of-home placement. The tape models involuntary contracting strategies, persuasion, work with a highly oppositional client (the mother), and ways of bringing the situation to a productive focus (see chapter 10). 3. Work with Involuntary Clients: The Consumer’s Perspective. Ron Rooney. This videotape includes a live interview with a consumer of mental health services. The consumer describes her history in hospitals, social ser vices, and work with a variety of helping professionals. She describes respect, listening,

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Appendix and supporting choices as professional activities that have helped her. This tape is referenced in chapter 7. Two training videotapes were developed by the University of Wisconsin School of Social Work. DVDs can be ordered for $15 each from UW-Madison Learning Support Ser vices, Mary Prochniak, Media Librarian, 1220 Linden Drive, Madison, WI 53706–1525. 1. Permanency Planning: Use of the Task- Centered Model with an Adolescent Toward Independent Living. The Contracting Phase. Nancy Taylor. 4744-C. This tape demonstrates the contracting process with an actual adolescent client (see chapters 8). 2. Permanency Planning: Use of the Task- Centered Model with an Adolescent Toward Independent Living. The Middle Phase. Nancy Taylor. 475-1-c. This tape demonstrates the six-week review session in which obstacles to original contracted goals are identified and new tasks are developed with an actual adolescent client. The tape includes a model of effective, middle-phase confrontation. It also includes a follow-up interview conducted by Ron Rooney (see chapters 8). Four training videotapes were developed by the University of Minnesota, School of Social Work. Links to these videos can be shared by contacting Ron Rooney at the School of Social Work, University of Minnesota: rrooney@umn .edu. 1. Nonvoluntary Client Contracting. Walter Mirk. 25 minutes. This tape depicts an actual initial session between a county mental health worker and a nonvoluntary client pressured by her public agency social worker to seek help (see chapter 8). 2. Socialization with a Probation Client. Bill Linden. 26 minutes. Contracting with a mandated client about to enter prison presents a challenge for any practitioner. Linden demonstrates ways in which choice and respect for the client can be introduced into an other wise highly coercive situation. Linden also demonstrates well-timed, respectful confrontation with this actual client (see chapter 8). 3. Work with Involuntary Clients in the Middle Phase. Cheri Brady. 22 minutes. This tape depicts a middle-phase session with a nonvoluntary client. The methods used draw heavily on the task-centered approach. The tape models methods for dealing with tasks that have not been completed, examination of obstacles, role plays, developing new tasks, appropriate middle-phase confrontation, and summarization (see chapter 9). 4. Socialization at Chemical Dependency Intake. Dick Leonard. 40 minutes. Chemical dependency settings have been associated with strongly confron-

Appendix tive methods designed to challenge and crack the defenses and denial of chemically dependent clients. Leonard models two different methods to approach intake situations in chemical de pendency inpatient settings. The same intake interview is hence presented twice, using different methods in each. The tape was developed with an actual client (see chapter 8).

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About the Editors

Ronald H. Rooney, PhD, Professor Emeritus, School of Social Work, University of Minnesota. Dr. Rooney is the author of Strategies for Work with Involuntary Clients (1992, 2009) as well as an author of Direct Social Work Practice, now in its tenth edition, with Dean Hepworth, Glenda Dewberry Rooney, and Kim Strom-Gottfried (2016). He is a licensed clinical social worker and has trained and consulted since 1978 in child welfare, family-based ser vices, and work with involuntary clients. Rebecca Mirick, PhD, Assistant Professor, School of Social Work, Salem State University. Dr. Mirick is a licensed clinical social worker. Dr. Mirick is an assistant professor at Salem State University School of Social Work where she teaches clinical practice, human behavior, research, and field seminar to undergraduate and graduate social work students. As a clinical social worker, Dr. Mirick has worked with children, adolescents, families, and adults in a variety of settings, including outpatient mental health, preschool, juvenile detention, and early intervention. Dr. Mirick’s research has focused on engagement and resistance to ser vices, including parents’ experiences with child welfare ser vices. For the past ten years, she has worked with Riverside Trauma Center in Needham, Massachusetts, on their suicide prevention work, which has included the development and evaluation of effective, evidence-based trainings for gatekeepers and clinicians on suicide assessment, response, and intervention.

Contributors

Julie Altman, PhD, Professor, California State University, Monterey Bay. Dr. Altman received her PhD from the University of Chicago and her MSW from University of Michigan. She is a professor and director of the Master of Social Work Program at California. Dr. Altman’s practice and scholarly work lies primarily in public child welfare, particularly regarding issues of workforce development and improved ser vice delivery, including the process of engaging parents in ser vices. Twice a Fulbright recipient, she is the author of numerous publications and peer-reviewed presentations and serves on a variety of editorial review boards. Dr. Altman consults with numerous communitybased child welfare agencies, particularly in the crafting of research and evaluation designs, and has been invited to work with staff in professional development, grant-writing, and other research activities locally, nationally, and internationally. Tony Bibus, PhD, Professor Emeritus, Augsburg College. Dr. Bibus is a professor emeritus in the social work department at Augsburg College. He is a licensed social worker and has practiced since 1970 in juvenile corrections, child welfare, family-based ser vices, and social work education. He has taught, trained, and published in such areas as supervision, cultural competence, international social work, welfare reform, social work regulation, citizenship-centered administration, social policy, ethical decision making, virtue ethics, and work with involuntary clients.

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Contributors Joan M. Blakey, MSW, PhD, Assistant Professor, Helen Bader School of Social Welfare, University of Wisconsin–Milwaukee. Dr. Blakey received her PhD in social work from the University of Chicago and her Master of Social Work and Bachelor of Science in African American Studies, Sociology, and Youth Studies from the University of Minnesota–Twin Cities. Dr. Blakey’s primary research interests include trauma and substance abuse among women who are involved with the child protection and criminal justice systems. She is interested in understanding the process of healing from trauma, creating trauma-informed systems of care, and testing the effectiveness of traumainformed interventions. Dr. Blakey’s practice and research experiences have primarily been with women and families with histories of substance abuse and trauma. As a junior faculty in the Department of Social Work, she has developed a solid research agenda in these areas as evidenced by her record of publications in various social ser vice journals such as Children and Youth Services Review, Journal of Social Work Practice in the Addictions, and Families in Society. Michael Chovanec, PhD Professor, St.  Catherine’s- St. Thomas University. Dr. Chovanec has taught for the past twenty0 years. His doctorate from the University of Minnesota concentrated on the dropout problem in domestic abuse treatment. He has been a clinician for the past thirty-eight years and works part-time as coordinator and group facilitator for a county domestic abuse program that he helped develop in 1988. He is licensed as a clinical social worker and marriage and family therapist in Minnesota. Tamara S. Davis, PhD, MSSW, Associate Professor and Associate Dean for Academic Affairs, College of Social Work, The Ohio State University. Dr. Davis received her PhD in social work from The University of Texas at Austin and completed a postdoctoral fellowship at the Hogg Foundation for Mental Health. She received her MSSW and bachelor’s degree in counseling and guidance from the University of Louisville. Dr.  Davis focuses her teaching, research, and scholarship on examining disparities and inequities in care for diverse and underserved populations and working with community organ izations to develop culturally responsive health and mental health ser vices and policies. Her current research focuses on integrating behavioral health ser vices into primary care settings. She has published works on integrated care, cultural competence assessment, mental health ser vice disparities and well-being among diverse populations, caregiver involvement in children’s mental health, diversity in social work curricula, and research methodology. Dr. Davis previously practiced social work and social administration in private and public human ser vices and

Contributors focused in the areas of child and youth mental health, child welfare, juvenile diversion, family-based ser vices, and community-based planning and evaluation. Cynthia Franklin, PhD, Stiernberg/Spencer Family Professor in Mental Health and Assistant Dean, School of Social Work, The University of Texas at Austin. Dr. Franklin also holds a faculty fellow appointment at the Meadows Center for Preventing Educational Risk in the Department of Special Education. Dr. Franklin has published over 150 publications in the professional literature and is a world-renowned scholar in school mental health. Dr. Franklin’s research examines the practice and effectiveness of solution-focused brief therapy with children and adolescents. She is the current editor-in-chief for the Encyclopedia of Social Work and is the author of several books, including, The School Services Sourcebook: A Guide for Schoolbased Professionals (Oxford University Press) and Solution Focused Brief Therapy: A Handbook of Evidence-base Practice (Oxford University Press). Over the past twenty-five years, Dr. Franklin has worked as a therapist, consultant, trainer, and researcher for schools and mental health agencies. She is a clinical fellow of the American Association of Marriage and Family Therapy and holds practice licenses in clinical social work and marriage and family therapy. Dr. Franklin’s research includes a meta-analysis of RCT studies on school mental health ser vices; efficacy and effectiveness studies on solutionfocused brief therapy (SFBT); and studies and systematic reviews of SFBT for the purposes of developing SFBT into an empirically supported treatment. Studies and systematic reviews have resulted in SFBT being recognized by US federal agencies such as the Substance Abuse and Mental Health Ser vices Administration’s National Registry for Evidence-based Programs and Practices (2013). Taking Charge, an intervention that she helped develop for Latina adolescents, was also recognized as a promising practice by Office of Juvenile Justice and Delinquency Prevention (OJJDP) and was added to the crime solutions model programs guide (2013). Debra Gohagan, PhD, Associate Professor, Mankato State University. Dr. Gohagan is professor and program director for the baccalaureate program, at Mankato State University in Minnesota. She has served as the Bachelor of Science SW program coordinator and contract manager for the Title IV-E Child Welfare Program for more than ten years. Dr. Gohagan has more than twenty years of direct practice in children and family ser vices. Since 2010, she has integrated knowledge and skills related to Signs of Safety, also referred to as Safety Organized Practice in many contexts, as well as the impact of trauma into her professional academic and practice activities. Dr. Gohagan has published and presented extensively in local, national, and international contexts

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Contributors on child welfare, professional practice skills, and the use of teaching pedagogy and technology in social work education. Dr. Gohagan’s interests include providing international educational opportunities for students through student exchange programs and participation in Conflict Transformation and Social Justice summer schools. Samantha Guz, MSW student, University of Texas at Austin. Ms. Guz received a bachelor’s degree in psychology and sociology from Texas A&M University. During her undergraduate career, she began serving clients as an autism therapist, working with individuals on the autism spectrum and their families. After completing an honors thesis and graduating from Texas A&M she served rural homeless communities in Central Texas through the Texas A&M Extension Ser vice. Samantha will complete her master’s of social work in 2017. Her studies focus on serving at-risk youth and their families in schoolbased and community-based settings. In addition to her clinical experiences at CapCityKids, AGE of Central Texas, and LifeWorks, Ms. Guz has gained research experience in school-based research, qualitative analy sis, metaanalyses, and systematic literature reviews. Melinda Hohman, PhD, Professor and Director, School of Social Work, San Diego State University. Dr. Hohman earned her bachelor’s and master’s degrees in social work from the University of Pittsburgh and her PhD from Arizona State University. She joined the faculty at San Diego State University (SDSU) in 1995. She has taught courses on substance use disorders, cultural competency, and social work practice, including motivational interviewing (MI). Dr. Hohman has been an MI trainer since the late 1990s, and has been a member of the Motivational Interviewing Network of Trainers (MINT) since 1999. She has trained thousands of social workers, probation officers, and substance abuse counselors, among others, in MI, both across California and nationally. Dr. Hohman has served as a MINT Trainer of Trainers. She is also the author of Motivational Interviewing in Social Work Practice. Dr. Hohman consulted on the California SBIRT Project and was a lead trainer on MI for the health educators on this project. She also consulted on an SBIRT initiative at SDSU’s student health center. Dr. Hohman has published over forty articles and her areas of research include addiction assessment and treatment. Laura Hopson, PhD, Associate Professor and Bachelor of Science SW Program Director, University of Alabama School of Social Work. Dr. Hopson has over ten years of experience teaching social work students and practitioners in a variety of areas, including prevention of risk behavior, research methods, and school-based interventions. Her research focuses on prevention of health risk behaviors and academic failure among vulnerable

Contributors adolescents, especially ethnic minority adolescents from economically disadvantaged households. Her work also examines barriers to implementing evidence-based practices in community agencies and strategies for overcoming these barriers. Carol Jud, MSW, Human Ser vices Program Manager, West Suburban and South Human Ser vice Centers, Hennepin County Human Ser vices. Ms. Jud received her master’s degree in social work from the University of Minnesota–Twin Cities, and has worked in county social ser vices for twentyfour years. She spent over six years working as a child protection social worker before becoming a supervisor in child protection. She has supervised staff who serve both adults and children who have developmental disabilities, physical disabilities, and mental health issues, as well as adults and youth who are homeless. She has led multiple organizational change efforts at the county with the goal of providing better ser vices to community members. In her current position, she is working to open and operate community-based human ser vice centers designed to provide holistic ser vices to county residents. This work involves bringing multiple ser vice areas together in one place to provide quality ser vices. Carol has also taught classes on social work with involuntary clients to MSW students. Christine Kleinpeter, Psy.D., Professor, California State University, Long Beach. Dr. Kleinpeter is licensed in psychology and clinical social work, and has over fifteen years of clinical experience in a variety of inpatient and outpatient psychiatric settings. Her teaching interests are in clinical practice, human behavior, and mental health. She has conducted research in the areas of drug court outcomes, co-occurring drug court outcomes, college mental health outcomes, distance education, and surrogate parenting. She is a trainer in motivational interviewing and the Diagnostic Manual of Mental Disorders-5. She has trained many social service professionals, probation workers, child welfare workers, and corrections officers. She has served as the associate director and coordinator of academic programs and coordinator of the distance education program at the California State University School of Social Work in Long Beach. She has supervised marriage and family therapy marriage and family therapy interns and social work associates toward licensure with the Board of Behavioral Sciences in California. She is currently providing mental health ser vices at a community college integrated health center. Justine McGovern, PhD, LMSW, Assistant Professor, Lehman College Department of Social Work, City University of New York. Dr. McGovern’s research interests include the lived experience of dementia, families and the life course, diverse experiences of aging, international social work, and research methodologies, especially where increasing inclusivity and reducing

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Contributors ageism in scholarship are concerned. At Lehman, she teaches core courses and electives, including Social Work with Older Adults, and is a member of the Interdisciplinary Minor in Aging Steering Committee. Justine publishes and presents internationally. In addition, she has provided trainings to helping professionals and family caregivers for the Alzheimer’s Association, New York City Chapter, and the Brookdale Center for Healthy Aging, and professional development workshops for faculty at New York University, on CUNY campuses, and at Fordham University. Topics include living better with dementia, older adults and substance abuse, and motivational interviewing. Until recently, she managed a parental care practice, which focused on strengths-based decision-making for frail, older parents, and supporting dementia partners in care. Justine led a support group for adult children caregivers of parents with Alzheimer’s Disease for the Alzheimer’s Association in New York for four years. Laura Parker, PhD, Assistant Professor, Northern Iowa University. Dr. Parker’s PhD is from the University of Missouri. She has been an assistant professor at Columbia College in Maryland. Adriane Peck, LISW-S, MEDTAPP Integrated Care Program Manager, College of Social Work, The Ohio State University. Ms. Peck earned her master’s degree in social work from the University of Pennsylvania. She received her bachelor’s in psychology from Pennsylvania State University. Adriane has fifteen years of experience in direct social work practice in various areas of specialty, including mental health, substance use, and providing behavioral health care in primary care settings. She has practice experience in levels of behavioral health care including crisis, acute, outpatient, and integrated care. At MEDTAPP, she co-leads efforts to develop and implement a unique workforce training program and curriculum for clinical social work students. She is a member of the primary care behavioral health research team at The Ohio State University College of Social Work, where she contributes to efforts to evaluate student learning, examine disparities and inequities in care for diverse and underserved populations, and to study various aspects of integrating behavioral health ser vices into primary care settings. Adriane has also co-authored publications on the integrated care training program and its evaluation. Per Revstedt, MSc Psych, Revstedt and Hartman Inc., Malmoe, Sweden. Mr. Revstedt is a licensed psychologist and psychotherapist with supervisor expertise and is a specialist in clinical psychology. He worked in inpatient psychiatric care and therapeutic treatment in residential care for many years. He also has many years’ experience as a supervisor and trainer in the social services, the penal system, and psychiatry. In 1986, he published Motivationsarbete (fourth Swedish edition 2014) and in 2014 Motivational Work, Part 1–4 (in English).

Contributors Glenda Dewberry Rooney, MSW, PhD, Professor Emeritus, Department of Social Work, Augsburg College. Dr. Rooney is a licensed clinical social worker. Her work includes practice, consultation, training, and communitybased research in mental health, child welfare, and family ser vices, including ser vices to military families with the American Red Cross where she began her professional career as a caseworker. Dr. Rooney is an author, along with Kim Gottfried-Strom and Ronald H. Rooney, of Direct Social Work Practice: Theory and Skills (2016). Her chapter in that work, “Involuntary Status and Oppression in Strategies for Work with Involuntary Clients,” examines the dynamics of being a member of an oppressed group and an involuntary client. The chapter introduced the concept of the silent mandate, which is neither legal nor ethical. Tamara Strohauer, MSW, SDSU Research Foundation. Ms. Strohauer is a graduate of the School of Social Work at San Diego State University (SDSU). While there, she interned as an SBIRT interviewer at the student health center and also as a therapist at an intensive outpatient program for persons with co-occurring psychiatric and substance use disorders. She is an associate clinical social worker and certified addictions treatment counselor currently working as a counselor and instructor at the SDSU Research Foundation Driving Under the Influence Program. She is also the Southern Region SERVE Coordinator for the Title IV-E Stipend Program, working with Native students interested in the field of child welfare. Chris Trotter, PhD, Professor, Monash University School of Social Work, Melbourne, Australia. Dr. Trotter worked for many years as a community corrections officer and manager in adult corrections prior to his appointment to Monash University in 1991. He has undertaken many research projects and published widely on the subject of effective practice with involuntary clients, particularly those in the criminal justice system. He has an international reputation for his work particularly in relation to pro-social modeling. His book Working with Involuntary Clients, now in its third edition, is published in multiple languages and has sold widely around the world. His other books include Collaborative Family Work and Helping Abused Children and their Families. Dr. Trotter is director of the Monash Criminal Justice Research Consortium and is currently engaged in several research projects on effective supervision skills. Katherine van Wormer, MSSW, PhD, Professor of Social Work at the University of Northern Iowa. Dr.  van Wormer earner her PhD in sociology from the University of Georgia. In the 1960s, van Wormer participated in two civil rights movements— one in North Carolina and one in Northern Ireland, where she taught English for several years. In the late 1980s, she moved to

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Contributors Norway for two years to practice alcoholism counseling. Dr. van Wormer has authored or co-authored over twenty books and sixty articles. Works authored or co-authored by Dr.  van Wormer include Death by Domestic Violence: Preventing the Murders and the Murder- Suicides (2009); Working with Female Offenders: A Gender-Sensitive Approach (2010); two volumes of Human Behavior and the Social Environment, Micro and Macro Levels (2011); and Addiction Treatment: A Strengths Perspective (2010). Her most recent books are Restorative Justice Today (2012) and Women and the Criminal Justice System (2014). Dr. van Wormer and her co-author have done numerous speaking engagements related to their 2012 book, The Maid Narratives: African American Domestic Workers and their Employers in the Jim Crow South.

Index

Abstinence: from alcohol, 431; in substance abuse treatment, 418; viable alternative to, 430 Academic performance, and mental health needs, 480 Access to care, 382; of ethnic minorities, 383–384 Action awareness merging, in flow experience, 576 Action stage, of change, 59, 201 Active listening, 198 Addiction: changing concept of, 423–424; motivational strategies for, 431; new definition of, 424; opiate, 423; physiological basis in, 424; use of term, 419, 421 Addictive medications, in substance abuse treatment, 418 Adherence, treatment: definition for, 58; increasing, 58 Adolescent delinquency, family-centered practice in, 299 Adolescents: antisocial behavior of, 314; expectable motivations of, 338; help-seeking behavior of, 482; as involuntary clients, 478;

out-of-home placement for, 309; protecting, 171; reducing reactance of, 255; reframing strategies for, 228, 231; resistance of, 481, 482–483; SBIRT for, 461; scaling questions with, 486; solution-focused intervention approach with, 482, 485, 488–489; in stressful environments, 479; with suicidal ideation, 318 Adoption and Safe Families Act (ASFA) (1997), 504 Adversarial relationship, deadlock resulting in, 198–199 Advocacy: dismantling oppression through, 131–133; patient, in integrated care, 392–393 Advocates, practitioners as, 224 Affirmative action, 109 Affordable Care Act (ACA) (2010), 383, 428, 429, 431; collaborative health care supported by, 384 African American children, 479 African American males, in criminal justice system, 479–480

600

Index African Americans: in American educational system, 119; politically motivated image of, 108–109; propaganda targeted at, 109; toxic stress in lives of, 116–118, 120–121; and zero tolerance policies, 100. See also Oppressed groups Ageism, 410 Agencies: child welfare, 225; developing supportive environment for, 577; family service policies of, 306; hidden agenda of, 243; multiple, conflicting goals of, 244; in negotiation process, 244 Agency policies, and involuntary transactions, 7 Agenda, for involuntary groups, 333 Agendas, hidden, in family-centered practice, 323 Agitation, in persons with dementia, 412 Agreeable mandate strategies, 232, 233–234 Alcabes, A., 528 Alcohol: academic impact of, 465–466; withdrawal syndrome for, 420 Alcohol dependence, recovery from, 425 Alcoholism: diagnosis of, 425; new paradigm for, 431; research evaluation studies on, 426 Alcoholism treatment, assertiveness training groups in, 351 Alcohol use disorder: criteria for, 419–420; and SBIRT, 462 Alcohol Use Disorder Identification Test (AUDIT), 462, 468, 469 Alternative or family assessment response (AR), 314 Alternatives to aggression approaches, 248 Altman, Julie, 580 Alzheimer’s Association, 407 Alzheimer’s disease, 407. see also dementia Ambivalence, client, 179 American College Health Association (ACHA), 465 American Psychiatric Association (APA), 419 American Society of Addiction Medicine (ASAM), 424

Anderson, C., 306, 310 Anderson, M. L., 118 Andrews, D., 53, 528, 529 Anger: causes of, 121; as expression of trauma, 150; toward child protective services, 125 Antidepressants, in substance abuse treatment, 426 Antipsychotic medication, for mental health patients, 83, 84 Antle, B., 14, 510 Arab Spring, 110 Assessment, 175–179; conducting involuntary, 214–215; definition for, 167; deviance in, 169, 174; formats for, 168–169; guides for, 167–168; at initial contact, 191, 215; with involuntary clients, 167–169; involuntary vs. voluntary, 168; in just practice problem solving, 128–129; negative, 216–217; and reactance theory, 179–187; strategic self-presentation in, 187–191; tools for, 168 Association of Social Work Boards (ASWB), on contracting principles, 545 Assumptions, practitioner, at initial contact, 205 Attitudes: in family-centered practice, 319; in involuntary groups, 350, 351–352 Attitudes, influencing client: cognitive methods, 82–91; compliance-oriented methods, 69–82, 71f, 76f, 79f; persuasion methods, 69–82, 71f, 76f, 79f Attitudinal change, 275 Attorneys, and social workers, 559 Austin, M., 557, 558 Australia, child welfare policies in, 504 Authority: and legal and ethical perspectives, 35; of practitioners, 199 Autonomy, of self-referred client, 208–209 Babcock, J. C., 364 Bains, R. M., 480 Bashant, C., 141 Bathing, for persons with dementia, 413 Batterer intervention programs, 362

Index Baxter, V., 367 Bednar, S. G., 61 Behavior: linked to experiences of trauma, 156; resistance, 179. see also Resistance; Trauma Behavioral contracting, motivational congruence enhanced by, 57, 63 Behavioral health care, stigma as barrier to, 384 Behavioral health clinicians: clinical skills of, 395–396; and motivational interviewing, 398; short-term intervention models for, 396–397; understanding role of, 390–391 Behavioral health screening, 385 Behaviors, influencing client: cognitive methods, 82–91; compliance-oriented methods, 69–82, 71f, 76f, 79f; persuasion methods, 69–82, 71f, 76f, 79f Belenko, S., 52 Beliefs: hygiene, 414; in involuntary groups, 344, 350, 351–352 Beneficence: definition for, 30; selective vs. extensive, 30 Berg, I. K., 124, 311, 312 Bergeron, L., 38 Bergin, A. E., 366 Berliner, A. K., 330 Best practices: in child welfare services, 504; in corrections, 531–536; in domestic abuse treatment, 367; models for, 580 Bibus, A. A., 100, 103 Biopsychosocial functioning, effects of oppression on, 96 Black Lives Matter, 109–110 Blakey, Joan M., 8, 142, 150 Bond, C., 488 Bonta, James, 528, 529 Bowers, P. H., 142 Brain research, and substance abuse, 424 Bratter, T., 352 Brehm, Sharon, 51, 55–56, 183, 186 Bridges, A. J., 400 Brief Alcohol Screen and Intervention for College Students (BASICS), 463–464 “Broken windows” police practices, 99

Brooks, D., 141 Brown, V. B., 160 Bruce, E. J., 557, 558 Bucior, C., 120 “Buddy” systems, in domestic abuse programs, 375 Burke, B., 110 Burnout: complaint of, 555; in motivational work, 434, 439 California Personality Inventory (CPI) Socialization Scale, 527 Canada, child welfare policies in, 504 Capitulator response, of social workers, 554, 556, 573–574 Caplan, T., 368 Caplan and Thomas Group process model, 361, 368, 369 Care partners: resistance of, 409, 415–416; and specific dementia problems, 410–414; and stages of dementia, 409–410 Care team, in integrated care, 391 Carey, K. B., 466 Caring roles, and social control, xii Carlson, B., 148 Case information, for initial contact, 200 Case management: in corrections services, 536, 537; in task-centered approach, 275–276 Case managers, role of, 276 Case plans, as paperwork rituals, 242–243 Case studies, 34–38, 436; advantage of, 435; disadvantage of, 436; ethical limitations on client freedom, 34–38, 40–42; legal limitations on client freedom, 34–38; method, 435; vulnerable adult in, 40–42 Casey Family Program, 508 Change: in domestic abuse treatment, 364–365; reactance and, 542–544; self-attributed, 271; transtheoretical model of, 58–59; in unmotivated clients, 439; in work with involuntary clients, 577–578. see also Stages of change Chemical dependency counselors, 252

601

602

Index Chemical dependency problems, and intensive confrontation, 287–289 Chemical dependency treatment, 248, 366 Child abuse: domestic abusers with history of, 367; mandated reporting of, 38 Child abusers, with histories of trauma, 144 Childcare, need for, 125 Child custody, mediation for, 187–188 Child management issues, 209 Child protection services, 147, 537; anger toward, 125; and client’s understanding, 125; confrontation in, 222–223; and familycentered practice, 299, 301, 312–314; involuntary clients of, 129; parental perception of, 502; research on, 303; resistance in, 310; strengths-based approaches in, 313–314; trauma survivors in, 139 Child protection workers, 24; dual role of, 313 Child welfare, best practices in, 504; differential response pathways, 504, 505–506; family group conferencing, 511–513; safety organized practice models, 506–511; solution-focused brief treatment, 506, 509t; trauma-informed practice, 506 Child welfare agencies, collaboratively created service plans in, 225 Child welfare services: client engagement in, 503–504; excessive intrusion of, 107; strengths-based, collaborative models for, 513 Child welfare settings: best practices in, 497; collaborative work in, 500–502; nonvoluntary clients in, 494; successful engagement in, 502 Child welfare settings, nonvoluntariness in, 498; differences between clients and workers, 498–499; parents’ responses in, 499–500; power and authority in, 499 Child welfare system, 122; assumptions behind, 122; mandated reporting in, 100; nonvoluntary clients in, 57; and trauma survivors, 146

Child welfare work, case example of, 495–497 Child welfare workers: client’s perspective on, 496–497; progress of, 497–498; training for, 577–578. See also Professionals, child welfare Chinese populations, SFBT with, 489 Choice: coerced, 208, 223; constrained, 78, 226; and empowerment, 184–185; extent of, 62; at initial contact, 204; for involuntary clients, 55; negotiable vs. nonnegotiable, 57; for oppressed groups, 111; self-attribution of, 89 Choudhuri, D., 118 Chovanec, M., 52–53, 61, 62, 368, 580 Cinco de Mayo celebrations, 126 Cingolani, J., 14 Civil rights, 20 Classroom assignment, as silent mandate, 101–102, 119 Cleveland, Ohio, death of Tamit Rice in, 110 Client, definition for, 3–4 Client base, and involuntary status, 97, 97f Client-centered therapy, Rogers’s, 437 Client-clinician relationship, 399–400 Client referral status, 55 Clients, as agency “captives,” 540 Clients, involuntary, research agenda for work with, 578. See also Involuntary clients Client socialization, 528 Client’s view, in negotiation and contracting, 227–229 Client-worker relationship, in child welfare settings, 501 Clifford, D., 110 Coaches, practitioners as, 224 Cocaine, crack, 99 Codeine, 421 Code of Ethics, of National Association of Social Workers, 29, 113–114 Coercion, 51; inducement compared with, 78; intrusiveness of, 91; in involuntary groups, 334; in outpatient psychiatric care, 400; vs. persuasion, 41; studies of, 73

Index Coercion methods, 70, 70f. See also compliance-oriented methods; persuasion methods Cognitions, of unmotivated clients, 440 Cognitive balance theories, research on, 86 Cognitive behavioral approach, in substance abuse treatment, 427 Cognitive dissonance: in involuntary groups, 350; and nonvoluntary practitioners, 572 Cognitive impairment: dementia-related, 408; progressive, 410 Cognitive methods, with involuntary clients, 82. See also Persuasion Collaboration: in child welfare settings, 498; in school environments, 480–481 Collins, P. H., 118 Commitment, in motivational relationships, 450, 451 Commonality, in involuntary group meetings, 343 Communication: in dementia, 411–412; facilitating, 33; privileged, 23 Community college students, counseling services for, 466 Community College Task Force, 466 Community correction officers, 524 Community health, involuntary considerations in, 384–387 Community protection goals, 63 Compassion fatigue, of nonvoluntary practitioners, 572–573 Competence, and contracting options, 241 Complainant, in solution-focused approach, 484 Compliance: as coercive dynamic, 111; enhancing, 228; intrusiveness of, 91; of oppressed groups, 111; of unmotivated client, 445; use of term, 58 Compliance-oriented methods: case study, 70–72; concept of, 72; definition for, 69; inducement, 78–82, 79f; punishment, 72–77, 76f Comprehensive Addiction and Recovery Act (CARA) (2016), 428

Compromiser role, of practitioner, 199 Conciliatory attitude, of unmotivated client, 445 Confidentiality: and adolescent concerns, 481; definition for, 23; for families of involuntary clients, 321; at initial contact, 204; violation of, 23. See also Informed consent Conflict, and semivoluntary contracts, 225 Confrontation: appropriate, 218; assertive, 221, 285–287, 289; of cognitions, 454; continuum for, 218, 218f; in domestic abuse groups, 366, 367; empathic, 333; ethics of, 452; inappropriately use of, 290; inappropriate use of, 289; intensive, 287, 288–289; in involuntary groups, 346–347, 353; in motivational work, 452–453, 455–456; programmed, 288; selective, 216, 295; in socialization guidelines, 217; successful, 221; task-centered approach in, 284–291; underuse of, 290 Confrontational style, and problem behavior, 217 Confrontation-denial cycle, 64, 199, 289, 331 Connectedness, in dementia, 411–412 Conrad, P., 169 Consent form, valid, 22. See also Informed consent Contact rebuses, 443, 458; compliance, 446, 451; and confrontation, 452–453; destructive, 446; destructive and aggressive, 444–445; theory of, 447; types of, 444–446; understanding, 445; withdrawal, 446 Contacts, with families of involuntary clients, 304, 316–318, 317f Contemplation, definition for, 179 Contemplation phase, of change, 59 Contracting: and adverse beliefs, 242–245; definition for, 32, 57, 224–225; facilitating, 32; with families of involuntary clients, 321–323; goal of, 224; for involuntary clients, xii; strategies for, 240. See also Negotiation and contracting

603

604

Index Contracts: developing formal, 245; formalizing involuntary, 252–258, 254f; with mandated clients, 32; as paperwork rituals, 242–243; semivoluntary, 225, 226f, 227f; voluntary contracts, 226f, 227 Control: involuntary client’s view of, 119; response to loss of, 182 Control, sense of: for involuntary clients, 55; for oppressed groups, 112 Cooperation, of unmotivated client, 440 Co-planning, facilitating, 32 Corey, G., 353 Correctional boot camps, 77 Corrections: balanced approach in, 528–529; best practice in, 531–536; case studies in, 531–536; effectiveness of work in, 526–527; focusing on high-risk offenders in, 529; involuntary clients in, 524, 525–526; problem solving in, 527–528; pro-social modeling in, 527; rehabilitation in, 526; role clarification in, 528; structured learning programs in, 529–530 Counselors, as nonvoluntary practitioners, 13 Counter conditioning, teaching, 375 Court orders, reaction to, 121–122 Courts: domestic violence, 52–53; problemsolving, 52–53 Court system, social workers in, 559 Crack epidemic, 99 Criminalization, 109 Criminal justice system, 148; and rehabilitation, xii–xiii; trauma survivors in, 139; traumatized incarcerated women in, 148–149, 153 Criminogenic needs, 527–528 Crisis: definition for, 120; in task-centered approach, 283–284 Csikszentmihalyi, M., 575 Cullen, F., 528 Cultural differences, and family-centered practice, 302 Culturally different groups, and family group conferencing, 512

Cultural values, in child welfare settings, 498 Customer, in solution-focused approach, 484 Danger, in legal and ethical guidelines, 36 Daniels, J. W., 375–376 Darity, V. W., 182 Davis, R. C., 363 Debriefing, 573 Debt strategy, in persuasion methods, 84 Decentralization, of client services, 543 Decision making: about termination, 292, 293; client participation in, 33, 578; in involuntary groups, 350, 351; of self-referred client, 208–209 Decision-making stage, of change, 59 Defensiveness, of client, 443 Defiance-based paradoxical strategy, 239–240 De Jong, P., 124, 311 Delinquency: adolescent, 299; and social work services, 50 Dementia: care goals in, 416; and care partners, 406; causes of, 407, 408; consequences of, 407; definition for, 407–408; diagnosing, 408; impact of, 407; loss associated with, 405–406, 407; managing challenging behaviors associated with, 410–414; quality of life with, 406, 407, 414–416; resistance in, 405, 406, 409–410, 414–416; respite in middle stages of, 409; strengths-based, person-centered approach, 411–412; symptoms of, 408; types of, 407 Denhardt, J. V., 554 Denhardt, R. B., 554 Depression, and SBIRT, 462, 464–465 de Shazer, S., 309–310 Destructive behavior, 444 Deviance, 167; case vignette, 169, 170, 171–174, 178–179, 181–182, 183–184; definition for, 169; examples of, 169; and inadequate resources, 42; as individual pathology, 170, 172; integrative model of, 172; primary, 171–172; secondary, 173; social labeling perspective on, 171, 172–173; structural model of, 170–171, 172

Index Dewberry-Rooney, G., 8 Diagnosis and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 419, 420 Diagnostic indicators. See Stages-of-change approach Diallo, A. F., 480 DiClemente, C. C., 372 Differential response (DR) models, 504, 505–506 Distrust: dynamics of, 112–113; of police, 113. See also Trust Documents, electronic storage of, 544 Domestic abuse: costs of, 362; guidelines for best practices in, 367; problems of, 361–362; victims of, 361 Domestic abuse treatment, 361; attrition in, 366–367; beginning stage, 372–375; effectiveness of, 363–364; engagement in, 364–366; GEM of, 365–366; innovations in, 367–369; innovative models for, 376; interventions in, 370t; men in, 361; pregroup planning for, 369–371, 370t, 372; standard confrontational approaches in, 366–367 Domestic abuse treatment programs, 344; effectiveness of, 362, 367; ending stage, 375–376; involuntary/nonvoluntary participation in, 362–363; middle stage, 375; opening statement in, 371; work with contemplator in, 374–375 Domestic violence: groups for, 331; research in, 352; and SBIRT, 462; victims of, 84, 332 Domestic violence courts, 52–53 Domestic violence groups, 351–352 Domestic violence perpetrators: motivational congruence with, 63; treatment programs for, 55; work with, 61 Domestic violence shelters, 157 Dowd, E., 183 Drinking behaviors, and BASICS, 463–464 Dropouts, from domestic abuse programs, 364 Drug courts, 52, 579 Drug laws, revising, 424 Drug testing, mandatory, 422

Drug use, in minority vs. nonminority communities, 99–100 Due process: expansion of, 27; facilitating, 31–32; for involuntary clients, 21; legal movement to ensure, 29 Duluth model, 362, 366, 369, 373, 375 Duncan, B. L., 345 Eating disorders, in substance abuse treatment, 427 Eating habits, for persons with dementia, 413 Edleson, J. L., 54 Educational neglect, case study of, 122–123, 125–126, 130 Edwards, Steve, 508 Elder abuse, reporting, 39 Emotional and behavioral problems (EBD), 101–102, 103, 119 Emotions, and persuasion methods, 88 Empathy, 198; and corrections services, 530; expressing, 215 Emphatic statement, 221–222 Employee representatives, coordination with, 544 Employees: in integrated care, 394; training in trauma-informed care for, 397–398. See also Workforce Empowerment: and choice, 184–185; facilitating, 32; in integrated care, 386–387; and safety organized practice, 506 Enforcers, practitioners as, 224 Engagement process: in correctional groups, 366; in problem solving, 124–128 Entitlement, and propaganda of oppression, 108 Entitlement programs, characterization of recipients of, 109 ETHIC acronym, in policy making, 30–31 Ethical guidelines, 19–20; beneficence, 30; general, 31–34; for involuntary clients, 28–31; legal perspectives integrated with, 34–42; paternalism, 29–30; self-determination, 28–29

605

606

Index Ethical issues: in family-centered practice, 311; for involuntary groups, 334, 353; for management, 550–553; research on involuntary clients, 48–50 Ethics audit, 31 Ethics committees: agency guidelines developed by, 30; informed consent guidelines of, 33 Ethnicity: of involuntary clients, 132–133; and involuntary status, 100; superior-inferior construct in, 108 Ethnic minorities, access to care of, 383–384 Europe, child welfare policies in, 504 Evidence-based practice (EBP), 47–48, 537; in guidelines for practice, 578–579; for integrated care, 400 Evidenced-supported practices, ignoring, 142 Exemplification, in self-presentation, 190 Expectations, for nonvoluntary practitioners, 576 Extensions, in task-centered intervention, 293 Facework, in self-presentation, 190 Facilitators: in batterer intervention programs, 362, 365; in domestic abuse treatment programs, 371–372; in family group conferencing, 512 Families: low-income, single-parent, 302; nonvoluntary work with, 323; in safety organized practice, 506–507; voluntary, 304 Families, of involuntary clients, 316–318, 317f; adaptations for work with, 315–324; adapting treatment perspectives for, 307–311; blame felt by, 321; family-centered interventions for, 311–314; working with, 298–301, 324 Family-centered practice (FCP), 299; assessing voluntariness in, 303; disagreement with problem definition in, 300; ethical issues in, 311; home-based assessment in, 299–300; involuntary contact in, 304–307; and reluctance of participants, 301, 302; resurrection of resistance in, 309–310; settings for, 307–308; strengths-based approach in, 312, 313

“Family centered” services, 205 Family contact, involuntary: formal pressures for, 304–306; informal pressures for, 307; in mandated treatment, 307 Family group conferencing (FGC), in child welfare practices, 511–513 Family preservation movement, 312–313 Family reunification program, in child welfare setting, 503 Family systemic interventions, common factors in, 314–315 Family therapists, as nonvoluntary practitioners, 12–13 Family therapy, 298–299; attachment based, 318; goal conflict in, 308–309; role conflicts in, 310; second-order goals in, 309; systems perspectives in, 308; techniques, 300 Family transaction, involuntary, 304 Family units, unemployment destabilized, 479 “Family values,” 109 Fate control, 9 Fathers, in child welfare services, 499 Feder, L., 364 Fentanyl overdoses, 421 Finn, J. L., 123, 124, 125 Fischer, J., 50, 55 Fishman, Daniel B., 436 Flint, Michigan, water crisis of, 108 Flores, P., 54 Flow experiences, 575–576 Forrest, G., 290 Foster care, task-centered work in, 252, 253f Franklin, Cynthia, 580 Freedom, client: ethical limitations on, 34–38, 40–42; legal limitations on, 34–38; limitations on, 42 Freire, P., 130 Frye, M., 118 Functional noncapitulator response, of practitioners, 574 Funding priorities, 96 Furman, D., 22, 25

Index Gadow, S., 40 Galinsky, M., 349 Gambling, compulsive, 427 Gambrill, E., 57 Garvin, C. D., 331 Geller, J. L., 400 Gender, and child welfare service delivery, 499 Gendreau, P., 528 Germain, Carel, 177 Gilliland, B. F., 128 Gingerich, W. J., 510 Girvin, H., 303 Goals: in family-centered practice, 319; in involuntary groups, 345–350; for nonvoluntary practitioners, 575–576 Goal setting, in just practices problem solving, 129 Gohagan, Debra, 580 Goldsmith, A. H., 182 Gong, H., 489 Gray, B., 38 Group engagement measure (GEM), 365–366, 371 Group leaders, 340, 352. see also Facilitators Groups: members of, 126; nonvoluntary, 330; and social control, 331; substance abuse treatment, 331 Groups, involuntary, 329, 335–336, 353; attendance at, 347–348; beginning, 342–347; clarifying expectations in, 347; client feedback tools in, 348; closed, topicoriented, 349; cohesive, 347; composition of, 334–335; compulsory attendance in, 336; dangers of, 333–335; developing negotiable processes for, 336–337; enhancing participation in, 348; guidelines for, 330; introduction to, 331–332; mandated, 330; men in, 331; open-ended and closed, 349; postcontracting work with, 349–353; potential advantages of, 332–335; preparation for post-group of, 352–353; process rules for, 346; readiness to engage in change of, 345;

reasons for forming, 335–336; staffing limitations and, 335; stages of group change for, 339–340 Groups, involuntary, preplanning for, 335–341; meeting with prospective members, 337; pregroup preparation, 337–339 Guidelines: for ethical intervention, 19–20; for involuntary groups, 330; for involuntary practitioners, xii, xiii; legal, 31–42; for research with involuntary clients, 49; socialization, 213–223, 214f, 218f Guz, Samantha, 580 Halfway houses, working in, 525 Hanrahan, P., 55, 57 Harkness, D., 557 Harm reduction, 430; case for, 430–431; SBIRT, 473; use of term, 422 Harm Reduction Model, 424 Hatcher, S. S., 150 Health care, crisis in financing, 540 Health care reform, 382 Health disparities, 382–383; and integrated care, 383–384, 401 Health Insurance Marketplace, 428 Heide, K. M., 144 Helping, theories of, 178 Helping professionals, 20; and beliefs about racism, 127; carer support of, 409; and dementia, 406; and involuntary clients, 4; and least restrictive principle, 27; legal roles of, 20; main tasks of, 123; resistances of, 410. see also Professionals Helplessness, learned, 182 Hepworth, D. H., 528 Heroin overdoses, 421 Heymann, G., 38, 426 Hispanic children, 479. see also Latino patients Hispanic males, in criminal justice system, 479–480 Hohman, Melinda, 62, 580 Holdsworth, E., 366 Holistic care, access to, 383

607

608

Index Homebuilders Model, 312–313 Homeless people, 429 Home visits: for service assessment, 299–300; teams for, 563 Hope, in motivational relationship, 450, 451 Hopelessness, of unmotivated clients, 454 Hopson, Laura, 580 Hospitalization, voluntary, 25 Hostility, as expression of trauma, 150 Housing: poor, 117, 118; substandard, 106 Housing First options, 429 Howells, K., 365 Hsu, W., 489 Huband, N., 365 Hughes, R. C., 505–506 Humanistic approach, 441–442, 443 Humility, in child welfare setting, 498 Immigrant communities, and access to care, 383 Immigrants, banning of, 109 Impression management theory, 190 Incarcerated women, trauma among, 148 Incarceration, mass, 105. see also Corrections Incentives: definition for, 41; in problemsolving courts, 53 Inclusion interventions, in domestic abuse treatment, 368 Inclusion techniques, in involuntary groups, 348 Incompetent, legally, 25 Independent living, exploration of, 254 Inducement: case study, 78; compared with punishment, 80–81; consideration of, 81; continuous reinforcement schedule in, 81; definition for, 78; effectiveness with, 80–82; ethical use of, 80; intrusiveness of, 91; legal use of, 79; punishment in combination with, 81 Inductive questioning, 88 Inequality, and involuntary clients, 121 Influence attempts: consequences for relationship of, 85–86; dominance in, 84;

factors in effectiveness of, 83–84; personal benefits and, 85 Informed consent: in evidence-based practice, 48; facilitating, 31–32; with families of involuntary clients, 318–320; in familycentered practice, 306; in family therapy, 311; with involuntary clients, 21–23; and persuasion methods, 86–87; and potential for duress, 49–50; principle of, 22–23; in research with human beings, 48, 49; and right to treatment, 25 Informed consent strategies, 238–240; in negotiation and contracting, 225–226 Ingratiation, forms of, 188–189 In-home services, 103 Initial contact: arrangements for, 205–206; dialogue in, 208, 211–213; initial phase steps in, 206, 207f; initiating, 206–213, 207f; nonnegotiable agency and institutional policies at, 203; nonnegotiable requirements for, 202–203; physical arrangements of, 206; preparation for, 200–206, 201f; with probation officer, 212–213; with referred clients, 209–211; with self-referred clients, 206–209, 207f; socialization guidelines on, 213–223, 214f, 218f InSite, 430 Institutionalized living environment, client reaction to, 181–182 Insurance, lack of adequate, 382 Integrated care (IC), 400–401; clinical skills in, 395–396; and health disparities, 383–384; impact on patients of, 401; informed workforce in, 393–395; and lack of provider options, 386; maximizing efficiency in, 399; motivational interviewing in, 398, 400; patient perceptions of, 399–400; screening tools and protocols in, 395; short-term intervention models in, 396–397; training and education in, 394–395; trauma-informed care, 397–398; use of term, 382 Integrated care settings, involuntary clients in, 384–385; and lack of provider options, 386;

Index loyalty and lack of empowerment, 386–387; and pressures to seek medical care, 385; pressure to report symptoms, 386 Integrated care settings, involuntary providers in, 387–389; logistics for, 388; patients’ presenting issues, 387–388; and provider attitudes, 388–389; and stigma of mental illness, 388–389; training and education of, 389 Integrated care settings, patient-centered environment in: appointment policies, 392; with awareness to patient barriers in, 391–392; customer service, 390–391; patient advocacy, 392–393 Interprofessional interactions, hostile, 389 Intervention principles, 1 Interventions: coerced, 62; definition for, 287; effectiveness of, 48; guidelines for middlephase, 249, 278–291, 279f; legal vs. unethical, 39; and specific practice guidelines, 64. See also Task-centered approach; specific interventions Intervention theory, xi Interviewing, motivational, 59, 61–62, 63, 90, 473 Interviews, problem-solving, 531–536 Intimacy factor, in persuasion methods, 84 Intimidation, in self-presentation, 189 Introductory statement, for involuntary group meetings, 342–345 Intrusiveness, and confrontation techniques, 217 Investigations, legally mandated, 19 Involuntariness, effects of: anger-rage, 121–123; crises, 120–121; procedural justice, 123; reactance, 119–120; toxic stress, 120–121 Involuntariness, factors fostering, 553 Involuntarism, ignoring, 13–14 Involuntary clients: attempts to regain power of, 9–10; compared with “voluntary” clients, 62; definition for, 3–6; effectiveness with, 47; examples of, xi, xii; freedom from unnecessary treatment for, 26; and

inadequate resources, 42–43; invisible, 10; legally mandated, 4–5; as members of oppressed groups, 8; nonadherence with, 58; “nonvoluntary,” 4, 5; pressure felt by, 6; research with, 48–50. See also Domestic violence perpetrators; Sexual offenders; Unmotivated clients Involuntary clients, effectiveness with, 47, 51–58; court-ordered vs. voluntary, 51–53; and motivational congruence, 55–58; with motivational interviewing, 61–62; vs. nonvoluntary clients, 54–55; pro-social modeling in, 53–54; studies of, 50–51; transtheoretical stages of change model in, 61–62; of treatment of sex offenders, 60 Involuntary clients, legal issues with: confidentiality, 23; due process, 21; informed consent, 21–23; liability, 24; malpractice, 24; privileged communication, 23 Involuntary clients, legally mandated: choices for, 157, 158; collaborative model for, 159; and degrees of involuntariness, 140; empowerment of, 158; impact of trauma on, 149–154, 151t; internal trauma of, 152; lack of practitioners’ understanding of, 153–154; services-as-usual approach with, 140–142; and shame-based practices, 142; traumainformed care with, 143; as trauma survivors, 145, 154 Involuntary commitment, 25 Involuntary contact,, continuum of, 3 Involuntary practice, xii Involuntary practitioners, xi, 3 Involuntary service plans: definition for, 225; limitations of, 225; nonnegotiable requirements in, 244 “Involuntary service users,” 4 Involuntary status, 118, 127; attributes of oppression and, 110–116, 111t; changing, 11; client base and, 97, 97f; in dementia, 405; intersection with oppressed groups, 98, 98f; and oppression, 97–98, 97f, 98f; visibility of, 363

609

610

Index Involuntary status, pathways to, 98–99; ascribed status, 104–105; legal mandate, 99–100; silent mandate, 100–104 Involuntary transactions, xiii; definition for, 6–7; imbalance of power in, 104; in oppressed groups, 8; persuasion, 83; power differences in, 545 Irueste-Montes, A. M., 54 Jacobson, M., 123, 124, 125 James, R. K., 128 Jewell, L. M., 364 Jim Crow laws, 105 Jinks, M., 365 Johnson v. Solomon (1979), 25 Jones, J., 528 Judges, and social workers, 559. see also Courts Justice: action-focused, 106; distributive, 123; procedural, 123; restorative, 77 Just practice framework, 123 Just practice problem solving, 123–130; assessment in, 128–129; engagement process in, 124; goal setting in, 129 Juvenile justice system, and family-centered practice, 314 Juvenile sexual offenders, cognitive methods with, 82 Kadushin, A., 557 Kear-Colwell, J., 60 Keith-Lucas, A., 33 Kelly, S., 312 King, D. W., 145 King, L. A., 145 Kirk, S., 170 Kleinpeter, Christine, 62, 580 Labeling: deviant, 191; impact of, 174; resistant, 176–177 Labels: avoiding, 155; on initial contact, 200; in marginalization strategy, 115; stigma of, 115–116 Lambert, M. J., 366

Language, with involuntary clients, 155 Latino immigrant parents, 302. see also Hispanic children Latino patients, and integrated care, 400 Latino populations, SFBT with, 489 Latino youths, and zero tolerance policies, 100 Leaders: of involuntary groups, 344; of voluntary groups, 342. See also Facilitators Learned helplessness, 572 Learning, in involuntary groups, 332 Learning programs, in corrections, 529–530, 537 Least restrictive alternative, of 14th amendment, 25 Legal-ethical matrix, 34–42, 35t Legal framework, for work with involuntary clients, 26–27 Legal guidelines: ethical perspectives integrated with, 34–42; general, 31–34 Legal issues, 24; freedom from unnecessary treatment, 26; for involuntary groups, 334, 353; least restrictive alternative, 25; for management, 550–553; right to treatment, 25 Legal mandates, 99; absence of, 101; and involuntary transactions, 7 Legal procedures, 20 Legal requirements, at initial contact, 202 Legal status, and voluntarism, 11–12 Level of Supervision Inventory, Revised (LSIR), 529 Liability, of public agency employees, 24 Licensing regulations, 541 Lifton, R. T., 334 Lincourt, O., 341 Linking interventions, in domestic abuse treatment, 368 Low balling, practice of, 86 Lum, D., 105 Macgowen, M. J., 365 Maintenance stage, of change, 59, 201 Maiuro, R. D., 369 Malpractice, definition for, 24

Index Managed care, 540, 553 Management: buffering or amplifying dynamics by, 562; building cultural competence, 563; contractin g principles used by, 544–546; in involuntary context, 553–560; legal-ethical matrix for, 550–553; and mediating, 560–562; and performance issues, 546–550; practice guidelines for, 564–565; and safety, 563–564; support system for, 564; timely communication of, 544; and understanding reactance, 541–544; working with involuntary clients of, 41, 553–560. see also Supervision Mandated clients, 211–213 Mandates, and clients’ feelings, 121–122 Manipulation, avoiding, 33 Marginalization: and child welfare services, 501; and involuntary client status, 126; of minorities, 133; of oppressed groups, 105, 114–115; and strategic propaganda, 108–110 Martin, R., 21 Martinson, R., 50, 526 McMurran, M., 369 Media coverage: of protests, 109; of social service settings, 559 Mediation: court-ordered, 187; example of, 561–562 Mediation skills, for management, 560–561 Mediators, practitioners as, 224 Medicaid, nursing home residents with, 26 Medical care, 25. See also Integrated care Medicare, nursing home residents with, 26 Medicine, integrative, 382 Meeting rooms, for involuntary groups, 342 Meichenbaum, D., 58 Melton, G. J., 22 Memorial rituals, 573 Memory, in dementia, 408 Men: assaultive, 61; in domestic abuse treatment, 361 Mendonca, P., 55–56 Mental health: disparities in, 384; and pressures to seek medical care, 385; stigma of, 385

Mental health disorders, among college students, 466 Mental Health Parity and Addiction Equity Act (MHPAEA) (2008), 428 Mental health practitioners, and adolescent clients, 482. see also Practitioners Mental health professionals, 20 Mental health services, 382; school-based, 480 Mental health settings, social work effectiveness in, 49–50 Mental illness: and access to care, 383; negative biases toward, 388; stigma around, 393–394 Mental patients, informed consent for, 22 Mental status examination, for informed consent, 22 Mexican Americans: community acceptance of, 126–127, 128; and educational neglect, 122–123, 125–127, 129. see also Latino patients Miller, William R., 56, 177, 217, 303, 427, 468 Mindfulness training, 575 Minnesota, social service information system in, 542–543 Minorities: involuntary clients among, 98; marginalization of, 133; negative view of, 107; and sentencing laws, 99–100 Minority communities, and police, 112–113. see also Oppressed groups Mirick, Rebecca, 580 Moderation Management program, 430 Monitoring, in task-centered intervention, 294 Montes, F., 54 Mood-altering medications, in substance abuse treatment, 418 Mood-altering substances, in substance abuse treatment, 426 Moral reconation therapy, 82 Morphine, 421 Motivation: compliance demands integral to, 436–437; continuum of, 439–441; in preplanning for involuntary groups, 338; and therapeutic outcomes, 51; and voluntarism, 11–12

611

612

Index Motivational congruence: and behavioral contracting, 57; effectiveness of treatment and, 55–58; at initial contact, 203; interventions designed to enhance, 63; for nonvoluntary practitioners, 572; and performance issues, 548; potential for, 198; for sexual offenders, 60; and socialization methods, 56–57; and task-centered approach, 251–252; in task-centered approach, 289–290; with task-centered attributions, 295 Motivational interviewing, 59, 454; in domestic abuse treatment, 369; effectiveness of, 61–62, 63; in integrated care, 398, 400; with involuntary groups, 341; research on, 580; resistance in, 177; in SBIRT, 467–468, 473; in substance abuse treatment, 427–428; two-sided argument in, 90 Motivational Interviewing: Helping People Change (Miller and Rollnick), 427 Motivational process, 443 Motivational relationship, 434, 450–452 Motivational work, 434–436, 459; basic conditions for, 449–450; bonding process in, 447; confrontation in, 452–453, 455–456; contact rebus theory in, 447; continuity in, 457, 458–459; helper burnout in, 439; historical perspective for, 436–439; method and techniques in, 452–459; objective of, 442; planned length of, 457; and positive core of client, 458; values and theory for, 441–450 Motivational worker, openness of, 454 “Motivation paradox,” 437–438 Multimodal approaches, in correctional services, 530 Multisystemic therapy (MST), 314, 315 Munch, S., 564 Murphy, C. M., 364, 367, 369, 375–376 Mutual aid, in involuntary groups, 332 Nagda, B. A., 110 Naloxone (Narcan), for drug overdose, 422, 431 Naltrexone, in substance abuse treatment, 426

National Association of Social Workers (NASW): Code of Ethics of, 29, 113–114; on contracting principles, 543–544; on harm reduction, 424 National College Depression Partnership (NCDP), 464 National Institute of Alcohol Abuse and Alcoholism (NIAAA), 425 National Institute on Drug Abuse (NIDA)-4 screening tool, 395 National Longitudinal Alcohol Epidemiologic Survey, 425 Native Americans: historical oppression of, 114; SBIRT intervention for, 465. see also Oppressed groups Negotiation: clients’ view of, 244; with families of involuntary clients, 315 Negotiation and contracting, 224; get rid of mandate or outside pressure strategies in, 236–238; “good” and negotiated relationships, 224–227; steps in, 227–240 Negotiator role, of practitioner, 199 Negotiators, practitioners as, 224 Neighborhoods, inner-city, 118 The Netherlands, substance abuse treatment philosophy in, 429–430 New public service approach, in involuntary context, 554 New Zealand, child welfare policies in, 504 Nich finding, of practitioners, 574 Nickle, N., 352 Nicotine patches, in substance abuse treatment, 426 “No-knock” searches, 99 Nonadherence, use of term, 58 Noncapitulator response, of social workers, 554, 556, 573–575 Noncompliance: in child welfare work, 495; definition for, 58 Nonnegotiable requirements: at initial contact, 202–203. See also Legal mandates Nonnegotiable rules, in involuntary groups, 344

Index Nonvoluntariness, client, in child welfare settings, 495 Nonvoluntary clients: contracting with, 32–33; in drug court program, 52; invisible, 10; persuasion with, 91 Nonvoluntary groups, 345 Nonvoluntary status, pressured contact associated with, 103 Nooe, Roger, 171 Norcross, J., 372 Nurses, as nonvoluntary practitioners, 12–13 Nursing home residents, bill of rights for, 26 Obama, Pres. Barack, 428 Obstacle analysis, 282, 283 Obstacles: in task-centered approach, 281–283; in task implementation sequence, 269–271 Offending rates, and pro-social modeling, 527 Ohman, K., 22, 25 Older adults, self-presentation strategy of, 190 Opening statement, in domestic abuse treatment program, 371–372 Opioid epidemic, 418–419, 421–422 Oppositional behavior: in pregroup preparation, 337–338; in voluntary groups, 333 Oppressed groups, members of, 1, 7, 20; ascribed status for, 104; crises faced by, 120; involuntary clients, 8; involuntary status and, 98, 98f; media coverage of, 110; Native Americans, 114; and political neutrality, 132; self perception of, 104–105; in social work literature, 96; in social work practice, 133; studies of involuntary practice with, 579; vulnerable marginalized status of, 126 Oppressed groups, serving: consultation with supervisors, 131; dismantling oppression through political advocacy, 131–133; self-work reflective practice, 130–131 Oppression: definition for, 96, 104, 105; examples of, 106; experience of, 112; impact on daily living of, 128; on individual level, 106; and involuntary client status, 118, 126;

involuntary status and, 97–98, 97f, 98f; micro and macro nature of, 105–107; process of, 105; propaganda of, 108–110; within school system, 479; systems-level, 107–108; understanding experiences of, 97 Oppression, attributes of, 110–116, 111t; case study, 116–118, 120, 124, 127–128, 129, 130; compliance, 111; constrained selfdetermination, 113; distrust, 112–113; external locus of control, 112; historical legacy, 113–114; marginalization, 114–115; outsiders, 115–116; powerlessness, 114; stigma, 115–116 Oppression, effects of: anger-rage, 121–123; crises, 120–121; procedural justice, 123; reactance, 119–120; toxic stress, 120–121 Options, identifying negotiable, 204–205 Orientation phase, for involuntary groups, 349, 350–351 Outcome-based programs, limitations of, 553 Outcome Rating Scale (ORS), 374 Out-of-home placement: low overall rates of, 313; preventing unnecessary, 316 Outsiders: immigrant workers as, 128; involuntary clients as, 115–116 Overcorrection methods, 74 Overwhelmed, complaints of being, 546, 547, 549. See also Burnout Pain Management Best Practices task force, of ACA, 428–429 Parental rights, termination of, 504 Parenting skills, groups for teaching, 330 Parents: in child welfare settings, 494, 495, 503–504; collaboration of child welfare professionals with, 513; in DR child welfare pathway, 505; in involuntary child welfare services, 499–500; Latino immigrant, 302; perspective on child welfare services of, 502; reactance response of, 500; selfempowerment of, 508 Parents, in family-centered practice: and child protection workers, 305; passive resistance of, 303; shame of, 301–302

613

614

Index Parker, Laura, 62, 580 Parole officers, 524, 526 Participation: continuum of, 198t; ethic of, 123 Partners for Change Outcome Management System (PCOMS), 345–346, 348, 368; in domestic abuse treatment, 371–372 Pate, David, 120 Paternalism: definition for, 29; justification of, 29, 30; withholding information, 33 Patient Health Questionnaire (PHQ)-4 screening tool, 395 Peele, S., 420–421 Peer modeling, in voluntary groups, 333–334 Peers, influence of, 353 Performance issues: assessmemt of organizational performance, 575; burnout, 555; and disciplinary action, 550; for management, 546 Personality disorders, in domestic abusers, 367 Persuasion: complementary role of, 91; definition for, 41; ethical use of, 87–90, 91; legal use of, 86–87 Persuasion methods, 69–70, 83; case study, 83; intrusiveness of, 91; questionable, 87; recommendation for, 90–91; two-sided argument, 89–90 Peterson, L., 510 Pew Research Center, 424 Philosophies, for involuntary groups, 344 Pimps, behavior of, 146 Poertner, J., 558, 564 Police: as change agents, 112–113; excessive intrusion of, 107; as source of distrust, 113 Police lynching, 121 Police stops or searches: preparation for, 106; as source of municipal revenue, 100 Politicians, limited role of, 108 Pollock, P., 60 Postcontracting, with involuntary groups, 349–353 Poverty, 382; and oppression, 105 Power: coercive, 9, 10; in engagement process, 124; and marginalization, 114–115; and

professional myths of equality, 13–14; and self-presentation strategies, 190–191; and silent mandate, 103–104; unethical use of, 69 Power imbalance: in child welfare settings, 499; and informed consent, 23; in involuntary transaction, 7–8 Powerlessness: historical legacy of, 114; of oppressed groups, 114, 118 Power relationships, and negotiation, 224 Practice: self-work reflective, 130–131; trauma-informed, 140 Practice guidelines, xiii. See also Guidelines Practice methods instructors, xii Practitioners: authority of, 199; and conflict with client, 198; dual roles of, 14; evidencebased, 47–48; guidelines for agency-based, 21; hidden agenda of, 243; ignoring involuntarism, 13–14; involuntary practice issues for, 12–14; and minimum mandated requirements, 240; in negotiation process, 244; nonvoluntary, 12–13; public agency, 571; public vs. private, 20; role conflict for, 310–311; unconscious use of influence by, 69. See also influence attempts Practitioners, nonvoluntary, 571–572; compassion fatigue of, 572–573; coping styles of, 574–575; disempowerment of, 573; flow for, 575=576; and job stress, 572–573; motivational congruence and, 572; organizational interventions for, 575; organizational support for, 575; protected practice for, 573; turnover for, 572 Pragmatists, practitioners as, 574 Precontemplation phase, of change, 59 Pregiving, in persuasion methods, 84 Pregroup planning, for domestic abuse treatment, 369–371, 370t, 372 Prejudgment, avoiding, 205 Prejudice, issues of, 43 Preparation for experiences, for involuntary groups, 350, 352–353 Preparation stage, of change, 59 Prescription drug overdoses, 421

Index Pressured contact, assessment of response to, 215 Pretherapy training, 56 Primary care health centers, 384–385 Primary care practice, incorporating behavioral health into, 383 Prisoners, depressed, 525 Prison populations, 536. See also Corrections Prisons, working in, 525 Privilege: and propaganda of oppression, 108; violation of, 23 Privileged communication, definition for, 23 Probation officers, 53, 524, 526; initial contact with, 212–213, 213–221, 214f; pro-social, 527 Problem solving: in corrections, 527–528; ethical obligation of effective, 133; just practice, 123–130; social control and, 528–529 Problem-solving courts, 52–53 Problem-solving interviews, 531–536 Procedural justice, 123 Prochaska, J. O., 372 Professionals, 20; in corrections, 524; distrust of, 112; nonvoluntary interaction with, 100–101; reaction to anger of, 150; serving oppressed involuntary groups, 130–133. See also Helping professionals; Mental health professionals Professionals, child welfare, 502; and child’s safety, 508; collaboration with parents of, 513; and “Signs of Safety” model, 510; and solution-focused casework model, 510–511; task of, 507 Program integrity, concept of, 537 Progress review sessions, in task-centered approach, 278–280 Propaganda: about inferiority of otherness, 109; of oppression, 108–110; oratory, 109; progressive strategies co-opted through, 109 Pro-social modeling: in corrections, 527, 537; definition for, 53; goal of, 53–54; opposite of, 87; principle of, 83 Prostitution, in poor economy, 106 Psychiatrists, as nonvoluntary practitioners, 12–13

Psychologists: as nonvoluntary practitioners, 12–13; prison, 524 Psychology, humanistic, 441 Psychosocial self, effects of oppression on, 96 Psychosurgery, informed consent for, 22 Psychotherapy: for less privileged groups, 435; Rogers’s client-centered, 437 Public agency employees, liability of, 24 Public education systems, 479 Public Health Questionnaire-9 (PHQ-9), 464, 468, 469 Public opinion, and involuntary clients, 63. see also Media coverage; Propaganda Public policies, 96; and involuntary status, 102–103; oppressed groups and, 122–123; politics of, 131 Public school system: and at-risk youth, 480; mental health screening in, 479. see also Schools Punishment: in combination with inducement, 81; compared with inducement, 80–81; context for, 72–74; corporal, 7; in corrections, 528–529; cruel and unusual, 79; as deterrent, 77; effective use of, 75–78, 76f; ethical use of, 74–75; inappropriate use of, 75; ineffective use of, 76–77; involuntary clients view of, 119; legal use of, 74; positive, 73 Purdy, F., 352 Quality of life, for persons with dementia, 406, 407, 414–416 Questioning, inductive, 88, 219–221 Questions: and assertive confrontation, 285–287; scaling, 468, 486 Quid pro quo strategies, 234–236 Race: of involuntary clients, 132–133; and involuntary status, 100 Racial minorities, access to care of, 383–384 Racial status, of involuntary clients, 8 Racism: oppression rooted in, 105; within school system, 479; superior-inferior construct in, 108

615

616

Index Rage, causes of, 121 Reactance, 167; and change, 542–544; definition for, 119; feeling of, 500; at initial contact, 204; and management strategies, 541–544; patterns of, 180; professionals’ response to, 119; reduced, 183, 184; strategies to increase, 185 Reactance theory, 1, 72, 179–180, 180–183, 191; in child welfare services, 499–500; in domestic abuse treatment, 368, 371; and involuntary groups, 340; practice implications of, 183; and programmed confrontation, 288; value of, 186–187 Reamer, Frederic, 28, 29, 31, 38, 50–51 Recidivism: and moral reconation therapy, 82; of sex offenders, 60 Recidivism research, in corrections, 537 Recontracting, in task-centered intervention, 293–294 Referrals: clarification of, 55; mandated, 211–213, 229; self-referred clients, 206–209, 207f Referred clients, initial contact with, 209–211 Reframing strategies: in family-centered practice, 322, 323; for mandated clients, 229–231; in negotiation and contracting, 229–232; for nonvoluntary clients, 228 Regehr, C., 14 Rehabilitation, and criminal justice goals, xii–xiii Rehabilitation programs, in corrections, 526, 536 Reid, W., 55, 57, 132 Rein, M., 13, 14 Reinforcement: continuous, 80; in corrections, 527, 537; intermittent schedules for, 81; negative, 73 Relapse, in domestic abuse treatment, 375–376 Relationship skills, and corrections services, 530 Reporting, mandated, 38 Research: on cognitive balance theories, 86; on effective practice, 578; on ethical practice,

578; with involuntary clients, 48–50; on trauma-informed care, 160; on work with nonvoluntary clients, 579–580 Resilience theory, and safety organized practice, 506–508 Resistance, 167; adolescents’, 481, 482–483; behaviors associated with, 175–176; in child welfare settings, 495, 499; of clients, 197; concept of, 177; definitions for, 176, 484; in dementia, 405, 406, 414–416; example of, 175, 179, 180–181, 183, 184; as positive, 179; reframing, 177–178, 191; use of term, 176–177 Resnikoff, N., 121 Resources, limited: in corrections, 529; and initial contact, 240; in involuntary transaction, 7; for nonvoluntary practitioners, 573; in task-centered approach, 277–278 Response cost, in punishment, 73 Restitution, goal of, 74 Retention, of competent social workers, 558 Review panel, to assess informed consent, 49 Review sessions, in task-centered approach, 278–280 Rewards: effectiveness of, 80; in nonvoluntary conditions, 79 Rights: civil, 20; identifying at initial contact, 203, 204; of mandated vs. nonvoluntary clients, 27 Risk assessment, in corrections settings, 529, 537 Roberts, D., 107 Rogers, Carl, 427; later work with schizophrenic patients of, 454; personcentered therapy of, 441; on therapeutic process, 439–440 Rohrbaugh, M., 185 Role conflicts, between family and practitioner, 316 Role models, in involuntary groups, 332 Role play, in task implementation sequence, 274 Role preparation, for practitioner and client, 199 Rollnick, S., 177, 217, 303, 468

Index Rooney, Ronald H., 97, 100, 103, 124, 362, 508, 528 Rosenberg, B., 312 Rouse v. Cameron (1966), 25 Rubin, A., 57 Ryan, B. C., 141 Safe Return registry, 412 Safety: defined, 159; in dementia, 412; physical, 159–160 Safety organized practice (SOP) models: in child welfare services, 506–511; effectiveness of, 510–511; family group conferencing in, 512–513 Saleeby, D. S., 130 Saltzman, R., 22, 25 SBIRT. See Screening, Brief Intervention, and Referral to Treatment Scare tactics, in corrections, 528–529 Schneider, J. W., 169 Schools: mental health needs and services in, 478; public school system, 479, 480; and tax base, 106 School-to-prison pipeline, 479 Schopler, J. H., 349 Screening: behavioral health, 385; in integrated care, 395 Screening, Brief Intervention, and Referral to Treatment (SBIRT), 461, 473; case study for, 468–473; components of, 462–463; defined, 462–464; for depression, 464–465; implementation of, 467; motivational interviewing in, 467–468, 473; in student health centers, 466; in university/ community college settings, 465–466 Seabury, B., 57 Seigers, D. K. L., 466 Self-assessment techniques, in appropriate confrontation, 218 Self-attribution, 199; and behavioral change, 275; promotion of, 272–273; for social workers, 554; with task-centered interventions, 295

Self-confrontation: means of stimulating, 219; in socialization guidelines, 218 Self-determination: constrained, 111, 113; definition for, 28; limiting, 28–29; positive, 42; principle of, 42 Self evaluation, in domestic abuse programs, 373 Self-feeling positive strategy, in persuasion methods, 84–85 Self-interest, client-perceived, 267 Self-presentation, strategic, 167, 187–188, 189; case study, 187–188, 189; for older adults, 190; specific strategies, 188–191 Self-promotion, in self-presentation, 190 Self-referred clients: contacts with, 206–207, 207f; example of, 208–209; reducing reactance with, 207 Self-reflection, 131 Self reflection, 435 Self-victimization: of practitioners, 574; of social workers, 554, 556 Semivoluntary contracts, 227, 241 Sentencing laws, mandatory, 99 Service users, involuntary, 19. See also involuntary clients Sessions, Atty. Gen. Jeff, 429 Sexual offenders: motivational congruence with, 63; treatment of, 60 Sexual predator, as client, 4 Shafer, M., 148 Shame, feelings of, and family-centered practice, 301 Shame-based practice, 142 Shaming, stigmatic, 77 Sherman, W. R., 554, 573, 574 Shields, S. A., 343 Shireman, C., 50–51 Shoham, V., 185 Shulman, Lawrence, 544, 557 “Signs of Safety” model, 494; for child welfare service delivery, 508; manifestations of reactance in, 508–510; SFT scaling technique of, 508; Turnell’s, 510

617

618

Index Silent mandate, 100–101; case studies, 101–103; definition for, 101; as imposed service, 101; power of, 127 Skill-learning phase, for involuntary groups, 349, 351 Skills: in negotiation process, 245; in preplanning for involuntary groups, 338 Smith, T., 51 Social control: and caring roles, xii; and problem solving, 528–529; public policy, 131 Social control groups, 331 Social ethic, 131 Socialization: client, 528; for involuntary clients, xii; for practitioner and client, 199 Socialization guidelines, 213–223, 214f, 216, 218f Socialization methods, with involuntary clients, 56–57, 63 Socializing, in poor communities, 107 Social justice: advocating for, 33–34; and involuntary clients, 121 Social labeling theory, 191; deviance in, 172–173, 174 Social norms, and legally mandated involuntary clients, 141 Social service information system (SSIS), in Minnesota, 542–543 Social services, involuntary, 50 Social welfare organizations, distrust of, 112 Social Work Code of Ethics, 4 Social workers: dual responsibility of, 132; dual roles of, 14; ethical guidelines for, 20–21; as nonvoluntary practitioners, 13; prison, 524. see also National Association of Social Workers Societal rules, oppressed groups and, 122–123 Socratic method, 88–89 Solomon, E. P., 144 Solution-focused brief therapy (SFBT), 478; with adolescents, 481, 485, 488–489; behavioral tasks in, 487–488; in child welfare settings, 506, 509t; cross-cultural adaptability of, 489; delivering compliments in, 487; efficacy of, 489–490; finding exceptions to problem in, 485–486; for

involuntary adolescent clients, 483; with involuntary clients, 483–485; “not knowing” in, 485; research on, 580; scaling questions in, 486; in school settings, 488; setting small achievable goals in, 487; versatility of, 490 Solution-focused therapists, 484, 485 Solution-focused treatment (SFT), 186, 368; with adolescents, 482; with families, 306; in family-centered practice, 312; in involuntary groups, 349; question types and examples, 508, 509t; SFBT in, 488; in “Signs of Safety,” 508 Sørgaard, K., 73 Spanish-speaking individuals, integrated care for, 399 Special interest groups, 559 Specialist workers, in corrections services, 536 Spencer, P. C., 564 Stage models, 339 Stages of change: in domestic abuse treatment, 370t; in initial contact, 200–202, 201f; for involuntary groups, 339–340; for sexual offenders, 60; transtheoretical model of, 58–59 Stages of change model, 302; for child welfare sample, 303; in domestic abuse treatment, 369; effectiveness of, 61–62, 63 Stages of group change, and individual change, 340–342 Staudt, M., 502 Stein, T., 57 Stewart, S., 306, 310 Stigma: and child welfare services, 501; of involuntary clients, 115–116; of mental health, 385 Stigmatization, 77 Strengths-based approaches: for adolescents, 482; in child protective services, 313–314; of child welfare agencies, 494–495; for child welfare services, 502, 504, 513; in dementia care, 405–407; family-centered practice as, 313; with involuntary clients, 483. See also Solutions-focused approach Strengths perspective, and safety organized practice, 506

Index Stress: among college students, 466; toxic, 116–118, 120–121 Stress management, 575 Strohauer, Tamara, 62, 580 Student health centers, SBIRT in, 466 Substance Abuse and Mental Health Services Administration (SAMHSA), 143–144, 398, 422; national registry of, 488 Substance Abuse and Mental Health Services Administration (SAMHSA) survey, 422, 427 Substance Abuse and Mental Health Services Administration (SAMHSA) website, 422 Substance abuse counselors, 142, 419 Substance abuse treatment: case example, 147–148, 152; clients for, 418; to control cravings, 426–427; medication-assisted therapy in, 423; Moderation Management, 430; paradigm shift in, 424–426; to prevent relapse, 426–427; in trauma histories, 147; U.S. statistics for, 422–423 Substance abuse treatment groups, 341 Substance use disorder: and child welfare services, 501; defined, 419–421; funding for treatment for, 429; global view of, 429–430; officially defined, 431; and SBIRT, 462 Suicide attempt, and motivational work, 456 Superior-inferior construct, 108 Superiority, and propaganda of oppression, 108 Supervising staff, in welfare reform environment, 558 Supervision: effectiveness of, 557, 558; enforceable standards for, 541; and job satisfaction, 557; research on, 557–558; strengths-based approaches in, 557 Supervisors: attending to safety, 563–564; buffering or amplifying dynamics by, 562; building cultural competence, 563; caseload of, 79; contractin g principles used by, 544–546; educational function of, 556–557; functions of, 556; in involuntary context, 553–560; legal-ethical matrix for, 550–553; and mediating, 560–562; and performance issues, 546–550; practice guidelines for,

564–565; proactive, 558; support function of, 557; timely communication of, 544; and understanding reactance, 541–544; working with involuntary clients of, 41, 553–560 Supervisory practice, 540, 564–565 Supplication, in self-presentation, 189–190 Support, in involuntary groups, 332 Switzerland, substance abuse treatment philosophy in, 429–430 “Symptom prescription,” 185 Systems perspective, in family-centered practice, 324 Task-centered intervention, 295; adaptations of, 248–249, 250–252, 251f; advantages and disadvantages of, 250, 251f; case management in, 275–276; choices in, 295; confrontation in, 284–291; crises in, 283–284; development of general tasks in, 257–258; establishing goals in, 256–257; exceptions to use of, 250; in foster care, 252, 253f; guidelines for middle phase in, 278–291, 279f; identifying obstacles to progress in, 281–283; introduction to, 249–250; involuntary contract in, 252–258, 254f; limitations of, 252; linking clients with resources, 277–278; middle-phase change principles in, 274–278; motivational congruence in, 251–252, 289–290; revising and summarizing in, 290–291; of supervisors, 548; target problems in, 253–256, 253f; task implementation sequence in, 258, 259f, 260–274, 269f; termination phase, 291–295; time limits in, 250, 258; timing in, 295; values based on, 249 Task developments, specificity of, 295 Task implementation sequence (TIS), 258, 259f; anticipating obstacles in, 269–271; disagreeable tasks in, 264, 265f; incentives in, 272–273; initial client tasks in, 260–267, 265f; initial practitioner tasks in, 268, 269f; and provision of rationale, 271–272; rehearsal in, 273–274; summarization in, 274 Taylor, B. G., 363

619

620

Index Teams, for home visits, 563 Teens, out-of-home placement for, 309. See also Adolescents Temporary Assistance for Needy Families (TANF), recipients of, 53–54 Termination, in task-centered intervention, 291–295 “Term substitution,” 177 Terr, L. C., 144 Tetley, A., 365 Therapeutic Reactance Scale (TRS), 183, 186–187 Thomas, H., 368 Thomas’s unilateral family therapy model, 287–288 Thompson, I., 421 “Thought reform,” 334 Time-out, use of, 74 Ting, L. A., 364 Tobacco use, and SBIRT, 462 Token economy system, 70–71 Torture: description for, 72; and use of medical personnel, 73 Toxic stress: definition for, 120; examples of, 116–118, 120–121 Training videotapes, 578, 585–587 Transactional perspective, proactive guidelines for, 191 Transformational leadership style, 575 Transition session, in task-centered intervention, 294–295 Transparency, in family-centered practice, 316 Trauma: common effects of, 150, 151t, 152–154; external expression of, 150; factors exacerbating, 145; internal expressions of, 151t, 152; system generated, 141; types of, 144; understanding of, 143–144 Trauma, among involuntary client populations, 145–149; case example, 146–147, 153; in child welfare system, 146; and criminal justice system, 148–149; impact of, 149–154, 151t; among incarcerated women and men, 148; and substance abuse treatment, 147–148

Trauma history, viewed as isolated event, 141 Trauma-informed care, 1, 139; absence of, 142; in community health settings, 397; creating, 142; different kind of commitment to, 155–156; importance of, 160; paradigm shift as, 143; as privilege, 139; as right, 140 Trauma-informed practice, and child welfare services, 506 Trauma survivors, 154; characteristics of, 154; coping strategies and adaptations of, 156–157; different kind of practice for, 155–156; and following clients’ lead, 160; giving clients choices, 157–158; healing through relationships with others, 159; and importance of safety, 159; investment in, 154–155; living moment to moment, 158 Treatment: advocating for fair, 33–34; and client legal rights, 27; confrontational ways of, 142; in corrections services, 536; freedom from unnecessary, 26; involuntary client responses to, 62; and research with human subjects, 48–49; right to, 25 Treatment programs, twelve-step-oriented, 425, 426 Trotter, C., 53, 101, 124 Trump, Pres. Donald, 429 Trust: in child welfare settings, 499; in contracting process, 243–244; for involuntary client, 121; in involuntary groups, 339; in motivational relationship, 450, 451 Tsui, Ming-sum, 557 Turk, D., 58 Turnell, Andrew, 508, 510 Turnell’s “Signs of Safety” model, 510 Unemployed persons, 53 Unfair conditions, issues of, 43 Unions, coordination with, 544 United Kingdom, substance abuse treatment philosophy in, 429–430 United States: historically oppressed groups in, 113–114; substance abuse treatment in, 418, 430–431

Index University students, binge drinking of, 465 Unmotivated, use of term, 443 Unmotivated clients, 434; case studies, 441, 442–443, 444–446, 448–449, 451; change in, 439; characteristics of, 437–438, 440; in closed wards, 437; connection process with, 445–446; contact with, 439; latently motivated person among, 443–444. See also Motivational work Urinalysis tests, in substance abuse treatment, 418 Values: family, 109; in family-centered practice, 319; for involuntary clients, 215; and persuasion methods, 88 Vancouver, Canada, injection facility in, 430 Van Wormer, Katherine, 61, 62, 580 Veum, J. R., 182 Victim reports, to measure recidivism, 364 Videka-Sherman, L., 49, 51, 54, 55, 56 Visitor, in solution-focused therapy, 484 Vogt, D. S., 145 Voluntarism: “coerced,” 55; continuum of, 1, 10–12; and fate control, 9; level of, 62; reducing perceived lack of, 55–56 Voluntary case plans, 226f, 227 Voluntary clients: identification of, 5–6; studies of, 54–55 Voter fraud, 109 Voter registration outreach, 554 Vulnerability, and involuntary client status, 126 Walker, K. O., 399 War on drugs, 429 War on drugs, 109

Waterboarding, 72 Welfare recipients, stringent work requirements for, 132 Welfare reform, 109, 558 Welfare-to-work programs, limitations of, 553 Wenocur, S., 554, 573, 574 Westbrook, T. M., 564 West Virginia, opioid overdose rate in, 421–422 White, M., 13.14 Whyte, W. H., 131 Wilson, D. B., 364 Wiltse, K., 57 Withdrawal: in motivational work, 446; of practitioners, 574; of social workers, 554, 556 Withdrawal syndrome, for alcohol, 420 Withholding information, 33 Women, battered, 367. see also Domestic abuse; Domestic abuse treatment Wood, Katherine, 50–51 Workforce, at community health centers, 393–395 “Working alliance,” 437 Working conditions, flow experience and, 576 Work readiness program, 9 Wormith, J. S., 364 Worth, D., 160 Yale Program on Supervision, 544 Yatchmenoff, D., 497 Yates, P. M., 60 Yin, Robert, 435 Young, I. M., 109 Young adults, SBIRT for, 461. see also Adolescents Youth justice worker, 526

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