Client engagement is a very essential, but often challenging part of an effective therapeutic process. And it’s fast becoming an increasing focus for psychology researchers like the National Alliance on Mental Illness, whose figures show that 70% of patients drop out of therapy after their first or second visit.[1] But does it have other benefits, besides facilitating continued treatment?

In this article, we’ll look at why it’s patient and client engagement is such an essential ingredient in delivering high-quality blended care outcomes, as well as what it looks like and how practitioners can build more of it.

Read on to explore different patterns of treatment engagement, as well as how it can be built and maintained in an online therapeutic relationship.

What is Client Engagement in Therapy?

Most therapists have a strong preference toward specific methods, models and techniques of how to achieve success in therapy. Some prefer cognitive behavioral therapy, others use strength-based approaches, holistic health philosophies, solution-focused and person-centered methodologies. But no matter which of these a therapist uses, none will work if a client is not engaged.[2]

Simply put, client engagement is present when patients become actively and fully immersed in their own treatment process. Client engagement is not a recent idea, but something that has been studied for decades.

What Does Good Client Engagement Look Like?

Client engagement is present when patients become actively and fully immersed in their own treatment process.

Many practitioners and researchers break down client engagement into three distinct aspects. According to the literature, these are[3]:

  1. Patient-therapist agreement on the goals of therapy
  2. The emotional bond that is created and maintained between patient or client and their practitioner, and
  3. Their collaboration on therapy-related activities.

To establish and enhance these dimensions, many therapists focus on developing and strengthening their own behaviors and skills in a way that contributes to these three areas, thus nurturing and growing the therapeutic alliance.

This means not only understanding themselves and what they bring into the relationship, but also knowing their clients and their specific needs well enough so that they can respond to and involve them collaboratively toward progress, commitment, and better therapeutic outcomes overall. 

Why Engagement Matters

As most practitioners will know, and as many studies show, engagement is a significant component of successful therapy.[4]

Benefits of Client Engagement

Patients who are highly engaged are much more likely to bond with the therapist, which generally leads to more successful outcomes. According to research, engaged clients are more likely to[5]:

  • Endorse more treatments
  • Exhibit greater levels of participation in the therapeutic process of therapy
  • Remain in treatment for a longer period, and
  • Eventually, to report higher satisfaction with end results compared to unengaged patients.

For therapists eager to help patients successfully, client engagement in therapy is key.

Engagement is Ongoing

Many patients report that feeling understood by their therapist is a key factor in helping them improve.[6] Often, and more specifically, it is the power of that therapeutic relationship that they describe as helpful in making progress.[7]

Some assume that client engagement only happens at the start of a treatment process, but this is not true. Even if a therapist has not managed to foster engagement with the patient in the first therapy session, it does not mean all is lost. Engagement is an ongoing process, which is why it is so important to work towards not only implementing it but also on maintaining it throughout the relationship.[8]

Common Mistakes

Sometimes the question of engagement is overlooked in the initial sessions as the practitioner strives to understand the patient and get them settled into the therapeutic environment so that they are comfortable. Tackling these problems can be done with an optimistic, empathetic, and committed approach.

Examples include:

  • Being genuinely engaged in the therapeutic relationship
  • Having unconditional positive regard for the client, and
  • Clearly communicating these attitudes.

It is also important for therapists to not get stuck with one single method or intervention when employing strategies for engagement. Diverse client base requires diverse approaches to engagement, particularly when treating clients who are dealing with chronic and serious conditions, personality issues, trauma or difficult life circumstances. 

Engagement is an ongoing process, which is why it is so important to work towards not only implementing it but also on maintaining it throughout the relationship.

Patterns of Treatment Engagement

The methods used to engage a client will vary with attitudes toward treatment that often become evident in the first session. Recognizing these behavioral patterns can help predict which methods are more likely to work with different patients. Adam Blanch of Good Psychology gives examples from his personal practice regarding how different modalities can be used effectively to engage clients.

These fall into five distinct categories of engagement patterns:

  • Meeting
  • Matching
  • Leading
  • Containment
  • Ignition

5 Steps to Engaging Patients

1. Meeting. Many patients enter therapy knowing something about what they need and are willing to create a collaborative client relationship. They want their therapists to meet them where they are and often benefit from solution-focused therapy.

2. Matching. Other clients have little insight and understanding of their needs and requiring the therapist to match to their experience and then lead them to a new perspective. This is where humanistic or interpersonal approaches to therapy can be effective.

3. Leading. In some cases, patients are very set in their ways. These patients will need the therapist to model, direct and lead them to explore the various aspects of themselves. This often involves psychodrama and process-oriented therapies.

4. Containment. Clients with unstable identities and broken boundaries will require therapists to hold and contain their experience until the patient is able to reintegrate themselves. Cognitive behavior therapy (CBT), Applied Behavior Analysis (ABA), and similar approaches are usually effective here.

5. Ignition. Occasionally patients arrive in extremely deficient states and are usually very shut down. This will often require therapists to provide fuel to re-ignite their drive and can be accomplished with motivational interviewing techniques and positive psychotherapy approaches.

Related: Your Ultimate Intrinsic Coaching Guide: Empower Others With This Methodology

Is There One Right Approach?

Of course, there are numerous approaches to engaging patients. Treatment and health engagement hinges a lot your particular client’s circumstances, how their began, and how they feel about general about therapy.[9]

Therapists know all too well how different their clients can be and how little you can anticipate from a new client when they first step into your office. And, all the recommendations and compatibility tests aside, only interacting with your client can help you find out if there is any chemistry between you or not.

Achieving Client Engagement

When first engaging with the client, it is important to do so on their terms. Sometimes this can be done by the practitioner:

  • Creating a casual, positive atmosphere
  • Talking about things that are unrelated to the issue they are there to deal with
  • Helping patients relax, and set themselves at ease.

Usually, relaxed clients are much more amenable to further disclosure. It’s easier to steer the conversation toward what brings them to therapy, what they would like to achieve and how will they know they have been successful in getting to their goals.

It’s also important to let them share their perspectives without interruption and validate whatever feelings show up in the session.[10] Sometimes negative emotions will signal that they are not feeling heard. It can also be immensely helpful to listen to any concerns they might have over the therapy process itself.

For example, if they don’t think one method or approach will help, such as many patients who are new to video or mobile therapy, they are not likely to cooperate. In such cases, it may be best to offer up alternatives allowing the patient to have input into their own treatment.

For many patients, a sense of autonomy is a critical part of feeling heard and understood, which in turn can lead to better health outcomes.[11]

Maintaining Client Engagement

Building and maintaining rapport is an ongoing process. Some clients will need time to settle into the therapeutic atmosphere at the begging of every appointment, others will be ready to pick up where they left off.

Meta-analyses of factors promoting a good therapeutic alliance suggest that personal connections, two-way dialogue, and a neutral approach can be helpful.[12]

Good Personal Connections

Clients who feel well connected to their therapists will often say that he or she can tell how their week went the moment they step into the office. As life happens, circumstances change and clients come to you having experienced different things during the time in between sessions, these experiences may have affected them in some way and they may be focused on those events rather than on the therapy session.

In such situations, it is good to meet them where they are and talk about what is occupying their mind and show that you are actively listening.

Encourage Dialogue

Another way of keeping clients engaged is to check in at intervals during the overall therapeutic process, to see how they are progressing toward their goals for therapy. It can be a good idea to ask questions regarding their perception of their progress, including[12]:

  • How they think they’re doing, and
  • What they’d like to see as future goals.

All this is done to ensure that the client is happy with where they are, the direction and focus of what is being discussed, and how they feel about their current mental health treatment plan. It’s also a good idea at this point to seek feedback – see whether the patient needs any additional input from you that might help move the sessions along in a more constructive manner. There are many client management programs out there that can keep you on top of who you’d like to check in with, saving you the hassle of maintaining manual records.

Reserving Judgment

One of the biggest keys to success with client engagement is managing to remain neutral. As a therapist, it is important to remember not to pick a side, even if you feel the client may be in the wrong.[12]

If you side against the client, or with another client if you are performing couples therapy, this can lead to that client becoming less engaged and even terminating the relationship.

Online Treatment Engagement

Many patients are moving to teletherapy – the ability to interact via text, phone, or video with a therapist of their choice. While mental health software has come a long way in optimizing the treatment process, one commonly raised issue with teletherapy is the concern that client engagement may be compromised.

With an estimated 60-65% of human communication taking place nonverbally, it’s only natural for some therapists to worry about how non-F2F interactions might damage client rapport.[13][14] Without subtleties such as gestures, speech patterns, and tone of voice, can a meaningful therapeutic alliance still be built?

A Look at the Research

As e-therapy solutions like iCBT and ABA software become more and more available, so is the research into their impacts on engagement.

Findings from the virtual care research indicates there are many ways to establish trusting, productive relationships with clients during online sessions. For example, we can look at how speech-language e-therapy practitioners built on general psychological practices to create strong therapeutic bonds via teletherapy.[15]

  1. Getting To Know Your Client. Building personal connections is important in both F2F and virtual therapy settings. Speech and language pathologists (SLP) practitioners used e-therapy’s flexibility to their advantage when getting to know clients. This involved making themselves available on multiple channels such as text, instant message, and video, so their clients felt they were “on the same level” and could reach out to them on whatever means was most convenient – often the computer.
  2. Fostering Open Communication With Parents. Admittedly, a rapport-building practice particular to child or adolescent therapeutic contexts. However, practitioners again reported making themselves available to parents outside of session times to solicit as much input as possible to facilitate more responsiveness and activation. Compared to practicing strictly within the time- and geographical-constraints a clinical setting alone, one SLP described this as being much more conducive to strong personal client relationships – particularly with their young clients.
  3. Making Personal Connections. Through the improved openness, creativity, and communication that flexible communication provided, SLPs reported greater client responsiveness and cooperation to therapy. As one practitioner described: “I actually feel like I have more time to build rapport than I would at the clinic because of having to redirect to a specific activity” (p.578).

Methods of communication are rarely the sole reason for compromised client engagement. Even in office settings clients are often uninterested and poorly engaged, meaning that disengagement is not significantly related to a mobile app or the setting the client is in.

Instead, it has more to do with the way the therapist interacts with the patient. As we have outlined earlier, the same steps can be applied to online therapy sessions. Of course, if you are not doing video therapy but sessions via text or phone, this can be harder, but nevertheless rapport with the client can, and must, be made.

Does Teletherapy Hurt Engagement?

In the instances where teletherapy is indeed the cause for a lack of client engagement in therapy, there are a number of tips that can help you improve this situation. There are several ways practitioners can go about this; for instance:

  • Eliminating distractions. At the beginning of the session you can ask the patient to remove any distractions – this may even involve getting the client to move to a different location in the house. In a teletherapy setting it can also be a good idea to mix up the different activities or ways that you offer therapy in order to keep the patient’s attention and help keep them focused on the task at hand.[16]
  • Simplifying the process. It is not unusual, particularly with first-time clients, for therapy to feel intimidating. Talk your client through what they can expect, answering any questions they may have, and providing help where necessary with any potential confusion, e.g. Informed Consent or intake forms.

Again though, we come back to the aspect of connection. This is because this really is the crux of the matter when it comes to engagement. Patients need to feel valued, listened to, and justified.

Creating a comfortable, safe, and relaxing environment for the patient is key, as is demonstrating that you are listening and responding to the client’s needs. Remember that client engagement is also about allowing the client to have a say in the treatment process, so give them that chance!

Finally, it’s good to end a session by asking the client how it went, what they liked or didn’t like, and what they would like to do next.[16]

Final Thoughts

No matter the location of the session, therapists can do many things to help encourage engagement from their clients. These methods will differ between patients and can even inform the types of treatments that should be given.

However, the key to successful client engagement is always through building a relationship between the patient and therapist. Create rapport, show a caring and understanding attitude, listen to your client and allow them to have a say in the treatment process, and you will soon find your way to excellent client engagement and successful therapy outcomes.

References

  1. ^ National Alliance on Mental Illness. (2016). Engagement: A New Standard for Mental Health Care. Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/Engagement-A-New-Standard-for-Mental-Health-Care/NAMI_Engagement_Web.pdf
  2. ^ Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: historical Excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270.
  3. ^ Meyers, L. (2014). Connecting with Clients. Retrieved from https://ct.counseling.org/2014/08/connecting-with-clients/
  4. ^ Yoskowitz, N. A. (2018). Client Engagement in Psychotherapy: The Roles of Client and Beginning Therapist Attachment Styles. Doctoral dissertation, Columbia University.
  5. ^ Thompson, S. J., Bender, K., Lantry, J., & Flynn, P. M. (2007). Treatment Engagement: Building Therapeutic Alliance in Home-Based Treatment with Adolescents and their Families. Contemporary Family Therapy, 29(1-2), 39.
  6. ^ Horvath, A. O., & Greenberg, L. S. (Eds.). (1994). Wiley series on personality processes. The working alliance: Theory, research, and practice. New Jersey: John Wiley & Sons.
  7. ^ Binder, P. E., Holgersen, H., & Nielsen, G. H. S. (2010). What is a “good outcome” in psychotherapy? A qualitative exploration of former patients' point of view. Psychotherapy Research, 20(3), 285.
  8. ^ McLaren, C. (2016). The Importance of Engagement. Retrieved from http://specializedfamilytherapy.com/the-importance-of-engagement/
  9. ^ Constantino, M. J., Castonguay, L. G., Zack, S. E., & DeGeorge, J. (2010). Engagement in psychotherapy: Factors contributing to the facilitation, demise, and restoration of the therapeutic alliance. In D. Castro-Blanco & M. S. Karver (Eds.), Elusive alliance: Treatment engagement strategies with high-risk adolescents (p. 21–57). Washington DC: American Psychological Association.
  10. ^ Bedi, R. P., Davis, M. D., & Williams, M. (2005). Critical Incidents in the Formation of the Therapeutic Alliance from the Client's Perspective. Psychotherapy: Theory, Research, Practice, Training, 42(3), 311.
  11. ^ Ng, J. Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325.
  12. ^ Nienhuis, J. B., Owen, J., Valentine, J. C., Winkeljohn Black, S., Halford, T. C., Parazak, S. E., Budge, S., & Hilsenroth, M. (2018). Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review. Psychotherapy Research, 28(4), 593.
  13. ^ Burgoon, J.K., Guerrero, L.K., & Floyd, K. (2009). Nonverbal Communication. Boston, MA: Allyn and Bacon.
  14. ^ Foley, G. N., & Gentile, J. P. (2010). Nonverbal communication in psychotherapy. Psychiatry (Edgmont), 7(6), 38.
  15. ^ Akamoglu, Y., Meadan, H., Pearson, J. N., & Cummings, K. (2018). Getting connected: Speech and language pathologists’ perceptions of building rapport via telepractice. Journal of Developmental and Physical Disabilities, 30(4), 569.
  16. ^ Goode, H. (2018). Telepractice: Are You Throwing Client Engagement To The Wolves?. Retrieved from https://globalteletherapy.com/telepractice-are-you-throwing-client-engagement-to-the-wolves/

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