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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Integrated Dual Disorders Treatment Workbook
Chapter 9: Engagement
INTRODUCTION
"Engagement" is the process of developing a trusting relationship, sometimes called a working alliance, with a client. Engagement is usually based on reaching out to the client, empathically understanding their situation and goals, offering practical assistance, and eventually helping them to understand that treatment can help him or her to reach those goals. Because many clients with dual disorders who have not yet engaged in treatment are in crisis, usually related to substance abuse and symptoms of mental illness, lack of psychosocial supports, and severe stress, developing a relationship that will foster recovery can be difficult and take time and creativity.
VIGNETTE
Sheryl is a 20-year-old woman with a diagnosis of schizophrenia. Her first contact with the mental health center was through a community outreach worker. Someone from the local shelter had called the mental health center because staff there were concerned about Sheryl's behavior. She often stayed up half the night yelling back at voices that she said were calling her names. Even more worrisome, she often spent nights on the street prostituting for cocaine.
The outreach worker met Sheryl in the shelter. She was suspicious, fidgety, distracted, and had difficulty talking coherently. The only goal she could think of was to get her own apartment. The outreach worker said that that was something they could work on and asked Sheryl to come in to the mental health center to meet with a psychiatrist. Sheryl refused to come to the mental health center, but she did agree to meet with the outreach worker again. The next day the outreach worker picked Sheryl up and took her out for a cup of coffee and a sandwich. Sheryl reported feeling that she had no one to help her, that she was totally alone. She was angry with her mother, who had hit her and kicked her out when she was 16. Her father refused to talk with her. She didn't know where her siblings were. She said she couldn't trust anyone.
The outreach worker began to meet with Sheryl each morning before she left the shelter and gradually introduced her to other team members. A team member tried to meet daily with Sheryl at the shelter, the soup kitchen, or the local coffee shop. A team member accompanied Sheryl to the Social Security office and helped her sign up for disability benefits. Sheryl continued to insist that an apartment was her only goal. After two months, the team agreed to help her find an apartment if she would meet with the team psychiatrist.
The psychiatrist diagnosed Sheryl with schizophrenia, alcohol dependence, and cocaine dependence; he prescribed an antipsychotic medication. Team members brought medications to Sheryl, and she agreed to take them knowing that the team would help her get money and an apartment. When she began receiving Supplemental Security Income benefits, the team helped Sheryl obtain an apartment and buy groceries. Within days, however, it became clear that Sheryl was prostituting and selling drugs in the apartment, and her landlord soon evicted her.
When Sheryl landed back in the shelter, the team offered again to help. Sheryl admitted that she had not been taking the medications, and she rejected suggestions regarding a payee and a group home. She wanted to control her money and to get another apartment.
For several weeks, Sheryl's behavior worsened with increasing paranoia, less predictable appearances in the shelter, and more frequent signs of physical abuse. At this point, she was arrested for breaking into her mother's home, stealing money, and assaulting her mother. Because of her psychotic appearance and behavior, she was diverted to a local psychiatric hospital. The team visited her regularly and worked with the hospital staff. As Sheryl took medications, got rest, and had a few weeks away from cocaine, she became clearer and more personable than the team had ever seen her. She expressed regrets about her life of addiction, prostitution, and victimization. She attended a group for women with dual diagnosis and another group for women with sexual abuse histories; she began to share her fears and anxieties with others. In anticipation of discharge, she agreed to allow the team to become her payee and to live in a supervised apartment. She expressed a strong interest in continuing with the groups.
Having been through the engagement process with several dual disorder clients like Sheryl, the team knew that she would probably continue to have crises and relapses. But they also knew that they were developing a relationship with her, that she liked and trusted some of them, and that the trusting relationship would eventually be her best chance of learning to participate in treatment, to control her illnesses, and pursue a different life.
HOW DOES ENGAGEMENT HAPPEN?
Engagement means developing regular contact and a helpful relationship that can foster recovery. Not all clients are as demoralized and distrustful as Sheryl, but it is common for people who are dominated by two untreated disorders to have difficulty entering into a treatment relationship. It often takes time, patience, an accepting attitude, a persistent approach, and being available when an opportunity appears. The outreach worker or counselor finds the client and tries to develop a relationship based on acceptance, empathy, and helpfulness. Pushing treatment prematurely can interfere with the engagement process.
Outreach is often necessary, particularly when clients are overwhelmed and unable to muster the courage and hopefulness that are necessary to pursue recovery. The outreach worker expresses empathic friendship by accepting the client as she is and using a technique called reflective listening. This means that the counselor listens carefully to the client's view of the situation and reflects this understanding back to the client to make sure it is correct, without attempting to interpret the situation, offer advice, or correct the client's misperceptions. Reflective listening does not mean accepting the client's view as correct; rather, it ensures that the counselor understands the client's view, the client's language, and the client's attempts to cope. Using this technique is non-threatening and begins the process of building a trusting relationship. (Please see the next chapter on Motivational Interviewing for more details on this approach.)
As part of establishing a relationship, the counselor asks about the client's goals. He then helps clients plan small realistic steps towards the goals, and offers assistance in pursuing goals that are healthy. For example, clients often need assistance in obtaining financial support, clothing, housing, employment, or a better relationship with their families. The client may not know how to pursue these goals effectively, but the counselor can help break the goals down into realistic steps.
Note that the counselor does not help to pursue self-destructive goals like obtaining an apartment when the client acknowledges that he will sell drugs from his apartment. In such a situation, the two attempt to find another goal that they can agree on. At the same time, the counselor does not confront the client about substance abuse while establishing a relationship. This is sometimes difficult for counselors to remember.
Working with a dual-disorder client can easily become derailed by the client's illnesses, crises, or attempts to cope with a bad situation. The counselor must remain positive and optimistic, avoid confrontation, and emphasize hope, self-efficacy, and the client's strengths. As they develop a relationship through working together, the client discovers that substance use and psychiatric symptoms are barriers to accomplishing his or her goals. At this point, the counselor suggests treatment possibilities, sets up an appropriate appointment, and, if the client wishes, accompanies the client to the appointment. The counselor is careful to stay on the client's side and to facilitate but not insist on entering treatment and adhering to treatment recommendations. Over a few months the relationship and the support will enable most clients to connect successfully with treatment.
THE ROLE OF CRISIS AND STABILIZATION
Despite heroic efforts to help, some clients, like Sheryl, will continue to experience wild fluctuations or to spiral downhill. Their lives are so dominated by illness, trauma, addiction, and instability that they don't see the need to master their illnesses and don't even hope for a better life, even with a counselor to help in the process. Sheryl's behavior indicates that she is severely addicted to crack cocaine, which has severely worsened her schizophrenia, caused her to lose her supports, and made it difficult for others to maintain a relationship with her. She needed respite, safety, and protection to recover her ability to see her situation rationally and to make good decisions for herself. Hospitalization and protected housing are often critical steps, but they may not be acceptable to the client.
As with Sheryl, the opportunity to turn the situation around often comes with a crisis. The client may experience a shocking realization, often during enforced sobriety, that he or she needs to get off the path of self-destruction and to do something different. Having a relationship with someone who can help at this point is critically important.
ENGAGEMENT TECHNIQUES WORK
The approach to engagement we have described here is commonly used and is quite effective. In the substance abuse literature, it is called motivational counseling, and in the mental health literature, it is known as strengths case management. The approach has been widely used with homeless clients and other extremely demoralized people who are difficult to engage in treatment. With such people, it can be a protracted process. With clients who are more intact, who have a helpful support network and a safe place to live, the process often goes much faster. Once clients are engaged in the relationship and begin to see that treatment might be helpful in reaching their goals, a variety of interventions for substance abuse and mental health problems can be used, but engagement nearly always precedes involvement in treatment.
Recommended reading
We strongly recommend the following book, which describes the engagement process and is extremely helpful for anyone attempting to engage dual-disorder clients in a treatment relationship.
Rapp, Charles. The Strengths Model. New York: Oxford Press 1998.
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