Even the Most Challenging Patients and Clients Can Be Engaged

Once on a nice day in July of 2012, while in Washington, DC, my dear friend, colleague, and fellow board member of the American Psychiatric Association, Eric Vanderlip, and I decided to have a walking meeting. Eric, a successful researcher and writer in integrated care, and I talked at length about the future of healthcare, the challenges we faced ahead, the potential root causes of such challenges, and the possible working solutions.

“One of the main challenges we face is figuring out how to really help our patients make decisions that serve them well, without the use of coercive measures,” I pondered out loud. “This is one area in which we have been failing, despite our best studies, our best technology, and our best medicine, and we need to do something about it, if we are to make any significant changes in our healthcare system,” I added.  “Mardoche, you have said it well. This is something I have been working on in my research on healthcare services, and I could not agree with you more,” responded Eric.

As I said in a previous article entitled, Five Tips to Help Engage Your Patients and Clients, engagement is the active patient and client involvement in his or her care, for best outcomes. And for us to help our patients and clients make decisions that serve them well, we need to establish and maintain safety and trust, and that starts with a strong engagement, the groundwork for which lies in the first appointment.

In three previous articles, I illustrated the case of Jose and Wood, the extent of the challenge Jose was for Wood, the level of dedication Wood showed, and how both of them eventually ended up establishing a therapeutic relationship through this type of engagement effort.

After Wood got up from his desk and sat next to Jose, Jose had no choice.  He started to see that Wood was in this with him; they were in this, together, and he had to reciprocate, and so, he did.  He decided to show Wood what he was looking at on his phone that had been consuming his attention, one video after the next, and so it went. It had been over 60 minutes and what would Wood write in his note? Wood knew better. He knew that human connection, ensuring engagement, and establishing trust from early on trumped everything else. His focus, therefore, had to be about ensuring the goals of engagement were met. “What is the point of making sure I obtain enough information to fill up and close my note, regardless of how reliable the information might be, especially if the patient is unlikely to return for a second visit?” Wood said to himself. In addition to the principles of engagement, Wood also made sure to establish and maintain safety. He found a way to conduct a quick risk assessment, without much interruption, and in the most natural and organic way possible.

“I’ll come here to see you. You know why? It’s because you treated me like a human being … I’m here because of Mr. Wood. For the first time, I felt like someone listened to me, treated me with respect and like a human being.”  Jose spoke these words about Wood.

Wood was able to accomplish that by:

1. Validating Jose;
2. Explaining what he was doing;
3. Meeting him where he was at;
4. Focusing on the moment; and
5. Showing instead of telling.  Wood also started with the end in mind; he was determined and committed, because he sincerely cared about Jose, and he prevailed.

References:

1. Baydar, N., Reid, M. J., & Webster-Stratton, C. (2003). The role of mental health factors and program engagement in the effectiveness of a preventive parenting program for Head Start mothers. Child Development, 74, 1433–1453.
2. Coatsworth, J. D., Santisteban, D. A., McBride, C. K., & Szapocznik, J. (2001). Brief strategic family therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent symptom severity. Family Process, 40, 313–332.
3. Dearing, R. L., Barrick, C., Dermen, K. H., & Walitzer, K. S. (2005). Indicators of client engagement: Influences on alcohol treatment satisfaction and outcomes. Psychology of Addictive Behaviors, 19, 71–78.
4. Littell, J. H., Alexander, L. B., & Reynolds, W. W. (2001). Client participation: Central and under investigated elements of intervention. Social Service Review, 75, 1–28.
5. Pinsof, W. M. (1994). An integrative systems perspective on the therapeutic alliance: Theoretical, clinical, and research implications. In A. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 173–195). New York: Wiley.