Stages of Change
and
Client Engagement
Strategies
“Engagement is defined as the process
through which a client begins to actively
participate in their treatment. It is also
considered the stage of the therapeutic
relationship that assists in having positive
treatment outcomes.”
(Friedlander, Escudero & Heatherington, 2006; Yatchmenoff, 2005; Tetley, Jinks, Huband & Howells, 2011;
Simpson & Joe, 2004).
Learning Objectives
• Understand the Transtheoretical Model of
Change.
• Learn clinician tasks associated with each
stage of change.
• Understand importance of engagement.
• Learn 15 strategies to engage difficult-toreach clients.
Why are we talking about
engagement?
• For too long practitioners in the behavioral
health field have been led by what they think
works rather than by evidence-based practices.
• 50% of dually-diagnosed clients drop out of
treatment prematurely.
• It is difficult to utilize an evidence based practice
unless clients are engaged in treatment first.
Facts and Findings
• Nearly 1 in 4 Americans meet the criteria for a MH or
SUD in a given year
• 50-70% of those who qualify for a MH or SUD treatment,
do not receive it.
• The vast majority of individuals with substance use and
other behavioral health conditions will not seek and
engage in treatment unsolicited.
• Tx programs are designed for those who are ready to
seek services and make a change
• Strategies to engage those individuals who are not ready
to seek help and change are desperately needed.
Importance of engagement
• Forty years of research shows client
engagement is the number one evidence-based
practice (Duncan, Miller, & Sparks 2004).
• Longer the clients are engaged in treatment, the
better the outcomes (Hubbard, Craddock, &
Anderson, 2003).
• Research also reveals that a working alliance
between the counselor and client is one of the
most important factors in retaining clients in
treatment. (De Weert-Van Oene et al., 2001)
Lambert’s pie: common factors
in therapeutic success
Important findings about client
retention
• Other findings: engaging clients by phone
prior to the first counseling session
decreases client no-shows (Miller, 2009)
• Counselors who possess qualities of
empathy, nurturance, warmth, and
genuineness do the best job of engaging
clients in treatment (Kasarabada et al.,
2002)
EMPATHY
Important findings about client
retention
• An egalitarian relationship during the
treatment planning process helps clients
stay engaged with the counseling process
(Corey, 2009).
• Respecting cultural differences during the
engagement phase of counseling helps
clients stay actively involved in therapy
(Sue & Sue, 2007).
Important findings about client
retention
• The use of motivational incentives
(rewards) increases programmatic
retention, and recovery rates (Higgins et
al., 2008).
• Involving family/ other support systems in
treatment increases programmatic
compliance and retention, decreases
relapses, and helps facilitate recovery
(Miller, 2009).
Important findings about client
retention
• Engagement strategies based upon the
client’s level of readiness to change helps
reduce resistance and keep clients
engaged in treatment longer (SAMHSA,
2008).
Reasons for client
disengagement
• Mandated status
• A lack of motivation to discontinue drug use/ other
behavioral change
• discomfort opening up to strangers,
• co-occurring conditions,
• multiple diagnoses,
• difficult symptomatology,
• initial therapeutic approaches that increase resistance,
• and confrontation techniques that leave clients feeling
defensive (O’Connell & Beyer, 2002).
Strategies to Engage
• 1. Provide a welcoming atmosphere:
– Who is the first person your client sees when
they walk through the door?
– What does your waiting area look like?
– Are there visual representations that reflect a
welcoming and safe space for all?
Strategies to Engage
• 2. Offer a snack/ water/ tea while the client
waits.
– This hospitality can be instrumental in
reducing client resistance within the first few
minutes of contact.
– Use of low-cost incentives, such as candy
bars, is effective in increasing engagement
and programmatic retention in treatment.
(Petry and Bohn (2003).
Strategies to Engage
• 3. Exude warmth
– the warmth of a counselor’s voice tone
communicated over the telephone prior to the
first counseling session can decrease client
dropout rates (Miller & Rollnick, 2002).
Strategies to engage
• Practical strategies:
– Conducting home visits
– Using a range of contact strategies, including phone
calls, home visits, notes on the door, letters, and text
messages
– Telephone reminders of appointments
– Follow up phone calls to address any issues between
appointments
– Regular contact with client. Contact at least weekly
with the client has been shown to result in higher
engagement rates than monthly contact
Strategies to Engage
• Practical Strategies
– Prompt referrals or following up quickly with clients
– Persistent follow up with clients. Caseworkers should
attempt contact at least 2-3 times where a client has
failed to attend a meeting or return a call
– Providing incentives such as food, vouchers and
social outings
– Provision of transport or access to travel vouchers
– Free telephone service to allow clients to contact the
service easily
Strategies to Engage
• Practical Strategies
– Utilizing existing relationships to create ‘warm
introductions’. Accompanying and being introduced by
a worker known to the family has been shown to
increase engagement rates.
– Flexible working hours, including possible work in the
evenings and weekends. This is not only relevant for
people who work or attend school during the day, but
also for people whose days may be filled with
appointments with other services as well.
Strategies to Engage
• 4. Focus on a strength and something the
client does well as soon as possible during
the rapport-building phase
– Many chemically dependent clients are
defensive and resistant to counseling
because they feel they have failed. A strengthbased approach can decrease that
defensiveness (Sharry, 2004).
Strategies to Engage
• Clients are often asked questions in the
initial intake session that increase their
feelings of stigma and defensiveness,
such as:
–
–
–
–
–
–
How much do you drink?
How many times have you relapsed?
Have you ever been treated for mental illness?
How many times were you hospitalized?
Have you ever attempted suicide? How many times?
Have you ever been arrested? How many times?
Strategies to Engage
• Strength-based questions can be instrumental in
decreasing clients’ resistance and facilitating
engagement (Sharry, 2004). Examples include:
–
–
–
–
What do you do well?
How have you been able to endure so much?
What do you like to do in your leisure time?
What are the best three moments you can recall in
your life?
Strategies to Engage
•
What is the best thing you have ever made happen?
• What is your previous life suffering preparing you to do
with the rest of your life?
• Which of your life challenges have taught you the most
about your own resilience?
• What sources of strength did you draw from as you
faced these challenges?
• What have you learned from what you’ve gone through?
Practical Strategies
1. Role clarification: Communicate the worker’s, the
client’s and the program’s role with the client. Clients
are unlikely to fully engage with the program until they
understand the role that all parties are to play.
2. Program clarification - Provide information about the
purpose of the intervention, the options for referrals,
negotiables and non-negotiables, what is expected to
occur while they are in the program and during each
session, confidentiality, the development of the case
plan and expectations, including the expectations the
client may have.
Practical Strategies
3. Demonstrating program relevance - The service should
demonstrate why this program will be of interest to the
young person and/or their family (and not just why the
service thinks it should be of interest)
4. ‘Normalizing’ with parents some of the issues they are
experiencing can provide perspective and assist
parents to better understand the role they should play
and encourage their responsibility.
Strategies to Engage
• 5. Explore the client’s experience with
counseling in the past
– If the experience was negative, let him or her
know how the experience will be different with
you.
– Ask clients to rate the session, specifically
focusing on whether the session met their
needs and what they would like to see
continued or changed in future sessions
(Duncan, Miller, & Sparks, 2004).
Strategies to Engage
• 6. Utilize stage-based interventions
– “There is no such thing as a resistant client,
but there are many helpers who struggle to
accept clients where they are at, and if we
accepted them where they were at, we would
have no resistance.”
Stages of Change
(Transtheoretical Model of Change)
Precontemplation
• The client is unaware, unable, or unwilling
to change.
– Counselor can
•
•
•
•
Establish rapport
Raise doubts about patterns of use
Give info on risks, pros and cons of use
The client is likely to be wary of the counselor and
of treatment, so try to keep the interview informal.
For example: "Let's talk. I hope I can be of help to
you. How about telling me what happened that
resulted in the fact that we're meeting?"
Contemplation
• The client is ambivalent or uncertain,
considering the possibility of change.
– Counselor can
• Discuss and weigh pros/cons
• Emphasize client's free choice and responsibility
• Elicit self-motivational statements: Reassure the
client that no one can force him to change.
• Ask questions that prompt motivation. For
example, "When you want to keep up your
motivation for doing something, what are some of
the things you say to yourself?"
Preparation
• The client asks questions, indicates
willingness and considers options to make
specific changes.
– Counselor can:
•
•
•
•
Clarify goals and strategies
Offer menu of options
Negotiate contract or plan
At this stage, the client shifts from "thinking about
it" to "planning first steps." For example, "What if
we start with a small plan and see how it goes?
The probation officer would be pleased if you
attended three AA meetings this week. Let's talk
about how you might do that."
Action
• The client takes steps toward change, but
is still unstable.
– Counselor can
•
•
•
•
Negotiate action plan
Acknowledge difficulties and support attempts
Identify risky situations and coping strategies
In case of relapse, normalize: For ex: "Relapse is
an event, but it's not an act of magic, so let's look
at what was going on right before you resumed
using. Once we identify some of what you were
thinking and feeling, we can devise some ways to
choose differently."
Maintenance
• Client has met initial goals, made changes
in lifestyle and now practices coping
strategies.
– Counselor can
•
•
•
•
Support and affirm changes
Rehearse new coping strategies
Review goals
Keep in contact
Maintenance
• In this stage, clients "keep on keeping on." The
counselor reminds the client about new tools to
maintain and reinforce recovery, such as:
–
–
–
–
–
Action plan
Awareness of risky situations
Coping strategies for each situation
Participation in 12-Step programs
Pursuit of hobbies and cultural activities
Strategies to Engage
• 7. Minimize confrontation.
– Confrontation leads to resistance and
premature termination.
– Confrontation can be traumatizing to
chemically dependent women, as the great
majority of them have histories of trauma prior
to treatment (Miller & Rollnick, 2002).
Strategies to Engage
• 8. Engage in mutual treatment planning.
– This respectful approach allows the client to
be a partner in his or her own counseling.
Establishing a partnership can be an effective
way of reducing resistance with difficult-to
reach clients (Corey, 2000). This process can
begin by asking the client, “What would you
like to accomplish in treatment?” or “What
would you like to see different in your life?”
Strategies to Engage
• 9. Have a sense of humor
– Humor in therapy has been found to reduce
resistance 8 (Buckmin, 1994).
– Humor increases feelings of equality in the counseling
relationship; brings the idealized counselor back to
life; can reduce resistance; decreases cross-cultural
tension; and it facilitates bonding between counselors
and clients.
– An important goal for using humor in counseling is to
improve the relationship between the counselor and
client, lessen client tension, increase client comfort,
and help client gain insight (Sanders, 2005).
Strategies to Engage
• 10. Avoid power struggles.
– Power struggles decrease engagement and
can lead to premature termination
(Rosengren, 2009).
– One way to avoid power struggles is to roll
with the client’s resistance. This can be
accomplished by simply acknowledging the
client’s discomfort when certain subjects are
brought up and allowing the discussion to shift
to other areas (Miller & Rollnick, 2002).
Strategies to Engage
• 11. Avoid early labels.
– Early labels can lead to clients feeling
defensive and being more difficult to engage
(Rosengren, 2009).
– Also explore what their diagnosis or “labels”
mean to them and the significant other’s in
their lives.
Strategies to Engage
• 12. Be willing to have a sensitive
discussion about race, gender, and other
differences if they are barriers to
communication.
– This can facilitate the building of rapport. A
good time to have such a discussion is when
the counselor senses that the differences he
or she has with his or her client are barriers to
trust (Sue & Sue, 2007).
Strategies to Engage
• 13. Ask for permission to give feedback.
– This respectful approach can go a long way
toward facilitating rapport. For many years
addictions counselors have given clients
unsolicited feedback filled with opinions
combined with confrontation, which often
created therapeutic walls rather than
therapeutic bridges (SAMHSA, 2008).
Strategies to Engage
• 14. Be aware of countertransference
reactions.
– Countertransference increases client resistance.
– Many difficult-to-reach clients may display
behaviors that are easy to judge
– Each person with a substance use disorder
affects seven people directly (Kinney, 2002).
These behaviors range from DUI offenses, theft,
antisocial behavior, physical abuse, sexual
abuse, domestic violence, etc.
Strategies to Engage
• 15. Honor a variety of approaches to
recovery.
– Assuming that there is only one way that
people recover is detrimental to client
recovery.
– Counselors can now engage clients in
recovery planning by offering a menu of
options.
Resources
• https://store.samhsa.gov/shin/content/SMA124097/SMA12-4097.pdf
• http://www.onthemarkconsulting25.com/Documents/STR
ATEGIES%20FOR%20ENGAGING%20DIFFICULT.pdf
• http://integrativecounselling.com.au/wpcontent/uploads/2012/08/Campiao-CQ-Alliancearticle.pdf
• https://www.nami.org/About-NAMI/PublicationsReports/Public-Policy-Reports/Engagement-A-NewStandard-for-Mental-HealthCare/NAMI_Engagement_Web.pdf