Transcript Client Engagement: Salient Ingredient for Successful

Client Engagement: Salient
Ingredient for Successful
Treatment Outcome
W. Thomas. Ph.D. LCSW, ICADC, SAP
Client Engagement
• Moral model, disease model, social learning theory
model and cognitive behavioral models are just a few
treatment models employed in the treatment of
substance –abusing clients.
• But all those models and paradigms would mean
nothing or do nothing if there is no client engagement
• What do we mean by client engagement?
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Client Engagement – Therapeutic alliance
• CE is a professional collaborative relationship between
the client and the professional, who creates a warm,
congenial, trusting environment so the client can feel
safe.
• CE is achieved through creating a therapeutic alliance
with client during the tx process.
• Without a TA there cannot be any tx –Cns and client will
meet and go through the motions.
• This presentation will examine the need for CE and some
of the pitfalls and how CE can be accomplished.
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Client Engagement
• CE (therapeutic alliance) is noted for playing a great part of client’s
improvement.
• To build the “facilitative conditions”: empathy, genuineness, positive
regard, and warmth should be cultivated by the Cns.
• What is important for the Cns in this process is that these conditions
are totally under the control of the Cns and it is for s/he to cultivate
those components in the repertoire of knowledge to be use when tx
substance-abusing clients.
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Client Engagement - First impression
• “First impression counts” in all aspects of live – more so in tx.
• During the first encounter with client, the Cns must be cordial,
friendly, helpful and everything to show the client that s/he is in the
right place.
• Time should be taken to explain the objective of the program
• Goals and ways to achieve those goals would have to be planned by
both persons and through circular questioning the goals must appear
to come from the client.
• State clearly what is expected from the client and most importantly
from the Cns
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Client Engagement
• The relationship between client and Cns is an crucial ingredient in
positive tx outcome.
• What we may want to call a construct was derived from theories of
transference by Freud in 1912, and was referred to as a feeling of
“collaboration, warmth, and support between the client and Cns.
• According to Bordin (1979), working together on goals to be achieved,
agreement on the kind of intervention and the affective bond
between them make up this construct or alliance, which gives rise to
positive tx outcome.
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Client Engagement
• CE is particularly important if not “fundamental” ,
because of the peculiar way most of our clients seek
tx (ordered by a Judge, disgusted family member, etc.)
and the skills they developed over the years of
“running”.
• Not trusting of strangers – tried to help self over the
years
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Client Engagement
• CE is crucial for all tx, but especially important for
substance-abusing population.
• Lifestyle of clients before tx sets up an adversarial
relationship between client and Cns. tell their inner
most secret to a total stranger – a professional.
• Criminal, shameful, repulsive personal & sexual
behaviors – behaviors which they want to forget.
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Client Engagement - Client’s Perspective
Client
a) Did not enter tx voluntarily.
b) Maintain a highly dysfunctional presupposition about therapy
c) Not honest at least at the beginning of tx
d) During tx involved in felonious activities –confidentiality problems
e) See Cns as part of the system and hence should not be trusted.
f) Feels that Cns does not care
g) Feels that Cns is different from them – demography and attitude.
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Client Engagement – Talk Medicine
• Confidentiality enjoyed by clients as well as threats from spouses
and family members would not easily cause one to give up those
secrets. “Talk medicine”.
• Client’s experiences are shared when client feels safe and trusts
the counselor or care giver.
• Trust opens the flood gates to hope and thus positive prospects
for successful tx outcome .
• Research documented the collaboration (alliance) when
measured have found to be associated with positive tx outcome
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Client Engagement
• The big question is how do we do that.
• The simple answer is through communication. But there are
powerful invisible barriers to communication with our
clients.
• Communication is not just spoken work, but the way Cns
interact with clients.
• Communication is a two way process.
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Client Engagement
• Cns must try to understand that CE is a task that does not transpire by
chance as fall from the sky –
• It can must be deliberately done
• CE also calls for the Cns to be vigilant in working with clients as the
relationship is always fluid, as the client not at all time want to be
there in tx.
• The fine-tuning of the relationship with the client is not a simple task,
but one should not feel flabbergasted.
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Client Engagement
• The building of trust is not separate from tx as it helps to buttress it;
trust is the corner stone for CE.
• Trust does not occur overnight as it is a slow process that requires lots
of patience – consistently high level of professionalism, honesty, and
well meaning action.
• Trust can be lost quickly and thus must be nurtured and painstakingly
maintained – crucial for tx success.
• Although the Cns knows that the client may not honest and truthful
s/he must continue to be honest and nurture that trust.
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Client Engagement
• Some basic elements that can help in trust building are:
1. Being available for clients
2. Being on time for sessions
3. Returning clients calls
4. Being around for emergencies
5. Check with client who fails to keep appointment
6. Always try to keep in contact with client
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Client Engagement
• The Cns has to be a role model, who has a very “clean” life around
the client – anything said in a derogatory way about someone else
can be seen as the Cns being disingenuous.
• The question of drug use by the Cns always comes up and must be
handle professionally
• Honesty is the best policy here (try and see, so much unwise to use,
always too afraid felt would have liked it – however refocus on client
as this is his/er session.
• Goal is to nurture the relationship not to get it sidetrack from the goal
of the session.
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Client Engagement – Setting Limits
• Cns needs to walk a fine line without being too considerate to cause
client to take advantage of the situation.
• The objective of the things that Cns does is to build a collaborate
relationship, not to become buddies.
• The Cns must set limits or boundaries, down ground rule so that a
respectful tone is maintained.
• The objective here is to remember the things must be in the best
interest of the(ir) clients.
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Client Engagement
• Most Cns. come to tx setting with some skills – some
personal qualities.
• Engagement skills are not born skills and anyone can develop
them provided one is prepared to work on them.
• Asking questions is only part of the process; the other
important, hidden and hard part is “to engage people who
are seemingly ‘programmed’ not to trust”.
• The true objective of CE is to foster a trusting safe
environment where client can ‘Talk’.
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Client Engagement
• It is the barrier to communicating with clients that prevents the
smooth flow of information.
• We sometimes forget a plethora of factors, such as class, how we
make clients feel in our presence, gender, and some of our other
biases sometimes unknowingly broadcast to clients.
• Most of all we CNS must be a good listener. – jokes etc
• Client must have the perception that s/he was “respected” – means
heard and understood.
• This gives client feeling of a part of the process as against the process.
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Client Engagement
• Tx is that of the client and not the Cns, it is important then that Cns
must do every thing to make the client feel at ease and comfortable.
• Cns must be able to speak and understand the language of the client
throughout the session. “clean” < > “free of illicit drugs”.
• Efforts are to be made to get the client to see through the “same pair
of eye” as that of the Cns.
• The client must enjoy the Cns’ full undivided attention for the entire
session.
• There should not be any cell phone interruptions - if necessary ask
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Client Engagement
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Client Engagement
• In mastering client engagement, the Cns must try his/er best to make
the client understand the point communicated. It is the function of
the Cns at all times to facilitate this understanding.
• The object of tx is positive outcome and Cns is obligated to work
extremely hard to achieve this goal.
• Since the agreed objective is positive outcome then Cns must not
only listen to client, but actively listen and encourage client to speak
so that client to feel part of the tx process.
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Client Engagement
• Then there is the unseen and dangerous factor of how the Cns feel
about the client. (No matter how you mask that feelings clients find
out).
• Do we have the moral rectitude to say if using drugs is immoral and
thus treat clients that way.
• Cns also use stereo-type to judge client and then treat them
accordingly.
• Be prepared to examine our own unconscious biases, myths and
beliefs, which underscore our actions towards clients.
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Client Engagement
• These actions serve to disempower clients not only in our
presence, but when they leave our offices. Clients should be
empowered to move towards self improvement.
• Cns should be prepared to adjust these thoughts and deal
with them: do not allow them to seep through the sessions
and infect the clients with uncertainty and distrust.
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Client Engagement
• These adjustment can be “fixed” through cultural awareness and also
through supervision. Speak honestly about issues to you supervisor.
• It is the Cns, who have to make the adjustments – sometimes the
client will observe the Cns and wait his/er “move”.
• Cns are human and bring to tx his/er own problems: these problems
may be personal and affect the biases of the Cns.
• Again do not let personal problems invade the space identified for
discussions with working with clients.
• This is the client’s time and must not be filled with Cns issues.
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Client Engagement
• The Client by some calculation understands the role and is always
willing to participate fully if there is clear communication.
• Again I cannot say enough that the Cns would have to adjust to the
client and not the other way around.
• Client adjustment will impact positively patient trust and feeling of
safety and that will result in better treatment outcome.
• Supervision with a competent supervisor will be able to at least start
to address any deep seated biases that affect the Cns.
• Some courses in cultural competence will address the problem of Cns,
who is insensitive to clients’
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Client Engagement
• Since the initiator of action in building trust is the Cns then progress
in tx lies in the actions of Cns. Are we observing the golden rule as we
relate to clients?
• How the Cns relate to the client should be underpinned by the Cns’
perspective of cultural competence.
• Cultural competence – focuses on the belief that everyone has
strengths and abilities to contribute to society. 9 Because of the
training associated with cultural competence, the Cns is able to
understand the barriers, and the issues of differences. 10
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Client Engagement
• Cns must to be honest with self and seek to examine actions taken
with each client. – journals
• Cns can stop generalizing and see as every client as different and an
individual with his/er own issues goal, etc.
• Case presentation serves to help in allowing the Cns to have peers
look at the same issue from a different perspective.
• What works is constant case presentation with a close collegue who
you feel comfortable with and discuss ‘away”.
• Last resort is paid therapy.
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Client Engagement
• Johnson (1994)listed five (5) characteristics of the effective Cns.
• They are :
a) Worldview
b) Hope
c) Humility
d) Trust
e) Empathy
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Client Engagement
• Worldview simply means the Cns must meet the client where the
client is (race, ethnicity, sexual orientation, class and perceptions,
beliefs & lifestyle choices.
• Hope – because the is the feeling that change for the better can take
place means that the client will strive for change
• Humility – Cns is human being with skills to be used to help people.
Sometimes it may be necessary to let clients know that you are not
superior to them.
• Trust – a multi faceted concept as it move a long the continuum from
no trust to complete trust.
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Client Engagement
• Denial – most substance abuser deny using and that is just part of the
way they start out the process.
• Cns must be aware of the four musketeers of substance-abusers
thinking:
• Denial, minimization, rationalization and projection.
• The work with substance-abusers is very intense and can be seen as
troublesome if you the Cns do not have enough tools in your tool box.
• Work with substance-abusing clients can be very rewarding also.
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