COGNITIVE MOTIVATIONAL CASE MANAGEMENT: NEGOTIATING BEHAVIOR CHANGE IN AN EMPLOYMENT SETTING COGNITIVE MOTIVATIONAL CASE MANAGEMENT IN EMPLOYMENT SETTINGS ?2 WORKING WITH PEOPLE NEEDING ASSISTANCE TO CHANGE 3590 RIVERGATE WAY, SUITE 1202, OTTAWA, ONTARIO , 613.240.7223 Cognitive Motivational Case Management - Tools for Negotiating Behavior Change training is the basis of a state-of-the-art model of client-centered case management training that combines motivational interviewing techniques with cognitive motivational tools as the basis of all interactions with clients. This model has been enthusiastically endorsed by professionals in other employment service setting where staff work with hard-to-serve clients. The techniques provide for a fresh approach that furnishes practical new skills that can be put to use immediately. Below, we provide a brief overview of the primary elements. A common challenge faced by criminal justice and employment service professionals is that they get discouraged in their work with hard-to-serve clients. Regardless of whether clients are uncooperative or not, ultimately the challenge involves helping people who are unmotivated. There is a need to convince people who face many obstacles that they can move beyond their current situations. Most employment service professionals recognize that building motivation is one of the most difficult tasks they encounter, and indeed, the real crux of achieving success with the hard-to-serve. We believe that a client-centered case management approach that closely monitors motivation levels and continuously negotiates behavior change with clients makes the greatest sense with hard-to- service clients in the welfare reform and employment context. In order to achieve these objectives, case managers need to acquire intervention skills that are easily learned and can be perfected through practice. The skills include interaction styles that pose the right questions to help clients become motivated and practical new thinking skills that can help people solve problems and tackle the challenges of self-sufficiency. The fundamental nature of service with hard-to- serve clients is that their situation requires a more intensive approach, often spread over a lengthy period of service contacts. While such clients are not necessarily resistant to services or unwilling to cooperate with case managers, they may have very poor resources for self-sufficiency or they may be experiencing repeated cycles of acute need for assistance. COGNITIVE MOTIVATIONAL CASE MANAGEMENT : NEGOTIATING BEHAVIOR CHANGE APPLIED IN AN EMPLOYMENT SETTING We believe that front-line staff who work with resistant clients need case management methods that equip them to effectively work "one-on-one" with clients on a daily basis. This involves the ability to choose from a menu of tools to confidently respond to the diversity of their client's characteristics. In addition, tools are needed to help case manager decide how to intervene with clients at the right times and in appropriate COGNITIVE MOTIVATIONAL CASE MANAGEMENT IN EMPLOYMENT SETTINGS ?3 WORKING WITH PEOPLE NEEDING ASSISTANCE TO CHANGE 3590 RIVERGATE WAY, SUITE 1202, OTTAWA, ONTARIO , 613.240.7223 sequences to affect positive outcomes. This describes a client-centered approach which promotes self-sufficiency by tailoring the style, type and level of interventions to match each client's profile. A helpful way to understand the case management issues that arise in serving welfare-to-work or chronically unemployed populations is to examine the notion of "readiness to change." In the employment service field this refers to client willingness, level of desire, or motivation to adopt new patterns of behavior which will promote longer-term economic self-sufficiency. We are convinced that clients vary in their readiness to change. Such readiness not only varies from client to the next, but also varies over time with individual clients. Readiness and the stages of change are an important organizing principle for client-centered case managers because it allows case managers to adjust the focus of the case management interventions to reflect the stage of change of the individual client at any one point in time. The stages of change are very helpful because they recognize that hard-to-serve clients may move forward and regress many times during service. With each stage there is an approach that can be used to negotiate behavior change toward the next progressive step. The tools we propose to use to assist case managers are based on motivational interviewing techniques as well as cognitive skills. Motivational interviewing is a relatively new method to help clients make important changes in their lives. The technique is both client-centered (paying attention to what the client says, needs, and desires), as well as directive (providing concrete advice on how to move forward). Motivational interviewing gives case managers a series of techniques for asking the right questions, giving the right amount of information, and timing the nature and frequency of interaction with clients in an efficient way. The techniques are based on very solid and proven methods for establishing excellent rapport with clients. Rather than "just theory", the approach gives case managers concrete tools that they can use in their every day interactions with clients. Motivational interviewing also helps case managers avoid many of the pitfalls that serve to detract from client progress and inadvertently initiate feelings of defeat. Training participants who are exposed to the motivational interviewing principles and techniques often have a sense that they are learning insightful new tools that are exciting to practice and easy to refine after thoughtful attempts with clients. The techniques give case managers a new and usable language for communicating more effectively with their clients. The training approach utilizes many visual cues and analogies that help participants quickly understand and begin to integrate the tools within their practice. One of the basic premises of motivational interviewing is that the motivation to change must be elicited from within the client rather than imposed by the case manager. Whereas some interventions use coercion, COGNITIVE MOTIVATIONAL CASE MANAGEMENT IN EMPLOYMENT SETTINGS ?4 WORKING WITH PEOPLE NEEDING ASSISTANCE TO CHANGE 3590 RIVERGATE WAY, SUITE 1202, OTTAWA, ONTARIO , 613.240.7223 persuasion, confrontation, and external contingencies as the main approach to case management, motivational interviewing attempts to mobilize the client's own motivation to facilitate behavior change. Change becomes negotiated with rather than imposed on the client. When the approach is done successfully, it is the client who presents arguments for change rather than the treatment provider. Because it is based on the careful application of interaction skills that truly build positive rapport, the approach resolves many of the problems of traditional case management approaches to working with clients over an extended period. There is an optimal blend of client input with case management direction and advice. In the model we are proposing, the use of cognitive skills is a complimentary component of case management. The "cognitive" element emphasizes the "thinking skills" that people need to solve problems and effectively deal with other people. Motivating clients to move from one stage of readiness to the next requires many concrete tools that are primarily "thinking" skills. The skills help case managers more effectively negotiate with clients to affect the positive outcomes they wish to achieve - movement toward self- sufficiency. Case managers need cognitive tools to help assess where clients are in the readiness process, as well as to move them forward. The cognitive tools are simple yet very powerful methods of achieving movement with clients. They take much of the guesswork out of the process of working with clients because they provide a series of steps to take in dealing with common situations. The cognitive skills provide frameworks for negotiation, help identify myths about change and motivation, consider alternative viewpoints, empathize with clients, avoid thinking traps, correctly identify problems, generate a greater range of options, set realistic goals, and follow rules of good listening. On paper the tools are simple. However, when case managers integrate them within their interactions with clients, they discover an increased mastery over their ability to break through barriers and to generate service options for their clients. The cognitive skills are also very important for clients. The use of the skills by case managers also becomes extended to helping clients gain new proficiencies. Clients not only need to be motivated to change, but they also need skills to initiate and maintain their agenda of behavioral change. Thinking skills give clients resources for solving problems and getting along with others in their living, work, and case management service environments. The skills furnish a method of thinking about problems, defining priorities for action, and selecting among a number of different options and alternatives. Thinking skills are essential for clients to set goals and make appropriate judgments when many different alternatives must be weighed. This case management model when used appropriately gets excellent results. When it is used in combination with the client attending the cognitive skills training program reThinking unEmployment, the client results are seen quicker and are even more impressive.