Engagement Skills: What We are Likely Missing

“I don’t know what to do anymore. Raul, says something and does something else. When I bring it up to him, he finds all types of excuses for what it is not going to work. I don’t know what to do anymore.” Laura started her case consultation session with RODIS, using these words, with much frustration on her face.

“A common and frustrated situation, which touches upon the need to emphasize two types of skills. Those of helping our patients and clients make healthier decisions, and those on engagement. Now, first thing first. How would you rate the level of rapport and trust established when you first started working with Raul?” Asked Rodis, in response to Laura’s frustrating situation.

The Socratic Motivational Practice has been developed by the SWEET Institute to provide clinicians with the ultimate tools to help patients and clients make healthier decisions, especially those who can be very challenging, including those involved in the criminal justice system, those with dual diagnosis, or severe trauma. This novel approach, which is based on a combination of the Socratic Method, Motivational Interviewing and other principles of Family System Therapy emphasizes the need to always first ensure rapport and trust as a foundation to prepare for a successful implementation of its’ principles, techniques and steps. Rapport and trust in turn can only be built through a strong framework of engagement which is the object of this article.

In two previous articles, entitled, 5 Tips to Help Engage your Patients and Clients, Part I, and Part II, I outlined a total of ten steps to follow. As a quick review, the ten steps outlined were:

Meet them where they’re at
Instill trust
Include them in all decisions
Establish concrete goals with clear metrics
Identify barriers and problem solve
Involve family members, the community, and use them as allies
Use motivators
Focus on the Patient or Client
Start the process early
Have an overall engagement strategy around engagement

Given the crucial steps entailed in the engagement framework, it may be clear why SMP emphasizes a strong engagement, which includes the establishment of rapport and trust as a foundation for success when it comes to helping our patients and clients make healthier decisions. Nonetheless, there are additional reasons why it is crucial for us to engage our patients and clients, as well as benefits to do so. Here are the big 7:

1. Difficult to engage

Many of our patients and clients, for a variety of reasons are simply difficult to engage. Not mastering the skills of engagement therefore means we are unlikely to work with them. This in turn means they are likely to be part of a revolving door, where no one can work with them, no clinic wants to accept them and treatment is being denied to them without anyone taking the responsibility. Now, some may be thinking “maybe these patients and clients themselves should be taking responsibility for being challenging.” While there may be some truth and several ways to answer this, one simple one is for us to remember that there is a reason why these patients are seeing us; there is a reason they behave in a challenging way; and there is a reason why they may not be taking responsibility for being challenging. Once you are able to see this perspective, you will then understand that we can help our patients behave differently, we can help them take responsibility by working with them, and for that to happen we will first ought to engage them.

2. Limited trust

For trust to take place we need to engage and for us to engage we need to help establish trust. Trust is a step to engagement, a product of engagement, and a reason why it is crucial for us to master the skills of engagement. Laura was having difficulties with Raul. Rodis asked him about trust and rapport in the beginning. Simply put, when we don’t trust, we don’t trust. This means we don’t trust the recommendations being provided, the advice being imparted, the information being shared, or even when others are telling us they care. This is from our primal brain. It is not rational, but it is us, and this in part explains why not only we can be biased, but why we may be unaware of our biases. Our patients and clients do just that. When they do not trust us, they don’t and they don’t trust anything else we may be doing or saying, even when they’re nodding, smiling, laughing, they just don’t trust us. Our task is therefore to ensure that we establish trust, from early on, and this takes place through the engagement framework. Breaking the barrier of limited trust in our patients and clients is another reason why it is crucial for us to master the skills of engagement.

3. Limited sense of safety

It is hard for any of us to learn adequately when we don’t feel safe. We are less open minded, more protective, worried, and cautious. We also are less likely to allow ourselves to be persuaded, to “give it a try.” For we simply don’t feel safe. When I teach residents and other clinicians, I explain to them how adequate language is paramount, always but particularly when meeting with our patients and clients for the first time. This is because of what we call in SMP, the trigger words. The more experienced and knowledgeable we are as clinicians, the easier it may be for us to identify trigger words to avoid. However, some words that may not be triggering for some may be for others, especially when we are meeting an individual for the first time. As a result, I recommend to clinicians to strive to use words that are as neutral as possible in order to establish and maintain safety. Furthermore, to establish and maintain safety takes place when we strive to be genuine, authentic, ourselves, which are part of the secrets and soft skills to an effective engagement. Our patients and clients are not at ease when there is a limited sense of safety, but our engagement skills can help break this barrier.

4. Strong transference

“She thinks she’s my mom. She’s just giving me advice right away when she does not even know me. She met me just 5 minutes ago.” Explained Ralph to Karen, referring to his previous therapist. It’s easy for us to just give some advice. Do this, do that. Except that advice rarely works, and almost never works. Why? Because Almost never do our patients come to us because of a lack of advice. They get to us because they are stuck, they are conflicted, their coping mechanisms have been failing and they often know the what to do, except that they don’t know the how. Therefore, unless we take the time for us to understand where our patients are, it can be not only premature but at times damaging to give “advice”. Another reason why it can be problematic to give advice is difficulty around strong transference. Strong transference that is not properly addressed can represent a barrier to treatment. We can easily overcome this barrier when we master the How of new strategies for an effective engagement.

5. Involuntary status

A common question I get from clinicians is: “what if the patient or client does not want to be here in our office, in our clinic, in our program, because he or she is court mandated, because the judge or the lawyer of the social worker wants him or her to be there. This situation is more common than not, and it happens across patient population. Some adolescents do not wish to come to us. They are being forced by the parents. The spouse may be forced by the partner, and some members of the family are being forced to participate in family therapy. In addition, either you do ER or inpatient work, some patients may be there against their will. The answer is, as long as you are doing this work, you can be sure that you will find a high enough number of patients who are in front of you against their will and you will need to assess what is going on, identify the core of the issue either through an adequate formulation, or diagnosis formulation, and then design a treatment plan. A daunting task that can be accomplished only through the mastery of the new strategies for an effective engagement.

6. Trauma reactivity

Only 7% of those exposed to a traumatic event will meet criteria for PTSD. For those who do not meet criteria, it does not mean they were not affected by the trauma. While someone may not necessarily present with full blown hypervigilance, nightmares, or flashbacks, exposure to trauma has its way to alter humans’ perception, ability to self-regulate, contributing to irritability and impulsivity. Distractibility and an array of coping mechanisms, often in the form of what we call cognitive errors (cognitive distortions) can become the new normal. This whole situation can be framed as trauma reactivity, and those presenting with this syndrome are more difficult to engage, hence the need to master the crucial skills of an effective engagement.

7. Disruptive relationships

When engagement skills are not optimal, there is an increase risk to make mistake as clinicians work on establishing a therapeutic relationship. When these mistakes are made at this early stage, they become more challenging to repair, unless the skills of engagement are mastered. The early stage of the relationship with our patients and clients is vulnerable and repair is more daunting. How we call or name our patients and clients; our own body language; how we respond to their body language; and how we make eye contact; are all necessary engagement skills that we simply ought to master. How we introduce our first encounter, the language we use, the types of questions we ask are skills that you, who, strive to make a difference in the lives of your patients and clients need to master. Lastly, how you allow your patients and clients to tell their story; how you structure the flow of your interview; how you switch gears, affirm, empathize and validate can make or break; and they are the some of the pillars for an effective engagement, and these are skills you can learn to master. This all is in addition to how we use silence; and how we respond to it

“I don’t know what to do anymore. Raul, says something and does something else. When I bring it up to him, he finds all types of excuses for what it is not going to work. I don’t know what to do anymore.” Laura started her case consultation session with RODIS, using these words, with much frustration on her face.

“A common and frustrated situation, which touches upon the need to emphasize two types of skills. Those of helping our patients and clients make healthier decisions, and on those on engagement. Now, first thing first. How would you rate the level of rapport and trust established when you first started working with Raul?” Asked Rodis, in response to Laura’s frustrating situation.

As one of the core beliefs of SMP, if there is a strong therapeutic relationship between us and our patients and clients, we will be able to help them make healthier decisions. However, it can be challenging to establish and maintain a strong therapeutic relationship under the following circumstances:

Difficult to engage patient and client
Limited trust
Limited sense of safety
Strong transference
Involuntary status
Trauma reactivity
Disruptive relationships

These challenges can be overcome through the new strategies to an effective engagement, and they are also reasons why you, as clinician need to master these skills.

Continue to master your craft so you continue to make a difference in the lives of your patients and clients, your career, your agency, and the system, as a whole.

References:

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Braveman, P. and Gottlieb, L., 2014. The social determinants of health: it’s time to consider the causes of the causes. Public health reports, 129(1_suppl2), pp.19-31.
Gallo JJ, et al. Emotions and medicine. What do patients expect from their physicians? J Gen Intern Med. 1997;12:453–4.