Client Engagement: Salient Ingredient for Successful Treatment Outcome

1. Client Engagement: Salient Ingredient for Successful Treatment Outcome W. Thomas. Ph.D. LCSW, ICADC, SAP

2. 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?

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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.

9. Client Engagement - Client’s Perspective Client • Did not enter tx voluntarily. • Maintain a highly dysfunctional presupposition about therapy • Not honest at least at the beginning of tx • During tx involved in felonious activities –confidentiality problems • See Cns as part of the system and hence should not be trusted. • Feels that Cns does not care • Feels that Cns is different from them – demography and attitude.

10. 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

11. 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.

12. 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.

13. 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.

14. Client Engagement • Some basic elements that can help in trust building are: • Being available for clients • Being on time for sessions • Returning clients calls • Being around for emergencies • Check with client who fails to keep appointment • Always try to keep in contact with client

15. 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.

16. 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.

17. 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.3 • 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’.

18. 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 heardand understood. • This gives client feeling of a part of the process as against the process.

19. 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

20. Client Engagement

21. 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.

22. 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.

23. 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.

24. 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.

25. 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’

26. 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

27. 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.

28. Client Engagement • Johnson (1994)listed five (5) characteristics of the effective Cns. • They are : • Worldview • Hope • Humility • Trust • Empathy

29. 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.

30. 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.

31. Bibliography • Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2009). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Personality Disorders: Theory, Research, and Treatment, (1), 80-89. • Beck, A. T., Liese, B. S., Newman, C. F., & Wright, F. D. (1993). Cognitive Therapy. New York, London: Guilford Press. • Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research & practice, 16(3), 252. • Boyle, S. W., Hull, G. H., Mather, J. H., Smith, L. L., & Farley, O. W. (2009). Direct Practice in Social Work. Boston, New York : Pearson.

32. Bibliography • Cross, T. L., Bazron, B. J., Dennis, K. W. & Isaacs, M. R. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed (Vol. 1.). Washington, DCCASSP Technical Assistance, Georgetown University Children Development Center. • Freud S. (1958). The Dynamics of Transference. London, United Kingdom: Hogarth Press • Greenson, R. (1967). The Technique and Practice of Psychoanalysis, vol 1International Universities Press. New York, 229-230. • Hall, A. M., Ferreira,, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010, August ). The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy, 90 no. 8, 1099-1110.

33. Bibliography • Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (n.d.). Alliance in Individual Psychotherapy. . Retrieved April 30, 2014, from http://www.nrepp.samhsa.gov/Norcross.aspx#chapter6 • Johnson, J. (2004). Fundamentals of Substance Abuse Practice. Pacific Grove, CA: Brooks/Cole Publishing. • Mallinckrodt, B. (1993). Session impact, working alliance, and treatment outcome in brief counseling. Journal of Counseling Psychology, 40, 25-32. • Moorey, S. (1989). Drug abusers. In J. Scott, J. M. Williams, & A. T. Beck (Eds.), Cognitive therapy in clinical practice: an illustrative casebook. London: Routledge.

34. Bibliography • Parham, T. A. (1993). Psychological storms: The African American struggle for identity. Chicago: African American Images. • Walborn, F. S. (1996). Process variables: Four common elements of counseling psychotherapy. Pacific Grove, CA: Brooks/Cole.