Clinical Supervision Protocol for Managing No-shows.
Procedure:
Team leaders and clinical supervisors will review clients who chronically no-show with their clinicians.
The following considerations should be explored. After reviewing the case with the clinician, an action
plan (page 2) should be determined regarding next steps for the client’s treatment.
Client Ambivalence:
1.) Explore with therapist which engagement strategies have been tried to engage the client in
therapy.
a.) Has client clearly articulated what they would like to be different in their life and what
they would want to accomplish from treatment? Has therapist used miracle question to
help flesh this out? Has therapist helped client prioritize what to start working on and
what to save for later?
b.) What is the client’s stage of change regarding issue that they are referred for or
regarding their goal for treatment? (See Appendix A below for questions to determine
client’s stage of change). Has therapist tried motivational interviewing strategies
appropriate to that stage? (See Appendix B below)
c.) In Solution Focused language, what type of client is this
(visitor/complainant/customer)? Has therapist tried SFBT strategies appropriate to
that type of client?
d.) Is the client unsure about the pro’s and cons of resolving the issue? See Appendix C
for example of decisional balance sheet
e.) Is the identified problem present for the client, or do they still need to explore
whether the “problem “is a problem for them. See Appendix D for questions to use that
elicit change statements.
f.) Are there other things happening in the clients life that are taking precedence at this
time?
2.) Is the client ready for a break in treatment?
3.) Is the client ready to be terminated?
4.) Is the client experiencing something uncomfortable in the therapist-client relationship?
5.) Is the treatment being offered the treatment that the client feels will be helpful?
Therapist ambivalence
1.) Is the therapist experiencing something in the relationship that is making them feel ambivalent
about meeting with the client?
2.) Is the therapist experiencing an “overload” that has them feeling that a no-show would provide
time for them to complete other over-whelming tasks.
3.) Is the therapist scheduling the client more regularly than the client needs because they are
anxious about the clients situation?
Clinical Supervision No Show Action Plan
Clinician’s name: ____________________
Client’s name: ______________________
Today’s date:_______________________
Date to follow up on plan in supervision: ______________
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Clinician will explore client’s ambivalence in session
Clinician will address the issues that are causing them to feel ambivalent
Schedule less frequently with the client
Have front desk do reminder calls for on-going appointments.
Schedule a treatment vacation with client (e.g., let’s break from therapy for the
summer and resume contact in the fall)
At next contact, notify client that he/she will now only be seen for a brief therapy
appointment during the clinician’s designated drop-in time with clients seen on a first
come, first served basis. If the designated time does not work for the client, the
client can be referred to drop in times of other clinicians on the team. If those times
also do not work for the client, the primary clinician is not required to offer more
times. If client is Medicaid and disagrees with plan, inform client of right to 1)request
other services from FBHP and 2)file a grievance with FBHP.
Refer client to and engage them in group only when clinically indicated.
At next contact, invite the client to call the front desk and schedule an appointment
when they are ready. Inform them that if no contact within 6 weeks, will need to go
back through Screening for services. Purpose of scheduling through front desk is to
have front desk be in charge of appointment setting, leaving therapist time for other
tasks. Also, having client talk to front desk discourages them from pulling therapist
into longer conversation on the phone.
Only allow client to call for same day appointment scheduled through front desk.
Have front desk make reminder calls to confirm appointments the morning before the
appointments. Any clients who say that they can no longer attend will create openings
in the therapist’s schedule for the next day. When these openings arise, front desk
staff will offer them to clients on the therapist’s short list. The short list could be
composed of clients who can only call for same day appointments.
DSS clients; require caseworker to bring client to next scheduled session
Link receiving medications with therapy appointments. Use when client’s lack of
engagement in therapy produces compromised mental health. This may mean
coordinating with MD that client gets only 2 weeks worth of meds from psychiatrist
and must pick up all future prescriptions until the next med appointment from therapist
at therapy sessions. It may also mean therapist attend next med appt.
Discuss with prescriber possibility of transferring client to PCP for services.
Close the case. (No need to send letter to client letting them know that case will be
closed.)
Comments:
Appendix A
DETERMINING A CLIENT’S STAGE OF CHANGE
To determine client’s stage of change, assess three areas:
1) Attitude 2) Intention 3) Past efforts
Attitude
Let’s take a few minutes to brainstorm these issues. Tell me what’s your
attitude/what do you think about X (X can be problem behavior e.g., drinking, or
change behavior e.g., quitting drinking)
Intention
What do you intend to do about this issue? OR
On a scale from 1-10, where 10 is the most motivation and 1 is the least, what’s your
motivation to X within the next couple of weeks. (X is the change behavior e.g., quit
drinking, come to therapy, learn and use new parenting strategies)
Past Efforts
What have you done before about this problem.
Carrots
“Tell me about the part of you that wants to do something about this/wants to come
to therapy/wants to spend more time with your children.”
“Tell me how you talk yourself into X (e.g., taking your medication, facing your fear of
social situations)
Obstacles
“Tell me about the part of you that doesn’t want to do something about this/doesn’t
want to come to therapy/doesn’t want to spend more time with your children.”
“Tell me how you talk yourself out of X (e.g. taking your meds, facing your fear of
social situations).
Appendix B
STEPS TO TAKE FOR PRE-CONTEMPLATOR
(I DON’T HAVE A PROBLEM!)
1) Reflective listening, double sided reflections, open-ended questions.
2) Massage resistance by discussing the pros of the behavior “Tell me about the part
of you that doesn’t want to quit smoking.” Gives you carrots and some obstacles.
3) Provide feedback. Can also point out two parts of story that don’t fit. “Help me
understand. You say you don’t have a problem with your drinking but you’re on your
third DUI.”
4) Brainstorm menu of alternatives.
5) Emphasize personal responsibility (in a nonjudgemental manner). “It’s up to you to
decide what to do with this information. Nobody can decide for you and nobody can
change your parenting style if you don’t want to change. It’s your choice and if
change is going to happen, you’re the one who has to do it.”
6) Advice “I hope you decide to…”
7) 1 affirmation every 5 minutes.
STEPS TO TAKE FOR CONTEMPLATOR
(MAYBE I DO…)
1) Decisional balance sheet. Getting at carrots and obstacles. Summarize.
2) Provide personally relevant information.
3) Past efforts. Reframe failures as some success to boost self efficacy.
4) Emphasize personal responsibility.
5) Reflect and affirm any self motivational statements.
6) Have they moved into determination stage? Ask “How important is this?” “Is it
worth it?” Elicit self motivational statements.
1)
2)
3)
4)
5)
STEPS TO TAKE FOR DETERMINATION STAGE
(I’VE GOT TO DO SOMETHING)
Clarify what they want to change. Don’t push immediate change.
Determine percent motivation for change (intention question).
Explore ambivalence about getting started. Identify carrots and remove
obstacles.
Anticipate obstacles. “Imagine the first week using this new skill” “What are some
situations it would be difficult to use this new approach?” Problem solve.
If client resistance increases, you’ve probably become a cheerleader ahead of
their degree of readiness for change. Go back to reflective listening.
6) When was the last time you felt this way? What would help you get started?
What’s kept you from getting started? What can the people closest to you do to
help or hinder your motivation?
1)
2)
3)
4)
5)
6)
7)
STEPS TO TAKE FOR ACTION STAGE
(I’VE STARTED)
How often in your life have you found yourself this ready to change? How long
does it last?
Are you able to actually start or does your motivation fizzle out right here?
What would help you get going at this stage?
What would keep you from getting started?
What have people closest to you done in the past to help or hinder you at this
stage?
What would you like to get from people closest to you at this stage?
Affirm client’s motivation for change.
STEPS TO TAKE FOR MAINTENANCE STAGE
(HOW DO I DO IT?)
1) What would help you the most at this stage?
2) What hinders you the most at this stage?
1)
2)
3)
4)
5)
6)
7)
STEPS TO TAKE FOR RELAPSE STAGE
(WHAT WENT WRONG?)
How many times has that happened before?
How do you feel when you fail?
Do you pull up your socks and start again right away?
Do you start thinking it’s not worth it and why even try?
Explore ambivalence about starting again.
Reframe relapse as a problem in learning, part of the process.
Affirm all the work done to date in each of the previous stages and start again.
Appendix C
Decisional Balance Sheet
Benefits of continuing
the behavior
Benefits of changing
the behavior
Consequences of
changing the behavior
Consequences of
continuing the behavior
Appendix D
SAMPLE QUESTIONS TO EVOKE CHANGE STATEMENTS
PROBLEM RECOGNITION:
i.
What makes you think this is a problem?
ii.
What difficulties have you had in relation to your X behavior?
iii.
In what ways has this been a problem for you?
iv.
How has it stopped you from doing what you want to do?
CONCERN:
i.
What is there about your X behavior that you or other people might see as
reasons for concern?
ii.
What worries you about your X behavior?
iii.
What can you imagine happening to you?
iv.
How do you feel about your X behavior?
v.
How much does that concern you?
vi.
In what ways does this concern you?
vii.
What do you think will happen if you don’t make a change?
INTENTION TO CHANGE:
i.
The fact that you’re here indicates that at least a part of you thinks it’s
time to do something. What are the reasons you see for making a change?
ii.
If you were 100% successful and things worked out exactly as you would
like, what would be different?
iii.
What things make you think that you should keep on doing X the way you
have been?...And what about the other side? What makes you think it’s time
for a change?
iv.
What are you thinking about gambling at this point?
v.
What would be the advantages of making a change?
vi.
I can see that you’re feeling stuck at the moment. What’s going to have to
change?
OPTIMISM:
i.
What makes you think that if you did decide to make a change, you could do
it?
ii.
What encourages you that you can change if you want to?
iii.
What do you think would work for you, if you decided to change?

** Remember **
Reinforce self motivational statements with reflective listening or supportive statements.

Encourage the client to continue by asking “what else?”