An Article For Clinicians - How to Manage with Poor Patient Engagement
/Many of us have had clients who struggle with engagement in therapy. This at times can be frustrating for both the therapist and the client. Our abilities to stay engaged and motivated become compromised and likely influence the therapeutic relationship. According to the text, Anxiety Treatment Failures in Anxiety Disorders, by Otto and Hoffman, a lack of engagement in treatment or unwillingness to comply with treatment protocol is one of the most important reasons for sub-optimal treatment response. The authors suggest that variables to consider include ambivalence, therapist approach, and negative cognitions throughout the therapeutic experience.
How ‘Warm’ Are You?
Hoffman and Otto suggest that the engagement factor with the therapist could influence the direction of recovery. They note having a ‘warm therapist’ contributes to better adherence. The authors don’t go into detail as to how they define ‘warm,’ but I do believe they are likely referring to Rogerian approaches to treatment. In short, Rogerian psychotherapy focuses on expressing empathy for the client’s situation, developing discrepancies, avoiding arguments, and rolling with resistance. When a therapist is able to demonstrate some understanding of the client’s experience it can strengthen the therapeutic relationship and influence the likelihood of future therapy being more effective (McMahon &Vernon).
What About You?
Compassion fatigue may also interfere with your abilities to provide warmth. If this is a concern, consider taking a break from therapy or seeking supervision/consultation. You may also want to assess for burnout. Catherine Cook-Conttone text, Mindfulness and Yoga for Embodied Self-Regulation: a primer for mental health professionals, provides a useful Mindful Self-Care Scale to help identify areas of weakness and strength in self-care behaviours. I have attached the scale for your convenience.
How Important are Cognitive Appraisals?
Otto and Hoffman suggest that negative cognitions are also likely to influence poor treatment response. Therapist are to consider assessing cognitions regularly throughout treatment for distortions and identify discrepancies. Otto and Hoffman argue that it’s important to point out difficulties in engagement early on and make recommendations as necessary. Imperative to the process of cognitive therapy is to have the client review their thoughts and identify appropriate cognitive distortions early on. Taking the necessary time to educate the client on specific OCD cognitive distortions may be helpful.
Brush Up on Scripts and Motivational Interviewing
Ambivalence involves having conflicting motivations regarding the need to change. This at times can be uncomfortable and frustrating for the client. Highlighting discrepancies can bring greater awareness to what clients say and do. McMahon and Vernon’s text, Cognitive and Rational-Emotive Behavior Therapy with Couples, provides an excellent example, “the therapist can look confused, scratch his or her forehead and say: ‘I’m a bit confused. I thought you said you wanted to stop your compulsions because you wanted to find a job and yet you still attend the session 20 minutes late. Help me out. I must be missing something.” Lastly, rolling with resistance requires helping to uncover and dispute their own irrational beliefs. A simple cost-benefit analysis may help with this. Helping clients develop scripts to help them review their motives for change could be helpful in sustaining treatment. This could be done by having them review the risks of maintaining the behaviour, what they have lost to their anxiety or OCD, how it has hurt their family, how their safety behaviours don’t work, and why they have no choice. You may also want to include how their life will improve and how they could cope with their fears if their worst-case scenario did happen (Grayson 2003).
Consider reviewing motivational interviewing and asking the following questions (Miller & Rollnick 2013):
Desire Questions:
How would you like things to change?
What do you hope together will accomplish?
Tell me what you don’t like about how things are now?
Ability Questions:
If you did decide to challenge your anxiety now, how could you do it?
What do you think you might be able to change?
What ideas do you have for how you could change, based on what we have been discussing? – It’s best to ask this question after providing psychoeducation.
Reasons:
Why would you want to have less anxiety?
What would make it worth your while to stop your compulsions?
What could be the advantages of learning to tolerate your anxiety?
Need:
How important is it for you to stop your safety behaviours?
How serious or urgent does this feel?
What About Exposophobia?
There are some individuals that are scared of engaging in treatment. Many of us who practice exposure and response prevention (ERP) are aware of this. Exposophobia is the term that describes those that fear engaging in ERP treatment. Many therapists themselves prefer not to use ERP in their practice because many fear upsetting their clients or creating a rupture in the therapeutic relationship (Springer & Tollin 2019). If you do encounter a client who is struggling with Exposophobia, it is important to hear their concerns and provide education to help manage their anxieties. This could mean providing empirically supported data regarding ERP and providing details regarding what a treatment plan would look like. This could help them better understand that treatment would not bring on intolerable anxiety, that they can tolerate their uncomfortable feelings, and that no extensive coping training is needed (Springer & Tollin 2019).
Otto & Hoffman 2010, Avoiding Treatment Failures in the Anxiety Disorders, Springer Link.
Greyson 2003, Freedom from OCD, Berkley Publishing Group.
McMahon and Vernon 2012, Cognitive and Rational-Emotive Behaviour Therapy with Couples.
Cook Cottene 2015, Mindfulness and Yoga Embodied Self-Regulation, Springer Publishing.
Springer and Tollin 2019, The Big Book of Exposures, New Harbringer