Aspirational Engagement: Creating Connections That Matter
Robert M. Robertson, Jr., M.S.W., L.S.W.
Aspirational Engagement:
Creating Connections That Matter
Robert M. Robertson, Jr., M.S.W., L.S.W.
Engagement is a core skill that practitioners must possess in order to
provide any meaningful direct counseling service. It is as much a function
of who the practititoner is as a person as who they are as a professional. The
process of engagement is itself a foundation “microtherapy” within the
process of direct services which helps define the speed and process of
service. This article examines engagement as a process and style as
well as strategies for the non voluntary or difficult to engage client.
Since I first wrote the training article Magic and Madness: Engagement Strategies for Difficult and Nonvoluntary Clients (1996) and revised it in 2006 with a different title that better reflected the new thinking (Engagement as a Microtherapy Skill), a great deal of experience and thinking about the process of engagement has occurred. The mindset and practice of Positive Youth Development (PYD) has become firmly imbedded in the way many (youth) workers think about, approach and provide services to youth and families. And while PYD began as a youth serving concept, it’s application applies as a general construct for serving almost all client populations.
While much has changed, much remains the same. Engagement remains the foundation of the service process. It makes little difference whether one is a counselor, an intake worker, a resident advisor or anyone else who has responsibility for working or interacting with clients. Engagement is the bedrock of the helping relationship. Quite simply, if you can not engage a client, you can not effectively work with the client. Thus, the critical continuum for the worker is the extent to which the client is engaged with the worker and connected to their own process.
The engagement process applies to all clients and all workers; no exceptions. It is a mutual process of connecting and creating a useful working relationship. Within that context though, the most formidable challenges for any worker is the successful engagement of the nonvoluntary or resistant client and their family system; those whose previous experiences and emotional safety warns them to proceed with caution. Without the cooperation of the client, even the most skillful counselor is only as successful as the beginning worker struggling to engage an equally unwilling or resistant client. These clients pose the same simple question to all workers regardless of their training, skill level, or experience - can I trust you enough to risk my present and
© 2010 Robert M. Robertson, Jr., M.S.W., L.S.W. is the Executive Vice President of Valley Youth House, Allentown, Pennsylvania. This article is revised and updated from Magic and Madness: Engagement Strategies for Difficult and Nonvoluntary Clients (1996) and Engagement as a Microtherapy Skill (2006) training article.
future emotional safety? Those who successfully engage the client are given permission to deal with new and more intimate levels of resistances to change. Those clients who do not engage with the counselor remain "stuck" waiting for the right counselor, circumstances, or opportunity to proceed with an acceptable level of anxiety, pain, and safety.
Aspirational Engagement focuses on a worker friendly understanding of the differences between aspirational engagement and “settling”, the nonvoluntary, resistant and difficult client and family system; the meaning and use of resistance as a natural part of the therapeutic process; a creative mindset and skill base for working with difficult clients; and useful techniques for engaging such clients. That understanding will facilitate an understanding and engagement of almost all clients regardless of their level of resistance. In addition, it will address many of the foundation elements of engagement as well as providing some practical strategies that one can consider, use, or adapt within their own practice, process and style.
The term client is used throughout the article to refer to the identified client, patient, family system, consumer, customer and other identifying names used within the human services to describe the person receiving a service. Worker refers to a counselor, therapist, intern or any other human service practitioner who is providing the service.
Aspiration vs Settling: It’s All About the Worker
Engagement is really more about a direction than a route to get there. The critical destination is a connection with the client that endures the stress and challenges of the work. The strength of that connection also defines how much stress and tension can be tolerated in the process of the work. In that abstract sense, the quality of relationship or connection is on a continuum of “no connection” to the strongest therapeutic connection possible that would carry a client through whatever trials, tribulations or obstacles that present themselves.
“No connection” is easy to consider based on the principle “if you can’t connect with the client, you can’t successfully work with the client”. Somewhere between “no connection” and the middle of the continuum is “settling”. Settling is the professional belief and expectation that simply meeting with the client constitutes engagement. It is one step beyond the client’s refusal to meet or be in the same space with the worker. It is supported by what Jay Haley referred to as the worker attitude and position of being “one-up” on the client. If both the worker and client are present, than something is supposed to happen. The “what’s supposed to happen” is more an expectation of the worker than the client as though the worker holds a “magic stick” that compels something therapeutic to happen; but it usually doesn’t. The client showing-up for appointments is not the same as something happening; particularly for clients compelled by authority.
Within the Positive Youth Development model (discussed later) at least two of the four critical elements (safety, control, connectedness, and opportunity) are absent. The absence of them at a minimum level creates significant barriers to engagement as a basis of meaningful work.
Aspirational engagement, by contrast, is very client-centered in the fullest sense of the concept. Engagement is an intentional and active process of being attentive to the critical PYD elements of creating an emotionally safe place (according to the client rather than the worker), creating a place where the client feels some sense of control over their own situation and in their life, establishing a relationship the client wants, and providing “real” opportunities the client can experience and use in their immediate situation. In this way the worker aspires to create a unique relationship and situation for the client to begin and continue working.
In considering the space between a “settling” engagement and an aspirational engagement the difference is the intentionality of creating something rather than just providing something. While settling requires the client to accept who the worker is, aspiration requires the worker to earn the relationship. Settling views a failure to engage as client resistance. Aspiration views a failure to engage as a worker barrier to understand and overcome.
Just as personal style is a critical element in how one engages others, personal style often characterizes whether an individual is an aspirational person or a settling person. While the worker has primary responsibility in the engagement process, understanding aspiration and settling can also be a helpful tool in considering clients. Aspirational clients tend to be those who are self-motivated to seek and engage in services. Settling clients tend to be more accepting of their circumstances, require high levels of support and encourangement, and are more risk aversive to personal change.
Given those very general assertions, it is easy to consider the challenges for a settling worker who has to work with a settling client. The settling worker often defaults to an authority or compliance position in attempting to move such a stuck client toward change. An aspirational worker with such a client will more likely seek to consider other motivational strategies to unstick the client. The essential point of aspiration versus settling is that it applies to both workers and clients and that the worker has the primary responsibility of being aspirational.
Positive Youth Development: It’s Different Than Strengths-Based
Normally, the order of discussing engagement would include an understanding of resistance before the introduction of Positive Youth Development (PYD) or strengths-based models. In this case it is more helpful to introduce PYD before resistance to assert the critical point that being aspirational and creative has to transcend the more traditional notions of deficiency and pathology as presented in the diagnostic process of understanding clients.
When I first wrote about PYD in Walking the Talk (Child Welfare, 1997) it was a concept everyone, including me, were working to get our arms around in practical ways. At the time I described it as a “strengths-based macroconcept that directs the programs and services available in communities to all young people rather than targeting only those with defined problems or those in high-risk situations.” Conceptually, it viewed youth and families as partners rather than clients.
After more than 15 years of proactively using PYD, training others how to use it as a practice foundation, and implementing it in outclient and residential youth service programs a few things are clear. First, PYD is more a mindset than a skill. It is more about who YOU are than how you practice. Who you are is a function of what you believe and how you live, not just how you practice.
Practitioners often confuse strengths-based practice with PYD. Strengths-based practice is an approach that identifies the client’s strengths and applies them to overcoming a problem. Strength-based practice strategies begin with the identification of a problem or why the client came for service and than focuses on resolving that problem. (Fest, 2005). PYD; by contrast, focuses on what all young people need to be healthy and accomplished, regardless of the presence or absence of problems. In other words, the process is treating and engaging those who present problems as you would those without problems. In that way, the worker remains genuine to who they are and honors the client by respecting what they are capable of achieving regardless of their issues or problems. PYD requires an understanding of the problem and issues which are secondary to the mindset of addressing them.
I had since refined the PYD definition to an operational and integrated mindset that creates, provides, and uses opportunity to create meaningful experiences for becoming a positive, competent and contributing adult.
In 2006 there was an epiphanous moment while I was training AmeriCorps members in the core concepts of PYD. They were to become faculty members in one of our six week Valley Youth House Youth Leadership Institute projects. Thirty minutes into the training, not only were they getting bored, but so was I as the trainer. How could they effectively communicate core PYD concepts to the participants if I could not be succinctly inspiring with them? Out of that moment came the consolidation of PYD concepts into 4 core PYD principles which I believe are also the foundation of the engagement and therapeutic process. (See PYD Made Easy Chart below)
Those principles are safety, connectedness to others, opportunity and control over one’s own life. Safety is all about feeling physically and emotionally safe. Connectedness to others is about having and building relationships with caring and connected adults. Opportunity is about creating and providing meaningful and purposeful activities. It is not about insight or intellect. Control over one’s own life is about having control over or significant input into one’s own life decisions. It is about creating real partnerships.
Figure 1: PYD Made Easy (Robertson, 2006)
Positive Youth Development
Made Easy
Safety
It is about feeling physically
and emotionally safe.
Control
(over One’s Life)
It is about having control over
or significant input into one’s
life decisions.
Positive Youth Development is…
an operational and integrated mindset that creates, provides, and uses opportunity to create meaningful experiences for becoming a positive, competent and contributing adult.
Connectedness
(to self & others)
It is about having and building relationships
with caring and connected adults. It is also about being connected with yourself and knowing and being able to ask for what you need.
Opportunity
(based)
It is about meaningful and
purposeful activities, not insight
or intellect.
The essential understanding of PYD is that it is the mindset and foundation for the engagement process as a microtherapy skill. It creates a safe opportunity for the client to become connected to the worker and experience the process as one which affords partnership and meaningful personal decision-making.
First Level Engagement Thinking
Engagement as a microtherapy skill is inclusive of many important elements such as understanding the nature, continuum and process of resistance, how clients respond to counseling and the counselor, joining, capturing the client, the worker’s style and creativity and the many things that can go wrong in the process. As stated earlier, the ability to work with a client is a function of one’s own ability to engage the client. It is the worker’s responsibility to engage the client, not the client’s. It determines the speed and amount of work to be accomplished.
While engagement is different than the work of therapy, it is the foundation of therapy on which all future work is built. As a microtherapy skill it serves as the subtext of the actual therapy. It is important not to mistake cooperation as engagement. Compliance is not the same as progress. Consider juvenile justice and other settings that exercise control and authority to gain compliance or cooperation. Upon discharge, seemingly apparent progress vanishes with the removal of the requirement for compliance.
For many clients, there have many workers before you. Consider the client’s experience and performance with each of them. Consider that if previous workers were successful there would be little need for you. It is reasonable to presume that based on previous worker experiences, clients could easily be worker weary.
Successful engagement, therefore, means you, the worker must be worker worthy. Clients do not generally get a say in who their worker will be. The process of engagement is subtly marketing yourself as a worthy worker. It may be unconscious and automatic, but like the client who makes their assessment of you pretty quickly, you are adjusting your presentation and engagement choices equally fast. These adjustments of presentation are especially helpful when working with family systems that hold a presumption of side or belief that the worker is operating with a bias toward one side or particular person.
The essential outcome goal of the engagement process is capturing the client in order for the work to continue. The strength of engagement allows the work to continue and engagement to rise to higher levels of trust and partnership.
Resistance: A Practical Understanding
In order to fully understand engagement the worker needs to acknowledge and appreciate resistance. The creative counselor's approach to resistance is that resistance, at some level and in some form, is inherent in the helping process and that it reflects the worker's momentary inability to transcend or understand the issues that block client movement, growth or resolution. It additionally enables the counselor to avoid confronting deficiencies in their agency's practices or themselves.
A typical example of this misjudging or mislabeling is the identification of a client who is unreceptive to an agency's service or a counselor's method or style as resistant. Such an assessment relieves both the agency and the worker of less comforting explanations for the client's behavior.
Both voluntary and non voluntary clients bring fears and hurts to a therapeutic process that are perceived or expressed as resistance to anyone who attempts to touch the source of the client's pain (Hartman & Reynolds, 1987). It is therefore important for the counselor to remain sensitive to the individual or family's general need for emotional stability during an expected time of change.
It is essential to include counselor resistance as both a possible and likely source of being "stuck". This may involve a dislike of the client as well as an unconscious dislike or triggering of unpleasant or traumatic material from the counselor's past. Typical indicators of this includes the counselor's feeling delight when a particular client cancels or no shows an appointment or is not home for an outreach visit, the counselor misses or avoids obvious diagnostic material, the counselor avoids specific case presentations or discussions in supervision or the counselor manages the case differently than other cases.
Many years ago Schlosberg and Kagan (1988) described a three step framework for working with resistance. It is based on developing a hypotheses about how the process of resistance protects the client from their primary fears (safety) and tests the counselor-client relationship. Table 1 (identified below) outlines the process for identifying typical patterns of resistance. The worker begins to use the resistance by identifying their own reactions and feeling to it. The worker's gut feelings provide clues to pressures and unstated messages. These can be used as indicators of the clients feelings and fears. A hypotheses can then be formulated as to how the resistant behavior makes sense as the foundation for creative interventions to engage the client., to build on their strengths, and to begin the process of change.
Table 1.
Working with resistance: A framework for assessment and treatment planning.
Primary Resistance Patterns (examples)
Denial ("No problem")
Blaming ("It's all _______'s fault.")
Labeling ("He's been diagnosed as _________.")
Fragility ("Don't push him hard.")
Driven parent ("If I don't do everything, no one will.")
Induction ("We like you. You're part of our family.")
Avoidance ("He couldn't be here.")
Crises ("We're in terrible trouble.")
Discounting ("It hasn't helped. You're no good.")
Helplessness ("What's the use?")
Environmental hurdles/dangers ("Cockroaches, lice ... it's the pits.")
Worker's resistance ("I can't, I shouldn't, I must...")
Identification of Feelings
Worker's reaction/feelings toward resistance
Client's feelings/beliefs, what they fear most
Development of Strategies to Engage the Client and Promote Growth
Hypothesis on the function of resistance in the worker-client interaction
Specific strategies
Resistance is an often overused and misused term and label whose origin is generally attributed to Freud and the long-term psychoanalytic process. Freud referred to resistance as an expected phenomenon within the treatment process whereby the uncovering of buried and threatening material usually leads to the client's development and use of defense mechanisms (Gitterman, 1983). The use of the term has become muddled over time and (mis)used by many practitioners to identify any client or family system that the worker has been unsuccessful in engaging, treating, or maintaining in a therapeutic process. This (mis)understanding of the client and their behaviors somehow relieves the worker from less comforting explanations of the client or family system's behavior (Gitterman).
For practical purposes within this article, resistance refers to any behavior or action by a client or worker which serves to protect the client, system, or worker from other persons, actions, feelings, or events they believe to be emotionally uncomfortable or painful to them. The belief may exist on a conscious or unconscious level. Emotional pain exists both on an emotional continuum and is relative to the respective individual or system. In other words, what is uncomfortable or painful to one person may not be so to another.
Therapeutic Myths of Resistance - It is important to clarify three important myths about the treatment process which have a direct relationship to engaging clients. The first is that clients come to counseling for change. This is especially not true for semi and non voluntary clients who do not initiate the process and those in which the entire family system does not cooperate in the therapeutic process such as a spouse or partner that refuses to participate initially or on an ongoing basis. Most often clients begin the therapeutic process with an agenda of staying comfortably where they are at in an emotional place that may seem painful to others but is safely familiar to them. Joel Bergman identifies the common process of clients who often expend a great deal of energy searching out a Dr. Homeostasis who will unwittingly assist them in fulfilling their mission of keeping things the same.
The second is that most people come to therapy believing in it. Most clients have some history of prior counseling and/or interaction with child welfare or a criminal justice type system which has not been helpful to them. They also have some preconceived notions of who counselors are and what they are up to in their work. Prior experience and current hopelessness make strong partners for disbelief of any positive outcome or value of the therapeutic process.
Consistent with the first two myths are that people come to counseling eager for solutions and that each family member is equally motivated. Family systems simply do not operate in this manner when the outcome is change and that power and control shifts in the system. Practical reasoning suggests that in order for someone to get stronger and more of something that someone must lose or give up power. Under such circumstances, at least one person in the system will perceive an impending loss of power or control.
Types of Resistance
Client Resistance - In the area of client or family resistance it is important to understand that the persistence of behaviors or resistance serves the important function of stability to the client. Old problematic behaviors support the belief "better a known devil that an unknown saint". Problems and behaviors may be uncomfortable, but they are certainly more familiar and manageable than the unknown feelings of some desired change that may actually feel worse, especially in the process of getting there. The growth capabilities of a person or family are often impeded by intimacy related issues. For the client identified as resistant this can take the form of either lost or a loss of intimacy or a fear of too much intimacy. The intimacy theme often reflects the growth capabilities of a person, marriage or system. It should be recognized that in some relationships there is only the experience of pain or no intimacy.
Worker Resistance - Resistance is often an accurate term to describe barriers to growth or change. It is most often misused by counselors or therapists to label clients rather than themselves. A clear second type of resistance therefore belongs to the worker. A common theme for the worker often has to do with their own family of origin issues which may have events or issues that were or are painful to them. This can be dormant or feel resolved until it is triggered by either the client or material about the client. It is often a double edged sword. For example, the worker may be a middle child in their own family which included the role of the peacemaker. While this is a generally good characteristic for a worker to have it may also prevent conflict from occurring in families with whom they work. One must be aware that our own issues may be long term and that client issues may actually be the same or similar to our own.
A second common area of resistance for new or inexperienced workers is a fear or anxiety of clients and working with them which inhibits the counselor's ability to do what they need to do. Workers may also feel some discomfort with the power of their role and may be reluctant to use it in a productive way to unstick family systems.
A related area of resistance is the worker's theory or knowledge base which may dictate what and how they hear information. It is crucial that counselors have an awareness of how they hear because of a tendency to hear certain things because they believe certain things. It is therefore important to read a diversity of material and be familiar with several approaches for balance.
Worker fatigue can be a cause of both worker resistance to particularly difficult topics and specific clients. You know you are experiencing fatigue when you are glad your client(s) cancel their appointment. It is important that workers know both their limits as well as how to energize themselves.
Certain types of cases may cause worker resistance to both the client and their material. It is important for workers to understand what type of clients push their buttons. Consideration in the areas of moral issues and values is important in self and therapeutic awareness. Workers should have a clear understanding of who they are as individuals and what is important to them.
The worker's sense or perception of appreciation from clients can be a relevant factor of worker resistance. Clients often push or keep counselors away as a means of emotional safety and protection. The personalization of transference may cause the worker to experience it as rejection. Additionally, the humanistic approach sometimes sets the worker up for offering personal intimacy when they will get back very little.
Closure issues for the worker are an additional form of resistance. Sometimes the worker has trouble closing, separating, or losing those they work with.
System Resistance - It is important to be aware of organizational blinders. The worker may work with a client group so long they only use or see their own approach. Another way of describing this prescription of choice is "we have met the enemy and they are us". Other forms of system resistance are the unavailability of adequate or appropriate space to conduct effective counseling. Excessive time and paperwork demands may also provide impediments to working successfully with clients.
The creative worker demonstrates an interest in identifying the issues which are presenting the resistance. This often involves seeking the meaning of behaviors and self-examination to determine who is actually presenting the primary resistance - the client or the worker. The creative worker demonstrates an ability to vary their style and feels greater freedom to take calculated therapeutic risks in pushing their own style and technique repertoire. The issue is often not one of penetrating the client's resistance, but of engagement wherein both the client and the worker examine the resistance for it's utility.
Resistance Strategies - The most important strategy in working with resistance is the worker's need to plan for and expect resistance. The amount of resistance from a client can be greatly reduced if the worker connects with the client on the client's issues and terms and utilizes a style and language similar to that of the client's comfort level and familiarity.
The use of treatment contracts assures agreement on issues to be worked on and how counseling time will be spent. Like a car, if something needs to be fixed, you fix it but do not tell the owner where to drive it. If they come in for an oil change, you do not tell them they an inspection.
Workers need to understand they will make mistakes. The better the counselor gets in their practice experience and style the quicker they will catch their mistakes. It is also helpful for workers to understand the Leviton Rule of Power Struggles - Avoid them or win them. If you know you are going to lose, do not invest in an emotionally draining power struggle. Avoid it and address it in a different way.
A metaphoric example to better understand the process of resistance in the therapeutic process is somewhat like an automobile journey in which both the client and worker each have their own steering wheel and set of brakes. In a best case scenario they have both agreed on the general (and sometimes specific) destination. (One common worker strategy guaranteed to ensure client resistance is to take the client on a trip to some unknown destination. The importance of trust and control in engagement is crucial.) The worker and client may not always agree on the specific route or speed of getting there, but should be clear on the final destination. (This is generally managed through clear goals on which the client and counselor agree.)
While the worker usually prefers to both drive and take the most direct route as expeditiously as possible, the client continues to ride the brakes, want to stop at rest areas, and enjoy the scenic back roads which often get the worker lost. The journey can get quite interesting depending on who the client and worker invite along for the trip. It is not uncommon to become so lost that in the journey back to the main road, the client and/or worker abandon or discontinue the trip. With engagement resistance the client simply refuses to get in the car.
The Difficult and Nonvoluntary Client
Workers present an interesting paradox regarding the nonvoluntary client. While most acknowledge their existence, few actually work with them. Services under traditional mental health and counseling education and practice standards dictates that service only commences upon the arrival of the client at the provider's office or facility. Stated otherwise, the client needs to be motivated enough to come to the practitioner's office to receive any service. Those who do not come do not receive any service. The paradox is that those who are often most in greatest need are also those who present the least willingness or capacity to come for service. This has somewhat changed during recent years due to resource limitations which are targeted more to the most problematic and difficult clients in the child welfare and juvenile justice systems. The resulting difference is that engagement has been redirected toward outreach which occurs in locations and settings other than program offices.
Nonvoluntary clients are those who have not personally initiated contact, do not see a need for any service, and who are referred and often pressured to make (significant) changes by another person, agency, or authority (Burstein, 1988). They are clients who are unable or unwilling to participate in services. Their unwillingness to participate in services or engage with the counselor represents the first major resistance which must be surmounted - engagement resistance. This resistance may not necessarily apply to all clients unable to participate due to physical or environmental handicaps such as lack of transportation, mental disability or other factors.
Client Characteristics - There are several thematic and specific characteristics common to the difficult to engage and nonvoluntary client. They have frequently been a prior human service recipient in which they found the service(s) or the worker(s) to be unhelpful or punitive. They, in their own experience, feel victimized by interventions from educators, social service or agency staff, and family courts. They often resist present and future interventions as intrusions into their family or personal lives (Kaplan, 1986). They often view human service professionals as intimidating parental figures who are insensitive to their personal or family's primary needs (Bell, 1963).
Thematically this often represents shame around parent or child behavior. It often serves a protection function for the individual or family which prevents discovery of a secret they are unable or unwilling to talk about.
Mistrust is an important thematic characteristic of the difficult or nonvoluntary client. Mistrust is basic to engagement resistance (Hartman and Reynolds, 1987). The client is trapped between his/her need for change and their need to protect their current patterns, role(s), and organizations (Bell). The resistant client brings fears and hurts to the therapeutic process that are expressed as a resistance to anyone who attempts to touch the source of their pain (Hartman and Reynolds).
Additional characteristics common to difficult and nonvoluntary clients includes a poor or low self concept which may present as aggressive behavior, depression, denial or avoidance, and the successful employment of other defense mechanisms.
While there are multiple characteristics of the difficult and nonvoluntary client, the most important feature is that they (initially) do not want the service nor do they want to engage in any therapeutic process. This may create some degree of confusion and/or conflict for the human service purists who strictly believe in client self determination.
Examples of such clients are those referred for services they did not request or desire. This includes many youth and families referred to counseling agencies or programs by public child welfare and juvenile justice agencies, schools, and hospitals (following an involuntary commitment). It includes youth referred by their parents with refusal by the child to participate in the service and parents brought involuntarily into the system because of their or their child's behavior(s) Often, one parent figure will participate while the other refuses involvement while claiming the (family system) problem has nothing to do with them.
Special Populations - In engaging difficult and nonvoluntary clients in general it is important to note several specific populations that present real challenges to engagement. Those populations include substance abusing, physical and sexual abuse perpetrators and family systems with a significant parent-child conflict in which the direction is reunification.
In the case of substance abuse and physical and sexual abuse perpetration the general theme the counselor needs to be prepared for is denial. There are several models of intervention in working with these populations. The traditional model is that of confrontation. This begins the process by expecting the client to accept or admit responsibility for some act or behavior. This approach generally only works well when there is a firm authority mandating participation by the client. While this might get the client into the process it does not mean that the client will be cooperative in the process or use the process in a productive way. For example, attendance at or completing a parenting course does not mean any of the material will be used or integrated.
It is important to understand that clients connect to the worker first in engagement and not the process. The worker is the tool that guides the client to growth and resolution. If the client connects to the worker it is more likely they will risk dealing with the difficult material.
Family systems in crisis with a goal of reuniting an unwilling adolescent or parent can be a real challenge because it is less about the worker and often more about not giving in. It is therefore imperative that the counselor remain and be perceived by the client as being neutral. Like the client who is abusive there is great defense and protection around maintaining one's position. Engagement must therefore convey a feeling that one can enter and participate in the therapeutic process without feeling they will lose something.
Engagement and Intervention Continuum
The Engagement and Intervention Continuum (Figure 2) consists of four phases: preliminary, pretreatment, treatment, and termination. The primary focus of engaging the client occurs within the preliminary and pretreatment phases.
During the preliminary phase the worker has no direct contact with the client. Referral information is obtained with particular attention paid to the presenting problem, individuals involved, onset of the problem(s), previous human service involvement and interventions, previous attempts to improve or resolve the situation, and demographic and environmental issues.
The purpose of this has important implications for the engagement process. It is extremely helpful in creating an initial hypothesis based on the counselor's best diagnostic sense of the situation. The information allows, as Shulman (1984) describes, the worker the opportunity to "jump into the client's shoes" and empathically experience and question what the client might be thinking and feeling before the counselor actually meets them. This advance opportunity is particularly helpful in anticipating what the client might be thinking about and anticipating their particularly unique point of view. From the client's point of view and with knowledge of prior human service involvement and experience with workers one can anticipate the client's concern and feeling about starting with a new worker. The process of "jumping into the client's shoes" is an affective rather than intellectual process.
Having an initial understanding of the client and likely issues also requires the worker to think about how they feel about the client and their situation. This involves an awareness of the worker's own issues, biases, willingness to take risks and personal comfort of working with the client in settings other than the office (client homes, schools, unfamiliar neighborhoods, etc.) if outreach is to be utilized as part of the engagement strategy. It additionally involves the counselor thinking about their own feeling about manipulation, their rescue fantasies of not letting clients fail, and what they believe will happen if they push a client toward goals and expectations for growth. It also involves being clear on their own ideas of professionalism which often may put a client off or create a "one down" feeling by the client.
Considering all of the dimensions of the preliminary phase the worker should be able to generate likely scenarios about what might happen during the first contact, either on the phone or in person. This will help prepare the counselor for maintaining a positive, proactive, and productive style which reduces the likelihood for any unanticipated surprises or situations which could cause the worker to become defensive or reactive. Preparation reduces, but never eliminates surprise. It is often an important client test of the counselor.
For the worker it should be more important to "do right" than "be right". It is easy to blur thoughtful advance consideration of possible scenarios and what they might mean with the creation of the worker's agenda. It is not uncommon for a worker to (unconsciously) seek information or ask questions which only relate to supporting the worker's initial impressions or expected situations. The worker should never be so focused on what he/she thinks that they miss important new information which might change an initial diagnostic impression.
The pretreatment (second) phase is focused around engagement of the client. It involves direct contact with the client. If the worker is unsuccessful in engaging the client, he/she can never be successful in the treatment phase and, at best, will remain stuck in the illusion of work (Shulman). Additional tasks of the pretreatment phase are intake information collection and contracting with the client around goals, expectations, and responsibilities.
During the third or treatment phase the primary services and interventions are implemented according to the contract or treatment plan. If the worker has been successful in engaging the client and overcoming the issues of engagement resistance, he/she will encounter a whole new set of resistance's during this phase.
The final termination phase concludes the process either with successful resolution of the issues that brought the client to treatment or being unsuccessful with the client dropping out of treatment or being closed for other reasons by the worker. Termination actually begins with the first session whether the worker actually discusses it or not. Termination, in a process sense, more formally begins in the treatment phase when the worker and client begin discussing goals and the projected length of service. This does not necessarily imply either success or failure.
Engagement Resistance
Engagement resistance is focused around the helping person's effort to involve the difficult or nonvoluntary client in a process or activity that the client knows or believes will lead to emotional pain. Engagement is equivalent to acknowledgment of the emotional pain and a voluntary commitment to (eventually) visit it.
The primary goal in working with difficult or nonvoluntary clients during the pretreatment phase is overcoming their engagement resistance. Once the counselor has thought about what it would be like to be in the client's situation or place, the worker's own feelings about working with the client and what they believe all the available information means diagnostically, it is time for personal contact with the client.
One might question why so much thought and effort should be expended before one actually has direct contact with the client. The old saying you only get one first impression underscores the importance of this first contact. In many ways, it establishes the framework or foundation for all future interactions.
To every client, the worker is an authority figure. It does not matter whether the worker believes it or views themselves in that way, it is the reality of the client experience. The worker automatically begins one up on the client. The client will react to that in many ways, most of which will be indirect. There is often a paradox of power where the client may feel, state, or act as though they are powerless, but act in a powerful way by controlling the engagement process through their resistance to engagement.
One of the first decisions clients make is whether to engage with the worker (Shulman). For the worker the question is how do they help the client lower their defenses when they have such a stake in maintaining them? Clients need to take steps in their own self interest, not the workers. The worker's role is to help them feel safe enough to take those steps.
Five basic assumptions (Schlosberg and Kagan, 1988) are important starting points for understanding and working with difficult, nonvoluntary, and chronic and multiproblem clients. The first is that you always begin where the client is. This old social work axiom refers to counselors and agencies who often feel a greater urgency or need for change than the client and begin with their own agenda regardless whether the client understands or accepts it. This impatience often creates barriers to both engaging and maintaining the client through the treatment process.
Secondly, (engagement) resistance often reflects unresolved issues within the family system that is acted out within the community and with agencies, therapists, and others. Thirdly, the level of resistance to engagement and counseling corresponds to both the pressure experienced for change and the pain inherent in confronting the dilemma.
Fourth, the type of resistance fits the emotional stage of the individuals within the family system and serves to maintain the family system at its current stage of development. Lastly, resistance tests the usefulness of the worker - client relationship. It provides the client with a valuable screening technique to determine whether it is safe for them to establish a relationship with the counselor and whether they are able to make potentially costly and painful changes.
The worker and client can not successfully move to the treatment phase until the client is successfully engaged. Within a family system treatment mode this means minimally engagement of at least one of the key members - either the identified client who is presenting the symptoms or problem behaviors or the parent figure who actually has the most power in the parental dyad.
Joining: The Therapeutic Mindset of Engagement
Joining is more an attitude than a technique. It is the umbrella under which all therapeutic interactions occur. Joining is letting the client know the counselor understands them and is working with and for them. Minuchen states that “only under their (the worker’s) protection can the client have the security to explore alternatives, try the unusual, and change. Joining is the glue that holds the therapeutic system together.” (Minuchen and Fishman, 1981) Jurick (1990) in his five step strategic therapy model, notes the worker must join with the client and learn to see the world through the client’s eyes in order to avoid being drawn into an unproductive coalition and becoming part of an existing problem.
In the simplest form, joining with a difficult or nonvoluntary client is about connecting with the client in a manner that dissipates initial engagement resistance and establishes a trust level between the client and counselor which allows the process to continue.
Because nonvoluntary clients have been difficult for other workers to engage does not mean that every new worker will have a similar experience. A worker about to engage a difficult or acting out client, particularly adolescents, or adults emotionally arrested in adolescence due to substance abuse issues, must first of all appreciate or unconditionally love them or refer them to someone else. These clients can be so obnoxious, so infuriating, so difficult that if the worker can not love them in spite of this, their therapeutic interventions will never work (Jelsma, 1990).
Those who work with difficult and nonvoluntary clients additionally benefit from an “unstoppable sense of humor and a keen appreciation for bizarre wit to keep at bay the ever-present specter of potential tragedy and to prevent work from degenerating into mutual hostility." Because the process of joining, engagement, and intervention spans a varying period of time, the worker additionally has to be willing to live in suspense until the client or family system rights itself (Jelsma),
Engagement: Capturing the Client
Engagement is similar to joining. Joining is the attitude necessary for engagement. Engagement is the active process of connecting with the client. Engaging the client in a trusting therapeutic relationship is a first order activity. Successful service can not proceed without a base level of client engagement and cooperation (Matthews & Robertson, 1994). Waters and Lawrence (1993) discuss "courageous engagement" for both workers and clients which requires taking calculated therapeutic risks and stepping out of familiar treatment ruts and routines. It requires courage to go after more than a safe and adequate outcome. Too often counselors are willing to settle for what the client is willing to settle for. The goal of creative engagement is to expand the client's vision of what is possible.
As stated before, clients with a previous history of child welfare, juvenile justice or counseling often have an experiential notion of both the counseling process and who counselors are as "helpers". There is often little distinction between a child welfare caseworker, a probation officer, a guidance counselor or a therapist. Long histories with any or all of these is generally an indication that successful engagement leading to real change will be a challenge. The fact that the present counselor has the client often indicates that all previous ones were unsuccessful and that the client is quite naturally ambivalent about repeating another unsuccessful therapeutic experience.
A common strategic error of workers is to get too far ahead of the process by beginning or moving to deeper levels of counseling before engagement or a therapeutic relationship has been established. The worker identifies the client as "resistant" because they will not address, cooperate or stay focused on the (worker's) goal or agenda. A supervisor should reasonably question two general areas - whether the worker has significantly engaged the client or system before beginning work on the issues the client appears to be resisting and whether the client is even aware of and in agreement with the goals the worker is addressing. Too often treatment plans are made unilaterally by the worker on what they believe the client should be working on as opposed to what the client feels prepared to and comfortable enough with working on. These contracts are by nature corrupt because they impose expectations and goals on clients without their consent or knowledge.
Engaging the more difficult and non voluntary clients who are unable or unwilling to come to the office for service is a double challenge. Outreach to the client's home, school or place of work is often necessary in order to initially access the client. The second challenge is a very personal experience which will determine whether the worker even gets a second chance to continue working with the client.
Practical engagement advice is to follow a preemptive version of what Shulman (1984) and Schwartz (1976) refer to as "tuning in" or "jumping into the client's shoes". This preparatory empathy with the client is a way of putting oneself in the client's shoes and trying to view the world through the client's eyes. Based on known information about the client's life, their stage of development; the nature of their previous experiences with human service agencies, and past and current (presenting) problems the worker can imagine what it is like to have lived the client's life, feel what they might be feeling, and anticipate what their unspoken questions and issues would be for a first therapeutic encounter. Additionally, the worker needs to be genuine, real and believable as a human being. While this may be offensive to many worker's self perceptions, clients have great intuition about bored, disinterested, cynical and uninspired workers. Workers need to recognize the difference between meeting or being with a client and actually being helpful and valued by them. Nothing meaningful in counseling ever happens without a successful client engagement.
Ground Zero: The Place Where Change Occurs
Ground zero is the place where growth, change, and movement occur. It is the result of a therapeutic climate created and managed by the worker. Ground zero is the impact point where worker's skill, style, and creative forces intersect with all the challenges the client brings to the therapeutic process. It is the dissolution of therapeutic impasse. It is the hot point where change and movement have the highest likelihood to occur. It is, hopefully, the worker who controls ground zero. In the best scenarios the worker is the fail-safe that prevents the client from their own "crash and burn." The worker's role is to insure client survival in those "crash and burn" situations.
Without engagement there is no ground zero. The exception to this is a crisis situation or workable moment which are ground zero opportunities. These situations are the engagement opportunities. Success in and feeling helped by the counselor creates successful engagement.
The Creative Self: Worker As Tool of Engagement
"It is important not to mistake the edge of the rut for the horizon"
Anonymous
When all is said and done the worker is the primary therapeutic tool in the counseling process. Considering that all workers, regardless of discipline, essentially receive the same educational knowledge base through which they understand development, feelings and behavior it is not surprising that workers generally all do fairly well with voluntary and motivated clients. The big difference shows up when workers encounter clients who are unmotivated, lack insight, present significant initial resistance to engagement, and have a noteworthy history of defeating past counselors. It is the latter group of clients that separates the workers with active creative selves from those with inactive creative selves.
The creative self is a mixture of innate talent, natural curiosity, divergent thinking, innovativeness, playfulness and mischievousness. The creative self has a strong connection between their "head" and their "heart". Their unusual instinct is well described by Joel Arthur Barker (1993) in his discussion of "paradigm pioneers". Those who choose to change their paradigm, method, intervention or style do it not as an act of head, but as an act of heart. They are captivated by a set of rules or observations that suggests they may be able to succeed where before they or others have failed.
Driven by the frustration of the old and the appeal of the new, the creative self is willing to cross the brink of doing it differently. The creative self also demonstrates the courage to act on its intuition.
The creative self is different in every worker. A life history of different family systems, life experiences, education and training, dreams, and visions make the worker rich with the skills and insights to guide others through their difficult times.
Engagement Strategies and Techniques
Thus far, Aspirational Engagement has been more of a knowledge base, understanding, and mindset about resistance as a concept and formidable issue, the difficult and nonvoluntary client, and the process of engagement. It is as important as any technique for actually engaging the client. It is not easy. It provides no assurance for success. It does, however, improve the opportunity for successful engagement of the difficult and nonvoluntary client.
Crucial engagement skills are consistent with good treatment skills. They require an attentiveness to the worker’s style and the effective use of the range of skills the counselor possesses. This is especially important during the engagement process when the worker - client relationship is so tenuous. While in an office setting, the goal for the worker would be to have the reluctant client return for a second appointment, the goal for the worker of a nonvoluntary client receiving outreach service is to be invited back for a second visit.
Workers should act the way they expect clients to behave. They must convey that the clients are the experts in their own lives. This serves an important empowerment function. They must be able to articulate what the client is experiencing but having trouble talking about. These powerful issues for the client are often projected onto the worker. Shulman refers to this process as projective identification.
Being clear is an important factor in building trust. It requires an ability to raise and discuss uncomfortable material with the client. Important engagement material or issues not addressed will continue beneath the surface and likely undermine the therapeutic process. This is an especially difficult process to negotiate for counselors who may fear saying the wrong thing or losing their client.
An additional important skill during engagement is containment (Shulman). Very simply, it refers to not arguing with clients about issues and the worker’s general ability to know when to keep their mouth shut.
The worker operates with multiple goals and utilizes many skills all at the same time. The overlapping goals contribute to the counselor’s mindset. At the forefront of those engagement goals is always reaching for the client’s strengths. This suggests a belief in the potential of the work and a refusal to accept even the client’s own self-description of weakness (Shulman). This is more difficult than it sounds considering most worker’s formal training is in the area of identifying deficits and problematic behavior(s) rather than identifying strengths. This is a central part of what helps clients act in a positive way in their own behalf.
Strategy and technique is a very individualized skill set. Their individualized use is a function of the style and the personality of the counselor. While the same strategies and techniques can be explained and taught to many workers, each one will adapt and use them differently depending on their own comfort level, creativeness, use of self, previous training and experience, comfort with personal risk-taking, and other factors too numerous to mention. That is the way it is supposed to be. Workers are different. Clients are different. Each strategy and technique has its own continuum with variations and alternatives to suit and meet the needs of clients and workers alike. The responsibility of the worker is to select both the most appropriate strategy and technique and the correct variation that presents the greatest opportunity for success.
For most workers, this process occurs rather automatically with little or no conscious thought. This infers a process which has become both routine and lacks a conscious effort toward individualizing the intervention to the client. Consciously thinking about the client and what it will take to successfully engage them will motivate the counselor and enhance the range and quality of engagement strategies the counselor possesses.
A variety of engagement strategies are identified below with short comment to provide further clarification. For purposes of identification and future reference they are listed in alphabetical order.
ART - Art is an expressive engagement strategy that allows clients to speak with a projective voice. This can be as formal as House-Tree-Person type of drawings, creative drawing versions of family sculpture, working with clay, books of pictures, a camera, and paper and pencil (or crayons, markers or paint). It can include a trip to an art museum or gallery. It can include the creation of individual or family collages. Art, like any other creative engagement strategy, must be a good fit and appropriate to the specific client or family.
BEING A GUEST - Being a guest is both a technique and an art. It honors the client by being the guest in a new relationship. It involves being respectful in a sometimes disrespectful or hostile non-office environment. It involves being gracious and tactful while being therapeutically manipulative. Typical examples include the acceptance of offered ice tea, use of the bathroom which offers new observational opportunities, or requests to use the phone when necessary. It additionally involve a mindset which simultaneously includes converting the client home to your office. With such a mindset the counselor feels greater permission to turn off the client’s television during scheduled meetings (remembering to request the client to do it first) or asking the client to deal with a disruptive child or pet. This also establishes and reinforces a therapeutic contract of expectation as well as providing less threatening intervention opportunities.
CONCRETE SERVICES - Beginning where the client is often means the worker has to attend to the immediate needs of the client such as food, services or other crisis type issues. It is very difficult to get clients to talk about feelings and issues when they are hungry, homeless, or in the middle of a crisis. Frequently, nonvoluntary clients have unmet environmental or resource needs that can be tended to rather quickly. The ability to help the client meet one or several of those needs establishes in the client's mind both a sensitivity by the counselor to their situation as well as their willingness to take care of business. Providing immediate and helpful service provides the client with an experience the counselor is helpful and trustworthy.
CREATIVITY and RESOURCEFULNESS – This skill is inherently all about who the worker is by nature. This may also include the worker being given permission to be that way by their organization. This is almost magical in the way it can transform material and mood to a level of comfort for the anxious client. It requires a willingness to take calculated risks, being a bit playful depending on the situation, and a desire to be helpful rather quickly moving to a specific agenda. It additionally helps reduce start-up tension by demonstrating that counseling does not always have to be serious.
GAMES - Games, like other techniques, allow the client to divert their immediate attention from the focused process of discussing and disclosing. This often works well with children but also works with family systems, particularly when the worker wants to observe the natural interaction of the family system. It quickly highlights issues of natural hierarchy, power, control, competitiveness, fairness, tolerance and other types of family functioning.
FOOD - The counseling process is a very oral process. Food is often a simple way of stimulating the process. The use of a snack or treat allows the client to experience the counseling process in a nontraditional way. It allows the worker to give the client something which is both enjoyable and distracts them from the traditional format of talk therapy which is the counselor and client sitting in an office and talking about something the client wants to resist. This would include sharing a piece of candy or taking the adolescent client to McDonald's.
HANDSHAKES - One of the easiest ways to connect with a client is to simply shake their hand in the greeting process. It both literally and metaphorically connects the worker to the client. The worker can further reinforce the connection with the duration and firmness of the handshake as well as deciding whether to conclude the session in the same manner.
HUMOR - In an atmosphere of initial tension and anxiety humor can ease the transition to more serious material. This can be anywhere from light-hearted banter to a simple appropriate story or joke. The key here is keeping natural and appropriate. If the client does not perceive it as natural or appropriate it will become a barrier to engagement.
LANGUAGE - Clients often feel comfortable in the engagement process simply because the worker's choice of words and style of speaking conveys greater equality. Simple techniques include using the language (as appropriate) of the client and using metaphors related to areas of interest to the client. The goal is to help the client feel comfortable, connected and that they share something in common. Maintaining a "professional" attitude of keeping the client one down is a real barrier to engagement.
MAGIC - Magic has a way of capturing the imagination of clients, especially that of difficult and nonvoluntary ones. It has a very high entertainment value and appeals to every person's innate sense to know how something works. It works well with nonverbal and disorganized clients and family systems. For example, simple card tricks can change an anxious and withdrawn adolescent into one with attentive anticipation whose first response is usually either "how did you do that?" or "show me how you did that". Once you teach them you have given them an important gift of being able to do something successfully every time they do it. The worker may choose to trade the teaching of the trick for some specific expectation. It is a small price to pay for something that guarantees success to the client and initiates a bond because you gave them the gift. (A simple “mindreading” trick is located following the reference section of the article.)
With small children balloons and other playful activities work well. A frequent outcome is that the child or adolescent conveys to the parent and system persons that the worker is "OK". This is especially helpful if many referrals are made in a word of mouth manner.
MUSIC - It's been said that music is the international language and often is a great ice breaker with clients. This can include the use of actual instruments, music while transporting clients, having clients bring their favorite music (which becomes a projection of things they are feeling or would like to say), the use of or writing of lyrics, and direct contact with musical people.
OUTREACH - Outreach is the umbrella under which almost all work with nonvoluntary clients occurs. It is the extension of the client services by the agency or worker to non-office settings. If the worker has been unsuccessful in persuading the nonvoluntary client to come to the office through written or phone contacts there are only two alternatives; you close the case or you engage the client in a setting other than the worker’s office.
Outreach as a client service or goal will usually be defined in advance by the worker’s respective program or agency. Many agencies have predetermined they will not utilize nor provide outreach and as a result will not work with any client that does not come to the program or agency office.
There are various settings for outreach which includes client homes, schools, foster homes, residential treatment settings, street corners, and job sites. While not inclusive of all possible outreach settings the most frequently used are client homes and schools.
Outreach by nature is a turf issue. The worker is displaced to a setting other than his/her own. It is important to remember, particularly for counseling agencies, that counseling is a process, not a setting. Counseling can occur anywhere. The worker may feel some loss of control by being out of his/her element, particularly if it is a home or neighborhood where safety may be a worker issue.
It is, however, a powerful strategy in that the client feels a high degree of emotional safety, is less likely to leave during the interaction since they are already on their home turf, and is more likely to agree to future appointments. The client may choose to be away from home for those scheduled future interactions and the worker may change strategy to include unscheduled appointments as a result. It is also important to remember an eventual goal is to have the client come to the worker's office. This helps prepare the client to more proactively seek and obtain services in the future on their own.
Home visits provide the worker with important observational opportunities unparalleled in the office. The home becomes a projective instrument through it’s contents, arrangement of rooms and furniture, and the natural family system interaction that occurs.
Outreach will accomplish the goal of getting the client and the worker face to face. The content of the interaction will determine future client receptivity to and availability for future interactions.
The school as an outreach setting is more controlled for the worker in that it is neither the worker nor client’s turf. To the worker’s advantage, many adolescent clients will be more available simply because they view it as an opportunity to get out of class. Others may resist meeting in school because they feel personally embarrassed when their peers know they are seeing a counselor. Those clients who do not attend school for their scheduled school appointments may require outreach to the client’s home.
Outreach is the strategy that will set up the face to face interaction with nonvoluntary clients. The skill and technique within the interaction will define and determine the level of engagement that occurs.
PETS - Often clients relate to animals easier than counselors because of the unconditional nature of their response. The use of pets is also multi-sensory in that clients feel great permission and pleasure in petting animals. It is safe for the client and often triggers positive feelings the client has for their own present or past pets. It would not be uncommon for the client to begin by petting and actually talking to the animal before the worker, than to the worker about the animal and than to the worker about more relevant material. It also helps show the worker a softer and more caring side of the client.
PICTURES - The type of pictures the family has on their walls, in frames, on refrigerators and in family albums will tell you about who is important to the system as well as stories about them. The family album is also a safe way to talk about family members since the discussion begins with safe events and material they have already showed the worker.
PSYCHODRAMA - Psychodramatic techniques offer the client the safety of warming up, action, and interaction at a speed and level comfortable to them. It allows the client the opportunity to speak and respond to a double, mirror, or other. While psychodramatic techniques can be advanced, they can also be those most counselors have learned without realizing they were psychodramatic techniques such as the empty chair and role playing.
REMINDERS - These are especially helpful in mobilizing a family system where some members are more voluntary than others. This often works well with drug and alcohol family systems or other addictions where therapeutic engagement and investment levels vary. Reminders can be postcards or phone calls reminding the client of the appointment or the use of appointment cards given at the end of the previous appointment. It is also a helpful strategy to keep the appointment time relatively consistent every week and to schedule as many in advance as possible.
SETTING - As stated before, counseling is a process, not a setting. Therefore, one of the easiest ways to make a client feel comfortable is to create or use a comfortable setting. For some clients this might be a walk which allows the client to talk without looking at the worker and also stimulates the body metabolically making it easier to talk (particularly with depressed clients). The setting of a session might be a spontaneous choice based on where one is at. For example, clients are often very talkative during a transport to and from an appointment. Continuation of the session may occur at the destination without getting out of the car which often breaks the flow. This, like other strategies, is a function of outreach and a worker's willingness to step outside the traditional boundaries of counseling.
(COUNSELOR) STYLE - Style has an important power of engagement. It can calm or escalate the first interaction. For that reason it is important that workers understand their own style, whom it works well with, whom it does not work well with, why those interactions work or do not work, and how the variety of clients they work with perceive them.
A worker can be whoever they want to be and use whatever style they want as long as they know how to make it work for them in their interactions with clients. While one can aspire to be like the masters of therapy, supervisors, or other workers they want to emulate, it is more important that they aspire to be themselves in the best way they can. Style without a good skill or technique fit is courting disaster with difficult and nonvoluntary clients.
A good introduction and opening line(s) often set the mood for everything that will follow. Remembering that you only get one first impression highlights this importance. This is especially important for new workers and clinical interns. Many clients are often unclear as to who the worker is, why they are there, and most importantly what it is they want from the client.
Simple contracting such as agreeing to meet a specific number of times, agreement on the issues and problems to be worked on, and mutual expectations or ground rules for the work lets the client know where the counselor and client are going on this mutual therapeutic journey. Worker and client need to be in agreement on the purpose and general direction of the work. General goals are identified in the beginning as themes since further intake information will be necessary to aid the counselor and client in more specifically identifying more exact and measurable goals. This gives the client an important sense of control within the counseling process. Prolonged lack of clarity creates an unnecessary tension or anxiety in clients that only serves to maintain client mistrust of the counselor and inhibits the engagement process.
It is important that workers know why they are there and that they can convey that to the client in a manner which relieves anxiety and promotes trust. This can simply be achieved through advance worker thought about their opening sentences or statements to the client. While a good rap may sound redundant to the worker, the client is only hearing it for the first time.
UNANNOUNCED VISITS - Unannounced visits for elusive clients gives them less opportunity to avoid the worker or prepare a defensive plan. They are, in a sense, forced to respond to the worker in person. The worker's job is to be irresistible. As a strategy this only provides the opportunity to personally engage the client. The fact that the client has remained elusive speaks to the level of their resistance the counselor is likely to encounter.
VIDEO and FILM - Most clients have great exposure to television and movies. Most clients have their own opinions about what is good, bad, what worked, and what did not. The use of selected videos can be excellent transitions to client related material. Like other projective devices, the client is often unaware of the material they are sharing in their discussion of other's situations, the values inherent in the selected situation of the video and their own choice of favorite television shows and movies.
WHATEVER WORKS - This catch all category fits all other skills and strategies not mentioned. Each worker has a life history filled with successful experiences both within their respective discipline and outside of it. While workers have chosen a field which helps others they also have had a rich life experience of helping themselves in their own self interest. In that experience they have had to convince others, sell issues others had little or no interest in, touch the hearts of individuals they have never met before, and pursue others (usually the opposite gender) they really wanted to meet and know. In those quests, they learned much of what they need to know to be successful in engaging difficult and nonvoluntary clients.
Whatever it takes is reminiscent of what Minuchen (1981) described as therapeutic spontaneity. This requires a use of self in a way which the counselor must be an effective part of the client system able to respond to circumstances according to the client or system's rules while still maintaining their widest use of self. The worker's actions, though regulated by the goals of the therapeutic intervention are products of his/her relationship with the client.
Crash and Burn: Less Than Perfect Work
It would be a therapeutic marvel if everything we said and did as workers worked with clients. It doesn't. Risk-taking and creativity is by nature imperfect and fraught with the potential for failure which occurs in many ways and for many different reasons. It is therefore helpful to consider the reality and implications of therapeutic creativity which misses the mark during the engagement and start-up process.
Risk-taking can have important implications for both the client and worker. Unsuccessful risk-taking or less than perfect interventions can produce problematic effects for a client which may include creating an unmanageable crisis or relapse, triggering old known or unknown issues, placing the client at greater risk for an unwanted relapse or crisis, loss of trust, perceived or actual betrayal, and premature termination. This is more likely to occur with young or inexperienced workers who, for example, go into "healing" without the life experience or training necessary to understand the problems with which they are intervening. It is also possible the worker may be in over their head or they do not understand the meaning of the material the client has given them. In these cases Minuchen and Fishman (1982) suggest the counselor either consider excluding themselves from the case (which is not usually possible in most human service agencies) or acknowledge their ignorance and ask the client to educate them in such matters.
Crisis can be very much like a double edged sword. Just as a crisis can produce a workable moment than can lead to change, change can also lead to a crisis. It is therefore essential that the counselor understand which direction the are moving - toward a crisis or change.
A trusting relationship must almost always precede a client's willingness to accept risk. Risks need to be honest and fair in the client's perception. Timing is also an important element of therapeutic creativity. A perfect intervention can easily fail if it is ill timed.
Risk-taking can have equally important implications for the worker. For the beginning worker it is not unlikely they will already be knowingly or unknowingly dealing with their own client rescue fantasies. This includes a menu of feelings about losing the client, the client not liking them, not asking certain questions because they feel it would make the client uncomfortable and choosing easy or weak interventions that maintain their own personal emotional safety.
For the worker the material may also consciously or unconsciously trigger their own past issues. They may have anxiety about or fear their own material and not be willing to take risks with their own self. That avoidance prevents them from helping clients with the same or similar issues or themes. Just as the client must have a trusting relationship with the worker in order to accept risk, the worker must trust themselves in order to take or initiate a risk-taking intervention.
Successful risk-taking is empowering. The lower the risk the more acceptable it will likely be for the client and the worker. The higher the risk, the greater the stakes and the expectation for resistance.
Summary
Aspirational engagement as a microtherapy skill is the single most important worker skill because it is the determinant whether further work can continue and at what level. It is a skill that, in large part, is based on the individual style, characteristics and nature of the worker. While most workers can work with willing, cooperative and compliant clients, engagement skills are tested as clients move further up the resistance continuum toward absolute (initially) non-voluntary and non-compliant status.
As such, the difficult and nonvoluntary client is the most challenging to work with due to their reluctance or unwillingness to risk entering the therapeutic process. The issue of engagement resistance is the primary obstacle to moving forward with any meaningful intervention. Resistance is a barrier to be overcome by the worker, not an excuse to prevent successful service from occuring. The primary issue of overcoming resistance is understanding what purpose it serves and what it means to the client.
The worker is the primary tool of engagement. The worker's prior training, life experience, and creativeness join forces in an irresistible therapeutic alliance which allows the client to feel less anxious and defensive about the counselor and what he or she has to offer. In the end, each worker knows there will be some difficult and nonvoluntary clients they will never engage.
Critical worker skills necessary to be successful in engaging difficult and nonvoluntary client include an understanding of the engagement process, a personal feeling of safety and willingness to be creative, different, and irresistible, and a genuine interest in wanting to know and engage the client. One has to genuinely want to do the work and have an appreciation for the absurd, unacceptable and sometimes disgusting. Anything less will get in the way of the client experiencing the worker as one who can be helpful.
To modify one of Minuchen's thoughts, "Beyond technique there is the wisdom which is knowledge of the interconnectedness of things...when techniques are guided by such wisdom's, then (therapy) interventions become healing".
References
Barker, J.A. (1992). Paradigms: The business of discovering the future. New York, NY:
Harper-Collins Publishers, Inc.
Bell, J.E. (1963). A theoretical position for family group therapy. Family Process,
2(1),:1-14.
Fest, J. (2005). Positive youth development: Your questions answered. The Prevention
Researcher, 12 (Supplement, December),: 3-6.
Hartman, C., Reynolds, D. (1987). Resistant clients: Confrontation, interpretation, and
alliances. Social Work: 68(4):205-213.
Gitterman, A. (1983). Uses of resistance: A transactional view. Social Work: 28(2):127-
31.
Jelsma, B. (1990). Risky business. The Family Therapy Networker, 14(4):48-51
Jurick, A.P. (1990). The jujitsu approach. The Family Therapy Networker, 14(4):42-47.
Kaplan, L. (1986), Meeting with multiproblem families. Lexington, MA: D.C. Heath.
Matthews, J., Robertson, R.M. (1993). A promise of family: A practical guide to
understanding family preservation and home based programs. Allentown, PA:
Valley Youth House.
Minuchen, S., Fishman, H.C. (1982). Family therapy techniques. Cambridge, MA:
Harvard University Press.
Riebel, L. (1992). On with the show. Family Therapy Networker. 16(5):33-37.
Robertson, R.M. (1997). Walking the talk: Organizational modeling and commitment to
youth and staff development. Child Welfare, 76(5):577-589.
Robertson, R.M. (1989). The diagnostic - intervention paradigm. Allentown, PA: Valley
Youth House.
Robertson, R.M., Sweinhart, J. (1993). Ground zero and therapeutic creativity.
Allentown, PA: Valley Youth House.
Schlosberg, S., Kagan, R. (1988). Practice strategies for engaging chronic multi-
problem families. Social Work: 69(1).
Shulman, L. (1984). The skills of helping individuals and groups. Itasca, IL: F.E.
Peacock Publishers, Inc.
Waters, D., Lawrence, E. (1993). Competence, courage, and change: An appoach to
family therapy.
Waters, D., Lawrence, E. Creating a therapeutic vision. Family Therapy Networker.
17(6):52-8.
Wylie, M.S., Markowitz, L.M. (1992). Walking the wire. Family Therapy Networker.
16(5):19-30.
Mindreading 101: It’s Not What You Think
* Special thanks to Eric Anderson, magician, for sharing/teaching this simple mindreading activity.
Robert M. Robertson, Jr., M.S.W., L.S.W.
Aspirational Engagement:
Creating Connections That Matter
Robert M. Robertson, Jr., M.S.W., L.S.W.
Engagement is a core skill that practitioners must possess in order to
provide any meaningful direct counseling service. It is as much a function
of who the practititoner is as a person as who they are as a professional. The
process of engagement is itself a foundation “microtherapy” within the
process of direct services which helps define the speed and process of
service. This article examines engagement as a process and style as
well as strategies for the non voluntary or difficult to engage client.
Since I first wrote the training article Magic and Madness: Engagement Strategies for Difficult and Nonvoluntary Clients (1996) and revised it in 2006 with a different title that better reflected the new thinking (Engagement as a Microtherapy Skill), a great deal of experience and thinking about the process of engagement has occurred. The mindset and practice of Positive Youth Development (PYD) has become firmly imbedded in the way many (youth) workers think about, approach and provide services to youth and families. And while PYD began as a youth serving concept, it’s application applies as a general construct for serving almost all client populations.
While much has changed, much remains the same. Engagement remains the foundation of the service process. It makes little difference whether one is a counselor, an intake worker, a resident advisor or anyone else who has responsibility for working or interacting with clients. Engagement is the bedrock of the helping relationship. Quite simply, if you can not engage a client, you can not effectively work with the client. Thus, the critical continuum for the worker is the extent to which the client is engaged with the worker and connected to their own process.
The engagement process applies to all clients and all workers; no exceptions. It is a mutual process of connecting and creating a useful working relationship. Within that context though, the most formidable challenges for any worker is the successful engagement of the nonvoluntary or resistant client and their family system; those whose previous experiences and emotional safety warns them to proceed with caution. Without the cooperation of the client, even the most skillful counselor is only as successful as the beginning worker struggling to engage an equally unwilling or resistant client. These clients pose the same simple question to all workers regardless of their training, skill level, or experience - can I trust you enough to risk my present and
© 2010 Robert M. Robertson, Jr., M.S.W., L.S.W. is the Executive Vice President of Valley Youth House, Allentown, Pennsylvania. This article is revised and updated from Magic and Madness: Engagement Strategies for Difficult and Nonvoluntary Clients (1996) and Engagement as a Microtherapy Skill (2006) training article.
future emotional safety? Those who successfully engage the client are given permission to deal with new and more intimate levels of resistances to change. Those clients who do not engage with the counselor remain "stuck" waiting for the right counselor, circumstances, or opportunity to proceed with an acceptable level of anxiety, pain, and safety.
Aspirational Engagement focuses on a worker friendly understanding of the differences between aspirational engagement and “settling”, the nonvoluntary, resistant and difficult client and family system; the meaning and use of resistance as a natural part of the therapeutic process; a creative mindset and skill base for working with difficult clients; and useful techniques for engaging such clients. That understanding will facilitate an understanding and engagement of almost all clients regardless of their level of resistance. In addition, it will address many of the foundation elements of engagement as well as providing some practical strategies that one can consider, use, or adapt within their own practice, process and style.
The term client is used throughout the article to refer to the identified client, patient, family system, consumer, customer and other identifying names used within the human services to describe the person receiving a service. Worker refers to a counselor, therapist, intern or any other human service practitioner who is providing the service.
Aspiration vs Settling: It’s All About the Worker
Engagement is really more about a direction than a route to get there. The critical destination is a connection with the client that endures the stress and challenges of the work. The strength of that connection also defines how much stress and tension can be tolerated in the process of the work. In that abstract sense, the quality of relationship or connection is on a continuum of “no connection” to the strongest therapeutic connection possible that would carry a client through whatever trials, tribulations or obstacles that present themselves.
“No connection” is easy to consider based on the principle “if you can’t connect with the client, you can’t successfully work with the client”. Somewhere between “no connection” and the middle of the continuum is “settling”. Settling is the professional belief and expectation that simply meeting with the client constitutes engagement. It is one step beyond the client’s refusal to meet or be in the same space with the worker. It is supported by what Jay Haley referred to as the worker attitude and position of being “one-up” on the client. If both the worker and client are present, than something is supposed to happen. The “what’s supposed to happen” is more an expectation of the worker than the client as though the worker holds a “magic stick” that compels something therapeutic to happen; but it usually doesn’t. The client showing-up for appointments is not the same as something happening; particularly for clients compelled by authority.
Within the Positive Youth Development model (discussed later) at least two of the four critical elements (safety, control, connectedness, and opportunity) are absent. The absence of them at a minimum level creates significant barriers to engagement as a basis of meaningful work.
Aspirational engagement, by contrast, is very client-centered in the fullest sense of the concept. Engagement is an intentional and active process of being attentive to the critical PYD elements of creating an emotionally safe place (according to the client rather than the worker), creating a place where the client feels some sense of control over their own situation and in their life, establishing a relationship the client wants, and providing “real” opportunities the client can experience and use in their immediate situation. In this way the worker aspires to create a unique relationship and situation for the client to begin and continue working.
In considering the space between a “settling” engagement and an aspirational engagement the difference is the intentionality of creating something rather than just providing something. While settling requires the client to accept who the worker is, aspiration requires the worker to earn the relationship. Settling views a failure to engage as client resistance. Aspiration views a failure to engage as a worker barrier to understand and overcome.
Just as personal style is a critical element in how one engages others, personal style often characterizes whether an individual is an aspirational person or a settling person. While the worker has primary responsibility in the engagement process, understanding aspiration and settling can also be a helpful tool in considering clients. Aspirational clients tend to be those who are self-motivated to seek and engage in services. Settling clients tend to be more accepting of their circumstances, require high levels of support and encourangement, and are more risk aversive to personal change.
Given those very general assertions, it is easy to consider the challenges for a settling worker who has to work with a settling client. The settling worker often defaults to an authority or compliance position in attempting to move such a stuck client toward change. An aspirational worker with such a client will more likely seek to consider other motivational strategies to unstick the client. The essential point of aspiration versus settling is that it applies to both workers and clients and that the worker has the primary responsibility of being aspirational.
Positive Youth Development: It’s Different Than Strengths-Based
Normally, the order of discussing engagement would include an understanding of resistance before the introduction of Positive Youth Development (PYD) or strengths-based models. In this case it is more helpful to introduce PYD before resistance to assert the critical point that being aspirational and creative has to transcend the more traditional notions of deficiency and pathology as presented in the diagnostic process of understanding clients.
When I first wrote about PYD in Walking the Talk (Child Welfare, 1997) it was a concept everyone, including me, were working to get our arms around in practical ways. At the time I described it as a “strengths-based macroconcept that directs the programs and services available in communities to all young people rather than targeting only those with defined problems or those in high-risk situations.” Conceptually, it viewed youth and families as partners rather than clients.
After more than 15 years of proactively using PYD, training others how to use it as a practice foundation, and implementing it in outclient and residential youth service programs a few things are clear. First, PYD is more a mindset than a skill. It is more about who YOU are than how you practice. Who you are is a function of what you believe and how you live, not just how you practice.
Practitioners often confuse strengths-based practice with PYD. Strengths-based practice is an approach that identifies the client’s strengths and applies them to overcoming a problem. Strength-based practice strategies begin with the identification of a problem or why the client came for service and than focuses on resolving that problem. (Fest, 2005). PYD; by contrast, focuses on what all young people need to be healthy and accomplished, regardless of the presence or absence of problems. In other words, the process is treating and engaging those who present problems as you would those without problems. In that way, the worker remains genuine to who they are and honors the client by respecting what they are capable of achieving regardless of their issues or problems. PYD requires an understanding of the problem and issues which are secondary to the mindset of addressing them.
I had since refined the PYD definition to an operational and integrated mindset that creates, provides, and uses opportunity to create meaningful experiences for becoming a positive, competent and contributing adult.
In 2006 there was an epiphanous moment while I was training AmeriCorps members in the core concepts of PYD. They were to become faculty members in one of our six week Valley Youth House Youth Leadership Institute projects. Thirty minutes into the training, not only were they getting bored, but so was I as the trainer. How could they effectively communicate core PYD concepts to the participants if I could not be succinctly inspiring with them? Out of that moment came the consolidation of PYD concepts into 4 core PYD principles which I believe are also the foundation of the engagement and therapeutic process. (See PYD Made Easy Chart below)
Those principles are safety, connectedness to others, opportunity and control over one’s own life. Safety is all about feeling physically and emotionally safe. Connectedness to others is about having and building relationships with caring and connected adults. Opportunity is about creating and providing meaningful and purposeful activities. It is not about insight or intellect. Control over one’s own life is about having control over or significant input into one’s own life decisions. It is about creating real partnerships.
Figure 1: PYD Made Easy (Robertson, 2006)
Positive Youth Development
Made Easy
Safety
It is about feeling physically
and emotionally safe.
Control
(over One’s Life)
It is about having control over
or significant input into one’s
life decisions.
Positive Youth Development is…
an operational and integrated mindset that creates, provides, and uses opportunity to create meaningful experiences for becoming a positive, competent and contributing adult.
Connectedness
(to self & others)
It is about having and building relationships
with caring and connected adults. It is also about being connected with yourself and knowing and being able to ask for what you need.
Opportunity
(based)
It is about meaningful and
purposeful activities, not insight
or intellect.
The essential understanding of PYD is that it is the mindset and foundation for the engagement process as a microtherapy skill. It creates a safe opportunity for the client to become connected to the worker and experience the process as one which affords partnership and meaningful personal decision-making.
First Level Engagement Thinking
Engagement as a microtherapy skill is inclusive of many important elements such as understanding the nature, continuum and process of resistance, how clients respond to counseling and the counselor, joining, capturing the client, the worker’s style and creativity and the many things that can go wrong in the process. As stated earlier, the ability to work with a client is a function of one’s own ability to engage the client. It is the worker’s responsibility to engage the client, not the client’s. It determines the speed and amount of work to be accomplished.
While engagement is different than the work of therapy, it is the foundation of therapy on which all future work is built. As a microtherapy skill it serves as the subtext of the actual therapy. It is important not to mistake cooperation as engagement. Compliance is not the same as progress. Consider juvenile justice and other settings that exercise control and authority to gain compliance or cooperation. Upon discharge, seemingly apparent progress vanishes with the removal of the requirement for compliance.
For many clients, there have many workers before you. Consider the client’s experience and performance with each of them. Consider that if previous workers were successful there would be little need for you. It is reasonable to presume that based on previous worker experiences, clients could easily be worker weary.
Successful engagement, therefore, means you, the worker must be worker worthy. Clients do not generally get a say in who their worker will be. The process of engagement is subtly marketing yourself as a worthy worker. It may be unconscious and automatic, but like the client who makes their assessment of you pretty quickly, you are adjusting your presentation and engagement choices equally fast. These adjustments of presentation are especially helpful when working with family systems that hold a presumption of side or belief that the worker is operating with a bias toward one side or particular person.
The essential outcome goal of the engagement process is capturing the client in order for the work to continue. The strength of engagement allows the work to continue and engagement to rise to higher levels of trust and partnership.
Resistance: A Practical Understanding
In order to fully understand engagement the worker needs to acknowledge and appreciate resistance. The creative counselor's approach to resistance is that resistance, at some level and in some form, is inherent in the helping process and that it reflects the worker's momentary inability to transcend or understand the issues that block client movement, growth or resolution. It additionally enables the counselor to avoid confronting deficiencies in their agency's practices or themselves.
A typical example of this misjudging or mislabeling is the identification of a client who is unreceptive to an agency's service or a counselor's method or style as resistant. Such an assessment relieves both the agency and the worker of less comforting explanations for the client's behavior.
Both voluntary and non voluntary clients bring fears and hurts to a therapeutic process that are perceived or expressed as resistance to anyone who attempts to touch the source of the client's pain (Hartman & Reynolds, 1987). It is therefore important for the counselor to remain sensitive to the individual or family's general need for emotional stability during an expected time of change.
It is essential to include counselor resistance as both a possible and likely source of being "stuck". This may involve a dislike of the client as well as an unconscious dislike or triggering of unpleasant or traumatic material from the counselor's past. Typical indicators of this includes the counselor's feeling delight when a particular client cancels or no shows an appointment or is not home for an outreach visit, the counselor misses or avoids obvious diagnostic material, the counselor avoids specific case presentations or discussions in supervision or the counselor manages the case differently than other cases.
Many years ago Schlosberg and Kagan (1988) described a three step framework for working with resistance. It is based on developing a hypotheses about how the process of resistance protects the client from their primary fears (safety) and tests the counselor-client relationship. Table 1 (identified below) outlines the process for identifying typical patterns of resistance. The worker begins to use the resistance by identifying their own reactions and feeling to it. The worker's gut feelings provide clues to pressures and unstated messages. These can be used as indicators of the clients feelings and fears. A hypotheses can then be formulated as to how the resistant behavior makes sense as the foundation for creative interventions to engage the client., to build on their strengths, and to begin the process of change.
Table 1.
Working with resistance: A framework for assessment and treatment planning.
Primary Resistance Patterns (examples)
Denial ("No problem")
Blaming ("It's all _______'s fault.")
Labeling ("He's been diagnosed as _________.")
Fragility ("Don't push him hard.")
Driven parent ("If I don't do everything, no one will.")
Induction ("We like you. You're part of our family.")
Avoidance ("He couldn't be here.")
Crises ("We're in terrible trouble.")
Discounting ("It hasn't helped. You're no good.")
Helplessness ("What's the use?")
Environmental hurdles/dangers ("Cockroaches, lice ... it's the pits.")
Worker's resistance ("I can't, I shouldn't, I must...")
Identification of Feelings
Worker's reaction/feelings toward resistance
Client's feelings/beliefs, what they fear most
Development of Strategies to Engage the Client and Promote Growth
Hypothesis on the function of resistance in the worker-client interaction
Specific strategies
Resistance is an often overused and misused term and label whose origin is generally attributed to Freud and the long-term psychoanalytic process. Freud referred to resistance as an expected phenomenon within the treatment process whereby the uncovering of buried and threatening material usually leads to the client's development and use of defense mechanisms (Gitterman, 1983). The use of the term has become muddled over time and (mis)used by many practitioners to identify any client or family system that the worker has been unsuccessful in engaging, treating, or maintaining in a therapeutic process. This (mis)understanding of the client and their behaviors somehow relieves the worker from less comforting explanations of the client or family system's behavior (Gitterman).
For practical purposes within this article, resistance refers to any behavior or action by a client or worker which serves to protect the client, system, or worker from other persons, actions, feelings, or events they believe to be emotionally uncomfortable or painful to them. The belief may exist on a conscious or unconscious level. Emotional pain exists both on an emotional continuum and is relative to the respective individual or system. In other words, what is uncomfortable or painful to one person may not be so to another.
Therapeutic Myths of Resistance - It is important to clarify three important myths about the treatment process which have a direct relationship to engaging clients. The first is that clients come to counseling for change. This is especially not true for semi and non voluntary clients who do not initiate the process and those in which the entire family system does not cooperate in the therapeutic process such as a spouse or partner that refuses to participate initially or on an ongoing basis. Most often clients begin the therapeutic process with an agenda of staying comfortably where they are at in an emotional place that may seem painful to others but is safely familiar to them. Joel Bergman identifies the common process of clients who often expend a great deal of energy searching out a Dr. Homeostasis who will unwittingly assist them in fulfilling their mission of keeping things the same.
The second is that most people come to therapy believing in it. Most clients have some history of prior counseling and/or interaction with child welfare or a criminal justice type system which has not been helpful to them. They also have some preconceived notions of who counselors are and what they are up to in their work. Prior experience and current hopelessness make strong partners for disbelief of any positive outcome or value of the therapeutic process.
Consistent with the first two myths are that people come to counseling eager for solutions and that each family member is equally motivated. Family systems simply do not operate in this manner when the outcome is change and that power and control shifts in the system. Practical reasoning suggests that in order for someone to get stronger and more of something that someone must lose or give up power. Under such circumstances, at least one person in the system will perceive an impending loss of power or control.
Types of Resistance
Client Resistance - In the area of client or family resistance it is important to understand that the persistence of behaviors or resistance serves the important function of stability to the client. Old problematic behaviors support the belief "better a known devil that an unknown saint". Problems and behaviors may be uncomfortable, but they are certainly more familiar and manageable than the unknown feelings of some desired change that may actually feel worse, especially in the process of getting there. The growth capabilities of a person or family are often impeded by intimacy related issues. For the client identified as resistant this can take the form of either lost or a loss of intimacy or a fear of too much intimacy. The intimacy theme often reflects the growth capabilities of a person, marriage or system. It should be recognized that in some relationships there is only the experience of pain or no intimacy.
Worker Resistance - Resistance is often an accurate term to describe barriers to growth or change. It is most often misused by counselors or therapists to label clients rather than themselves. A clear second type of resistance therefore belongs to the worker. A common theme for the worker often has to do with their own family of origin issues which may have events or issues that were or are painful to them. This can be dormant or feel resolved until it is triggered by either the client or material about the client. It is often a double edged sword. For example, the worker may be a middle child in their own family which included the role of the peacemaker. While this is a generally good characteristic for a worker to have it may also prevent conflict from occurring in families with whom they work. One must be aware that our own issues may be long term and that client issues may actually be the same or similar to our own.
A second common area of resistance for new or inexperienced workers is a fear or anxiety of clients and working with them which inhibits the counselor's ability to do what they need to do. Workers may also feel some discomfort with the power of their role and may be reluctant to use it in a productive way to unstick family systems.
A related area of resistance is the worker's theory or knowledge base which may dictate what and how they hear information. It is crucial that counselors have an awareness of how they hear because of a tendency to hear certain things because they believe certain things. It is therefore important to read a diversity of material and be familiar with several approaches for balance.
Worker fatigue can be a cause of both worker resistance to particularly difficult topics and specific clients. You know you are experiencing fatigue when you are glad your client(s) cancel their appointment. It is important that workers know both their limits as well as how to energize themselves.
Certain types of cases may cause worker resistance to both the client and their material. It is important for workers to understand what type of clients push their buttons. Consideration in the areas of moral issues and values is important in self and therapeutic awareness. Workers should have a clear understanding of who they are as individuals and what is important to them.
The worker's sense or perception of appreciation from clients can be a relevant factor of worker resistance. Clients often push or keep counselors away as a means of emotional safety and protection. The personalization of transference may cause the worker to experience it as rejection. Additionally, the humanistic approach sometimes sets the worker up for offering personal intimacy when they will get back very little.
Closure issues for the worker are an additional form of resistance. Sometimes the worker has trouble closing, separating, or losing those they work with.
System Resistance - It is important to be aware of organizational blinders. The worker may work with a client group so long they only use or see their own approach. Another way of describing this prescription of choice is "we have met the enemy and they are us". Other forms of system resistance are the unavailability of adequate or appropriate space to conduct effective counseling. Excessive time and paperwork demands may also provide impediments to working successfully with clients.
The creative worker demonstrates an interest in identifying the issues which are presenting the resistance. This often involves seeking the meaning of behaviors and self-examination to determine who is actually presenting the primary resistance - the client or the worker. The creative worker demonstrates an ability to vary their style and feels greater freedom to take calculated therapeutic risks in pushing their own style and technique repertoire. The issue is often not one of penetrating the client's resistance, but of engagement wherein both the client and the worker examine the resistance for it's utility.
Resistance Strategies - The most important strategy in working with resistance is the worker's need to plan for and expect resistance. The amount of resistance from a client can be greatly reduced if the worker connects with the client on the client's issues and terms and utilizes a style and language similar to that of the client's comfort level and familiarity.
The use of treatment contracts assures agreement on issues to be worked on and how counseling time will be spent. Like a car, if something needs to be fixed, you fix it but do not tell the owner where to drive it. If they come in for an oil change, you do not tell them they an inspection.
Workers need to understand they will make mistakes. The better the counselor gets in their practice experience and style the quicker they will catch their mistakes. It is also helpful for workers to understand the Leviton Rule of Power Struggles - Avoid them or win them. If you know you are going to lose, do not invest in an emotionally draining power struggle. Avoid it and address it in a different way.
A metaphoric example to better understand the process of resistance in the therapeutic process is somewhat like an automobile journey in which both the client and worker each have their own steering wheel and set of brakes. In a best case scenario they have both agreed on the general (and sometimes specific) destination. (One common worker strategy guaranteed to ensure client resistance is to take the client on a trip to some unknown destination. The importance of trust and control in engagement is crucial.) The worker and client may not always agree on the specific route or speed of getting there, but should be clear on the final destination. (This is generally managed through clear goals on which the client and counselor agree.)
While the worker usually prefers to both drive and take the most direct route as expeditiously as possible, the client continues to ride the brakes, want to stop at rest areas, and enjoy the scenic back roads which often get the worker lost. The journey can get quite interesting depending on who the client and worker invite along for the trip. It is not uncommon to become so lost that in the journey back to the main road, the client and/or worker abandon or discontinue the trip. With engagement resistance the client simply refuses to get in the car.
The Difficult and Nonvoluntary Client
Workers present an interesting paradox regarding the nonvoluntary client. While most acknowledge their existence, few actually work with them. Services under traditional mental health and counseling education and practice standards dictates that service only commences upon the arrival of the client at the provider's office or facility. Stated otherwise, the client needs to be motivated enough to come to the practitioner's office to receive any service. Those who do not come do not receive any service. The paradox is that those who are often most in greatest need are also those who present the least willingness or capacity to come for service. This has somewhat changed during recent years due to resource limitations which are targeted more to the most problematic and difficult clients in the child welfare and juvenile justice systems. The resulting difference is that engagement has been redirected toward outreach which occurs in locations and settings other than program offices.
Nonvoluntary clients are those who have not personally initiated contact, do not see a need for any service, and who are referred and often pressured to make (significant) changes by another person, agency, or authority (Burstein, 1988). They are clients who are unable or unwilling to participate in services. Their unwillingness to participate in services or engage with the counselor represents the first major resistance which must be surmounted - engagement resistance. This resistance may not necessarily apply to all clients unable to participate due to physical or environmental handicaps such as lack of transportation, mental disability or other factors.
Client Characteristics - There are several thematic and specific characteristics common to the difficult to engage and nonvoluntary client. They have frequently been a prior human service recipient in which they found the service(s) or the worker(s) to be unhelpful or punitive. They, in their own experience, feel victimized by interventions from educators, social service or agency staff, and family courts. They often resist present and future interventions as intrusions into their family or personal lives (Kaplan, 1986). They often view human service professionals as intimidating parental figures who are insensitive to their personal or family's primary needs (Bell, 1963).
Thematically this often represents shame around parent or child behavior. It often serves a protection function for the individual or family which prevents discovery of a secret they are unable or unwilling to talk about.
Mistrust is an important thematic characteristic of the difficult or nonvoluntary client. Mistrust is basic to engagement resistance (Hartman and Reynolds, 1987). The client is trapped between his/her need for change and their need to protect their current patterns, role(s), and organizations (Bell). The resistant client brings fears and hurts to the therapeutic process that are expressed as a resistance to anyone who attempts to touch the source of their pain (Hartman and Reynolds).
Additional characteristics common to difficult and nonvoluntary clients includes a poor or low self concept which may present as aggressive behavior, depression, denial or avoidance, and the successful employment of other defense mechanisms.
While there are multiple characteristics of the difficult and nonvoluntary client, the most important feature is that they (initially) do not want the service nor do they want to engage in any therapeutic process. This may create some degree of confusion and/or conflict for the human service purists who strictly believe in client self determination.
Examples of such clients are those referred for services they did not request or desire. This includes many youth and families referred to counseling agencies or programs by public child welfare and juvenile justice agencies, schools, and hospitals (following an involuntary commitment). It includes youth referred by their parents with refusal by the child to participate in the service and parents brought involuntarily into the system because of their or their child's behavior(s) Often, one parent figure will participate while the other refuses involvement while claiming the (family system) problem has nothing to do with them.
Special Populations - In engaging difficult and nonvoluntary clients in general it is important to note several specific populations that present real challenges to engagement. Those populations include substance abusing, physical and sexual abuse perpetrators and family systems with a significant parent-child conflict in which the direction is reunification.
In the case of substance abuse and physical and sexual abuse perpetration the general theme the counselor needs to be prepared for is denial. There are several models of intervention in working with these populations. The traditional model is that of confrontation. This begins the process by expecting the client to accept or admit responsibility for some act or behavior. This approach generally only works well when there is a firm authority mandating participation by the client. While this might get the client into the process it does not mean that the client will be cooperative in the process or use the process in a productive way. For example, attendance at or completing a parenting course does not mean any of the material will be used or integrated.
It is important to understand that clients connect to the worker first in engagement and not the process. The worker is the tool that guides the client to growth and resolution. If the client connects to the worker it is more likely they will risk dealing with the difficult material.
Family systems in crisis with a goal of reuniting an unwilling adolescent or parent can be a real challenge because it is less about the worker and often more about not giving in. It is therefore imperative that the counselor remain and be perceived by the client as being neutral. Like the client who is abusive there is great defense and protection around maintaining one's position. Engagement must therefore convey a feeling that one can enter and participate in the therapeutic process without feeling they will lose something.
Engagement and Intervention Continuum
The Engagement and Intervention Continuum (Figure 2) consists of four phases: preliminary, pretreatment, treatment, and termination. The primary focus of engaging the client occurs within the preliminary and pretreatment phases.
During the preliminary phase the worker has no direct contact with the client. Referral information is obtained with particular attention paid to the presenting problem, individuals involved, onset of the problem(s), previous human service involvement and interventions, previous attempts to improve or resolve the situation, and demographic and environmental issues.
The purpose of this has important implications for the engagement process. It is extremely helpful in creating an initial hypothesis based on the counselor's best diagnostic sense of the situation. The information allows, as Shulman (1984) describes, the worker the opportunity to "jump into the client's shoes" and empathically experience and question what the client might be thinking and feeling before the counselor actually meets them. This advance opportunity is particularly helpful in anticipating what the client might be thinking about and anticipating their particularly unique point of view. From the client's point of view and with knowledge of prior human service involvement and experience with workers one can anticipate the client's concern and feeling about starting with a new worker. The process of "jumping into the client's shoes" is an affective rather than intellectual process.
Having an initial understanding of the client and likely issues also requires the worker to think about how they feel about the client and their situation. This involves an awareness of the worker's own issues, biases, willingness to take risks and personal comfort of working with the client in settings other than the office (client homes, schools, unfamiliar neighborhoods, etc.) if outreach is to be utilized as part of the engagement strategy. It additionally involves the counselor thinking about their own feeling about manipulation, their rescue fantasies of not letting clients fail, and what they believe will happen if they push a client toward goals and expectations for growth. It also involves being clear on their own ideas of professionalism which often may put a client off or create a "one down" feeling by the client.
Considering all of the dimensions of the preliminary phase the worker should be able to generate likely scenarios about what might happen during the first contact, either on the phone or in person. This will help prepare the counselor for maintaining a positive, proactive, and productive style which reduces the likelihood for any unanticipated surprises or situations which could cause the worker to become defensive or reactive. Preparation reduces, but never eliminates surprise. It is often an important client test of the counselor.
For the worker it should be more important to "do right" than "be right". It is easy to blur thoughtful advance consideration of possible scenarios and what they might mean with the creation of the worker's agenda. It is not uncommon for a worker to (unconsciously) seek information or ask questions which only relate to supporting the worker's initial impressions or expected situations. The worker should never be so focused on what he/she thinks that they miss important new information which might change an initial diagnostic impression.
The pretreatment (second) phase is focused around engagement of the client. It involves direct contact with the client. If the worker is unsuccessful in engaging the client, he/she can never be successful in the treatment phase and, at best, will remain stuck in the illusion of work (Shulman). Additional tasks of the pretreatment phase are intake information collection and contracting with the client around goals, expectations, and responsibilities.
During the third or treatment phase the primary services and interventions are implemented according to the contract or treatment plan. If the worker has been successful in engaging the client and overcoming the issues of engagement resistance, he/she will encounter a whole new set of resistance's during this phase.
The final termination phase concludes the process either with successful resolution of the issues that brought the client to treatment or being unsuccessful with the client dropping out of treatment or being closed for other reasons by the worker. Termination actually begins with the first session whether the worker actually discusses it or not. Termination, in a process sense, more formally begins in the treatment phase when the worker and client begin discussing goals and the projected length of service. This does not necessarily imply either success or failure.
Engagement Resistance
Engagement resistance is focused around the helping person's effort to involve the difficult or nonvoluntary client in a process or activity that the client knows or believes will lead to emotional pain. Engagement is equivalent to acknowledgment of the emotional pain and a voluntary commitment to (eventually) visit it.
The primary goal in working with difficult or nonvoluntary clients during the pretreatment phase is overcoming their engagement resistance. Once the counselor has thought about what it would be like to be in the client's situation or place, the worker's own feelings about working with the client and what they believe all the available information means diagnostically, it is time for personal contact with the client.
One might question why so much thought and effort should be expended before one actually has direct contact with the client. The old saying you only get one first impression underscores the importance of this first contact. In many ways, it establishes the framework or foundation for all future interactions.
To every client, the worker is an authority figure. It does not matter whether the worker believes it or views themselves in that way, it is the reality of the client experience. The worker automatically begins one up on the client. The client will react to that in many ways, most of which will be indirect. There is often a paradox of power where the client may feel, state, or act as though they are powerless, but act in a powerful way by controlling the engagement process through their resistance to engagement.
One of the first decisions clients make is whether to engage with the worker (Shulman). For the worker the question is how do they help the client lower their defenses when they have such a stake in maintaining them? Clients need to take steps in their own self interest, not the workers. The worker's role is to help them feel safe enough to take those steps.
Five basic assumptions (Schlosberg and Kagan, 1988) are important starting points for understanding and working with difficult, nonvoluntary, and chronic and multiproblem clients. The first is that you always begin where the client is. This old social work axiom refers to counselors and agencies who often feel a greater urgency or need for change than the client and begin with their own agenda regardless whether the client understands or accepts it. This impatience often creates barriers to both engaging and maintaining the client through the treatment process.
Secondly, (engagement) resistance often reflects unresolved issues within the family system that is acted out within the community and with agencies, therapists, and others. Thirdly, the level of resistance to engagement and counseling corresponds to both the pressure experienced for change and the pain inherent in confronting the dilemma.
Fourth, the type of resistance fits the emotional stage of the individuals within the family system and serves to maintain the family system at its current stage of development. Lastly, resistance tests the usefulness of the worker - client relationship. It provides the client with a valuable screening technique to determine whether it is safe for them to establish a relationship with the counselor and whether they are able to make potentially costly and painful changes.
The worker and client can not successfully move to the treatment phase until the client is successfully engaged. Within a family system treatment mode this means minimally engagement of at least one of the key members - either the identified client who is presenting the symptoms or problem behaviors or the parent figure who actually has the most power in the parental dyad.
Joining: The Therapeutic Mindset of Engagement
Joining is more an attitude than a technique. It is the umbrella under which all therapeutic interactions occur. Joining is letting the client know the counselor understands them and is working with and for them. Minuchen states that “only under their (the worker’s) protection can the client have the security to explore alternatives, try the unusual, and change. Joining is the glue that holds the therapeutic system together.” (Minuchen and Fishman, 1981) Jurick (1990) in his five step strategic therapy model, notes the worker must join with the client and learn to see the world through the client’s eyes in order to avoid being drawn into an unproductive coalition and becoming part of an existing problem.
In the simplest form, joining with a difficult or nonvoluntary client is about connecting with the client in a manner that dissipates initial engagement resistance and establishes a trust level between the client and counselor which allows the process to continue.
Because nonvoluntary clients have been difficult for other workers to engage does not mean that every new worker will have a similar experience. A worker about to engage a difficult or acting out client, particularly adolescents, or adults emotionally arrested in adolescence due to substance abuse issues, must first of all appreciate or unconditionally love them or refer them to someone else. These clients can be so obnoxious, so infuriating, so difficult that if the worker can not love them in spite of this, their therapeutic interventions will never work (Jelsma, 1990).
Those who work with difficult and nonvoluntary clients additionally benefit from an “unstoppable sense of humor and a keen appreciation for bizarre wit to keep at bay the ever-present specter of potential tragedy and to prevent work from degenerating into mutual hostility." Because the process of joining, engagement, and intervention spans a varying period of time, the worker additionally has to be willing to live in suspense until the client or family system rights itself (Jelsma),
Engagement: Capturing the Client
Engagement is similar to joining. Joining is the attitude necessary for engagement. Engagement is the active process of connecting with the client. Engaging the client in a trusting therapeutic relationship is a first order activity. Successful service can not proceed without a base level of client engagement and cooperation (Matthews & Robertson, 1994). Waters and Lawrence (1993) discuss "courageous engagement" for both workers and clients which requires taking calculated therapeutic risks and stepping out of familiar treatment ruts and routines. It requires courage to go after more than a safe and adequate outcome. Too often counselors are willing to settle for what the client is willing to settle for. The goal of creative engagement is to expand the client's vision of what is possible.
As stated before, clients with a previous history of child welfare, juvenile justice or counseling often have an experiential notion of both the counseling process and who counselors are as "helpers". There is often little distinction between a child welfare caseworker, a probation officer, a guidance counselor or a therapist. Long histories with any or all of these is generally an indication that successful engagement leading to real change will be a challenge. The fact that the present counselor has the client often indicates that all previous ones were unsuccessful and that the client is quite naturally ambivalent about repeating another unsuccessful therapeutic experience.
A common strategic error of workers is to get too far ahead of the process by beginning or moving to deeper levels of counseling before engagement or a therapeutic relationship has been established. The worker identifies the client as "resistant" because they will not address, cooperate or stay focused on the (worker's) goal or agenda. A supervisor should reasonably question two general areas - whether the worker has significantly engaged the client or system before beginning work on the issues the client appears to be resisting and whether the client is even aware of and in agreement with the goals the worker is addressing. Too often treatment plans are made unilaterally by the worker on what they believe the client should be working on as opposed to what the client feels prepared to and comfortable enough with working on. These contracts are by nature corrupt because they impose expectations and goals on clients without their consent or knowledge.
Engaging the more difficult and non voluntary clients who are unable or unwilling to come to the office for service is a double challenge. Outreach to the client's home, school or place of work is often necessary in order to initially access the client. The second challenge is a very personal experience which will determine whether the worker even gets a second chance to continue working with the client.
Practical engagement advice is to follow a preemptive version of what Shulman (1984) and Schwartz (1976) refer to as "tuning in" or "jumping into the client's shoes". This preparatory empathy with the client is a way of putting oneself in the client's shoes and trying to view the world through the client's eyes. Based on known information about the client's life, their stage of development; the nature of their previous experiences with human service agencies, and past and current (presenting) problems the worker can imagine what it is like to have lived the client's life, feel what they might be feeling, and anticipate what their unspoken questions and issues would be for a first therapeutic encounter. Additionally, the worker needs to be genuine, real and believable as a human being. While this may be offensive to many worker's self perceptions, clients have great intuition about bored, disinterested, cynical and uninspired workers. Workers need to recognize the difference between meeting or being with a client and actually being helpful and valued by them. Nothing meaningful in counseling ever happens without a successful client engagement.
Ground Zero: The Place Where Change Occurs
Ground zero is the place where growth, change, and movement occur. It is the result of a therapeutic climate created and managed by the worker. Ground zero is the impact point where worker's skill, style, and creative forces intersect with all the challenges the client brings to the therapeutic process. It is the dissolution of therapeutic impasse. It is the hot point where change and movement have the highest likelihood to occur. It is, hopefully, the worker who controls ground zero. In the best scenarios the worker is the fail-safe that prevents the client from their own "crash and burn." The worker's role is to insure client survival in those "crash and burn" situations.
Without engagement there is no ground zero. The exception to this is a crisis situation or workable moment which are ground zero opportunities. These situations are the engagement opportunities. Success in and feeling helped by the counselor creates successful engagement.
The Creative Self: Worker As Tool of Engagement
"It is important not to mistake the edge of the rut for the horizon"
Anonymous
When all is said and done the worker is the primary therapeutic tool in the counseling process. Considering that all workers, regardless of discipline, essentially receive the same educational knowledge base through which they understand development, feelings and behavior it is not surprising that workers generally all do fairly well with voluntary and motivated clients. The big difference shows up when workers encounter clients who are unmotivated, lack insight, present significant initial resistance to engagement, and have a noteworthy history of defeating past counselors. It is the latter group of clients that separates the workers with active creative selves from those with inactive creative selves.
The creative self is a mixture of innate talent, natural curiosity, divergent thinking, innovativeness, playfulness and mischievousness. The creative self has a strong connection between their "head" and their "heart". Their unusual instinct is well described by Joel Arthur Barker (1993) in his discussion of "paradigm pioneers". Those who choose to change their paradigm, method, intervention or style do it not as an act of head, but as an act of heart. They are captivated by a set of rules or observations that suggests they may be able to succeed where before they or others have failed.
Driven by the frustration of the old and the appeal of the new, the creative self is willing to cross the brink of doing it differently. The creative self also demonstrates the courage to act on its intuition.
The creative self is different in every worker. A life history of different family systems, life experiences, education and training, dreams, and visions make the worker rich with the skills and insights to guide others through their difficult times.
Engagement Strategies and Techniques
Thus far, Aspirational Engagement has been more of a knowledge base, understanding, and mindset about resistance as a concept and formidable issue, the difficult and nonvoluntary client, and the process of engagement. It is as important as any technique for actually engaging the client. It is not easy. It provides no assurance for success. It does, however, improve the opportunity for successful engagement of the difficult and nonvoluntary client.
Crucial engagement skills are consistent with good treatment skills. They require an attentiveness to the worker’s style and the effective use of the range of skills the counselor possesses. This is especially important during the engagement process when the worker - client relationship is so tenuous. While in an office setting, the goal for the worker would be to have the reluctant client return for a second appointment, the goal for the worker of a nonvoluntary client receiving outreach service is to be invited back for a second visit.
Workers should act the way they expect clients to behave. They must convey that the clients are the experts in their own lives. This serves an important empowerment function. They must be able to articulate what the client is experiencing but having trouble talking about. These powerful issues for the client are often projected onto the worker. Shulman refers to this process as projective identification.
Being clear is an important factor in building trust. It requires an ability to raise and discuss uncomfortable material with the client. Important engagement material or issues not addressed will continue beneath the surface and likely undermine the therapeutic process. This is an especially difficult process to negotiate for counselors who may fear saying the wrong thing or losing their client.
An additional important skill during engagement is containment (Shulman). Very simply, it refers to not arguing with clients about issues and the worker’s general ability to know when to keep their mouth shut.
The worker operates with multiple goals and utilizes many skills all at the same time. The overlapping goals contribute to the counselor’s mindset. At the forefront of those engagement goals is always reaching for the client’s strengths. This suggests a belief in the potential of the work and a refusal to accept even the client’s own self-description of weakness (Shulman). This is more difficult than it sounds considering most worker’s formal training is in the area of identifying deficits and problematic behavior(s) rather than identifying strengths. This is a central part of what helps clients act in a positive way in their own behalf.
Strategy and technique is a very individualized skill set. Their individualized use is a function of the style and the personality of the counselor. While the same strategies and techniques can be explained and taught to many workers, each one will adapt and use them differently depending on their own comfort level, creativeness, use of self, previous training and experience, comfort with personal risk-taking, and other factors too numerous to mention. That is the way it is supposed to be. Workers are different. Clients are different. Each strategy and technique has its own continuum with variations and alternatives to suit and meet the needs of clients and workers alike. The responsibility of the worker is to select both the most appropriate strategy and technique and the correct variation that presents the greatest opportunity for success.
For most workers, this process occurs rather automatically with little or no conscious thought. This infers a process which has become both routine and lacks a conscious effort toward individualizing the intervention to the client. Consciously thinking about the client and what it will take to successfully engage them will motivate the counselor and enhance the range and quality of engagement strategies the counselor possesses.
A variety of engagement strategies are identified below with short comment to provide further clarification. For purposes of identification and future reference they are listed in alphabetical order.
ART - Art is an expressive engagement strategy that allows clients to speak with a projective voice. This can be as formal as House-Tree-Person type of drawings, creative drawing versions of family sculpture, working with clay, books of pictures, a camera, and paper and pencil (or crayons, markers or paint). It can include a trip to an art museum or gallery. It can include the creation of individual or family collages. Art, like any other creative engagement strategy, must be a good fit and appropriate to the specific client or family.
BEING A GUEST - Being a guest is both a technique and an art. It honors the client by being the guest in a new relationship. It involves being respectful in a sometimes disrespectful or hostile non-office environment. It involves being gracious and tactful while being therapeutically manipulative. Typical examples include the acceptance of offered ice tea, use of the bathroom which offers new observational opportunities, or requests to use the phone when necessary. It additionally involve a mindset which simultaneously includes converting the client home to your office. With such a mindset the counselor feels greater permission to turn off the client’s television during scheduled meetings (remembering to request the client to do it first) or asking the client to deal with a disruptive child or pet. This also establishes and reinforces a therapeutic contract of expectation as well as providing less threatening intervention opportunities.
CONCRETE SERVICES - Beginning where the client is often means the worker has to attend to the immediate needs of the client such as food, services or other crisis type issues. It is very difficult to get clients to talk about feelings and issues when they are hungry, homeless, or in the middle of a crisis. Frequently, nonvoluntary clients have unmet environmental or resource needs that can be tended to rather quickly. The ability to help the client meet one or several of those needs establishes in the client's mind both a sensitivity by the counselor to their situation as well as their willingness to take care of business. Providing immediate and helpful service provides the client with an experience the counselor is helpful and trustworthy.
CREATIVITY and RESOURCEFULNESS – This skill is inherently all about who the worker is by nature. This may also include the worker being given permission to be that way by their organization. This is almost magical in the way it can transform material and mood to a level of comfort for the anxious client. It requires a willingness to take calculated risks, being a bit playful depending on the situation, and a desire to be helpful rather quickly moving to a specific agenda. It additionally helps reduce start-up tension by demonstrating that counseling does not always have to be serious.
GAMES - Games, like other techniques, allow the client to divert their immediate attention from the focused process of discussing and disclosing. This often works well with children but also works with family systems, particularly when the worker wants to observe the natural interaction of the family system. It quickly highlights issues of natural hierarchy, power, control, competitiveness, fairness, tolerance and other types of family functioning.
FOOD - The counseling process is a very oral process. Food is often a simple way of stimulating the process. The use of a snack or treat allows the client to experience the counseling process in a nontraditional way. It allows the worker to give the client something which is both enjoyable and distracts them from the traditional format of talk therapy which is the counselor and client sitting in an office and talking about something the client wants to resist. This would include sharing a piece of candy or taking the adolescent client to McDonald's.
HANDSHAKES - One of the easiest ways to connect with a client is to simply shake their hand in the greeting process. It both literally and metaphorically connects the worker to the client. The worker can further reinforce the connection with the duration and firmness of the handshake as well as deciding whether to conclude the session in the same manner.
HUMOR - In an atmosphere of initial tension and anxiety humor can ease the transition to more serious material. This can be anywhere from light-hearted banter to a simple appropriate story or joke. The key here is keeping natural and appropriate. If the client does not perceive it as natural or appropriate it will become a barrier to engagement.
LANGUAGE - Clients often feel comfortable in the engagement process simply because the worker's choice of words and style of speaking conveys greater equality. Simple techniques include using the language (as appropriate) of the client and using metaphors related to areas of interest to the client. The goal is to help the client feel comfortable, connected and that they share something in common. Maintaining a "professional" attitude of keeping the client one down is a real barrier to engagement.
MAGIC - Magic has a way of capturing the imagination of clients, especially that of difficult and nonvoluntary ones. It has a very high entertainment value and appeals to every person's innate sense to know how something works. It works well with nonverbal and disorganized clients and family systems. For example, simple card tricks can change an anxious and withdrawn adolescent into one with attentive anticipation whose first response is usually either "how did you do that?" or "show me how you did that". Once you teach them you have given them an important gift of being able to do something successfully every time they do it. The worker may choose to trade the teaching of the trick for some specific expectation. It is a small price to pay for something that guarantees success to the client and initiates a bond because you gave them the gift. (A simple “mindreading” trick is located following the reference section of the article.)
With small children balloons and other playful activities work well. A frequent outcome is that the child or adolescent conveys to the parent and system persons that the worker is "OK". This is especially helpful if many referrals are made in a word of mouth manner.
MUSIC - It's been said that music is the international language and often is a great ice breaker with clients. This can include the use of actual instruments, music while transporting clients, having clients bring their favorite music (which becomes a projection of things they are feeling or would like to say), the use of or writing of lyrics, and direct contact with musical people.
OUTREACH - Outreach is the umbrella under which almost all work with nonvoluntary clients occurs. It is the extension of the client services by the agency or worker to non-office settings. If the worker has been unsuccessful in persuading the nonvoluntary client to come to the office through written or phone contacts there are only two alternatives; you close the case or you engage the client in a setting other than the worker’s office.
Outreach as a client service or goal will usually be defined in advance by the worker’s respective program or agency. Many agencies have predetermined they will not utilize nor provide outreach and as a result will not work with any client that does not come to the program or agency office.
There are various settings for outreach which includes client homes, schools, foster homes, residential treatment settings, street corners, and job sites. While not inclusive of all possible outreach settings the most frequently used are client homes and schools.
Outreach by nature is a turf issue. The worker is displaced to a setting other than his/her own. It is important to remember, particularly for counseling agencies, that counseling is a process, not a setting. Counseling can occur anywhere. The worker may feel some loss of control by being out of his/her element, particularly if it is a home or neighborhood where safety may be a worker issue.
It is, however, a powerful strategy in that the client feels a high degree of emotional safety, is less likely to leave during the interaction since they are already on their home turf, and is more likely to agree to future appointments. The client may choose to be away from home for those scheduled future interactions and the worker may change strategy to include unscheduled appointments as a result. It is also important to remember an eventual goal is to have the client come to the worker's office. This helps prepare the client to more proactively seek and obtain services in the future on their own.
Home visits provide the worker with important observational opportunities unparalleled in the office. The home becomes a projective instrument through it’s contents, arrangement of rooms and furniture, and the natural family system interaction that occurs.
Outreach will accomplish the goal of getting the client and the worker face to face. The content of the interaction will determine future client receptivity to and availability for future interactions.
The school as an outreach setting is more controlled for the worker in that it is neither the worker nor client’s turf. To the worker’s advantage, many adolescent clients will be more available simply because they view it as an opportunity to get out of class. Others may resist meeting in school because they feel personally embarrassed when their peers know they are seeing a counselor. Those clients who do not attend school for their scheduled school appointments may require outreach to the client’s home.
Outreach is the strategy that will set up the face to face interaction with nonvoluntary clients. The skill and technique within the interaction will define and determine the level of engagement that occurs.
PETS - Often clients relate to animals easier than counselors because of the unconditional nature of their response. The use of pets is also multi-sensory in that clients feel great permission and pleasure in petting animals. It is safe for the client and often triggers positive feelings the client has for their own present or past pets. It would not be uncommon for the client to begin by petting and actually talking to the animal before the worker, than to the worker about the animal and than to the worker about more relevant material. It also helps show the worker a softer and more caring side of the client.
PICTURES - The type of pictures the family has on their walls, in frames, on refrigerators and in family albums will tell you about who is important to the system as well as stories about them. The family album is also a safe way to talk about family members since the discussion begins with safe events and material they have already showed the worker.
PSYCHODRAMA - Psychodramatic techniques offer the client the safety of warming up, action, and interaction at a speed and level comfortable to them. It allows the client the opportunity to speak and respond to a double, mirror, or other. While psychodramatic techniques can be advanced, they can also be those most counselors have learned without realizing they were psychodramatic techniques such as the empty chair and role playing.
REMINDERS - These are especially helpful in mobilizing a family system where some members are more voluntary than others. This often works well with drug and alcohol family systems or other addictions where therapeutic engagement and investment levels vary. Reminders can be postcards or phone calls reminding the client of the appointment or the use of appointment cards given at the end of the previous appointment. It is also a helpful strategy to keep the appointment time relatively consistent every week and to schedule as many in advance as possible.
SETTING - As stated before, counseling is a process, not a setting. Therefore, one of the easiest ways to make a client feel comfortable is to create or use a comfortable setting. For some clients this might be a walk which allows the client to talk without looking at the worker and also stimulates the body metabolically making it easier to talk (particularly with depressed clients). The setting of a session might be a spontaneous choice based on where one is at. For example, clients are often very talkative during a transport to and from an appointment. Continuation of the session may occur at the destination without getting out of the car which often breaks the flow. This, like other strategies, is a function of outreach and a worker's willingness to step outside the traditional boundaries of counseling.
(COUNSELOR) STYLE - Style has an important power of engagement. It can calm or escalate the first interaction. For that reason it is important that workers understand their own style, whom it works well with, whom it does not work well with, why those interactions work or do not work, and how the variety of clients they work with perceive them.
A worker can be whoever they want to be and use whatever style they want as long as they know how to make it work for them in their interactions with clients. While one can aspire to be like the masters of therapy, supervisors, or other workers they want to emulate, it is more important that they aspire to be themselves in the best way they can. Style without a good skill or technique fit is courting disaster with difficult and nonvoluntary clients.
A good introduction and opening line(s) often set the mood for everything that will follow. Remembering that you only get one first impression highlights this importance. This is especially important for new workers and clinical interns. Many clients are often unclear as to who the worker is, why they are there, and most importantly what it is they want from the client.
Simple contracting such as agreeing to meet a specific number of times, agreement on the issues and problems to be worked on, and mutual expectations or ground rules for the work lets the client know where the counselor and client are going on this mutual therapeutic journey. Worker and client need to be in agreement on the purpose and general direction of the work. General goals are identified in the beginning as themes since further intake information will be necessary to aid the counselor and client in more specifically identifying more exact and measurable goals. This gives the client an important sense of control within the counseling process. Prolonged lack of clarity creates an unnecessary tension or anxiety in clients that only serves to maintain client mistrust of the counselor and inhibits the engagement process.
It is important that workers know why they are there and that they can convey that to the client in a manner which relieves anxiety and promotes trust. This can simply be achieved through advance worker thought about their opening sentences or statements to the client. While a good rap may sound redundant to the worker, the client is only hearing it for the first time.
UNANNOUNCED VISITS - Unannounced visits for elusive clients gives them less opportunity to avoid the worker or prepare a defensive plan. They are, in a sense, forced to respond to the worker in person. The worker's job is to be irresistible. As a strategy this only provides the opportunity to personally engage the client. The fact that the client has remained elusive speaks to the level of their resistance the counselor is likely to encounter.
VIDEO and FILM - Most clients have great exposure to television and movies. Most clients have their own opinions about what is good, bad, what worked, and what did not. The use of selected videos can be excellent transitions to client related material. Like other projective devices, the client is often unaware of the material they are sharing in their discussion of other's situations, the values inherent in the selected situation of the video and their own choice of favorite television shows and movies.
WHATEVER WORKS - This catch all category fits all other skills and strategies not mentioned. Each worker has a life history filled with successful experiences both within their respective discipline and outside of it. While workers have chosen a field which helps others they also have had a rich life experience of helping themselves in their own self interest. In that experience they have had to convince others, sell issues others had little or no interest in, touch the hearts of individuals they have never met before, and pursue others (usually the opposite gender) they really wanted to meet and know. In those quests, they learned much of what they need to know to be successful in engaging difficult and nonvoluntary clients.
Whatever it takes is reminiscent of what Minuchen (1981) described as therapeutic spontaneity. This requires a use of self in a way which the counselor must be an effective part of the client system able to respond to circumstances according to the client or system's rules while still maintaining their widest use of self. The worker's actions, though regulated by the goals of the therapeutic intervention are products of his/her relationship with the client.
Crash and Burn: Less Than Perfect Work
It would be a therapeutic marvel if everything we said and did as workers worked with clients. It doesn't. Risk-taking and creativity is by nature imperfect and fraught with the potential for failure which occurs in many ways and for many different reasons. It is therefore helpful to consider the reality and implications of therapeutic creativity which misses the mark during the engagement and start-up process.
Risk-taking can have important implications for both the client and worker. Unsuccessful risk-taking or less than perfect interventions can produce problematic effects for a client which may include creating an unmanageable crisis or relapse, triggering old known or unknown issues, placing the client at greater risk for an unwanted relapse or crisis, loss of trust, perceived or actual betrayal, and premature termination. This is more likely to occur with young or inexperienced workers who, for example, go into "healing" without the life experience or training necessary to understand the problems with which they are intervening. It is also possible the worker may be in over their head or they do not understand the meaning of the material the client has given them. In these cases Minuchen and Fishman (1982) suggest the counselor either consider excluding themselves from the case (which is not usually possible in most human service agencies) or acknowledge their ignorance and ask the client to educate them in such matters.
Crisis can be very much like a double edged sword. Just as a crisis can produce a workable moment than can lead to change, change can also lead to a crisis. It is therefore essential that the counselor understand which direction the are moving - toward a crisis or change.
A trusting relationship must almost always precede a client's willingness to accept risk. Risks need to be honest and fair in the client's perception. Timing is also an important element of therapeutic creativity. A perfect intervention can easily fail if it is ill timed.
Risk-taking can have equally important implications for the worker. For the beginning worker it is not unlikely they will already be knowingly or unknowingly dealing with their own client rescue fantasies. This includes a menu of feelings about losing the client, the client not liking them, not asking certain questions because they feel it would make the client uncomfortable and choosing easy or weak interventions that maintain their own personal emotional safety.
For the worker the material may also consciously or unconsciously trigger their own past issues. They may have anxiety about or fear their own material and not be willing to take risks with their own self. That avoidance prevents them from helping clients with the same or similar issues or themes. Just as the client must have a trusting relationship with the worker in order to accept risk, the worker must trust themselves in order to take or initiate a risk-taking intervention.
Successful risk-taking is empowering. The lower the risk the more acceptable it will likely be for the client and the worker. The higher the risk, the greater the stakes and the expectation for resistance.
Summary
Aspirational engagement as a microtherapy skill is the single most important worker skill because it is the determinant whether further work can continue and at what level. It is a skill that, in large part, is based on the individual style, characteristics and nature of the worker. While most workers can work with willing, cooperative and compliant clients, engagement skills are tested as clients move further up the resistance continuum toward absolute (initially) non-voluntary and non-compliant status.
As such, the difficult and nonvoluntary client is the most challenging to work with due to their reluctance or unwillingness to risk entering the therapeutic process. The issue of engagement resistance is the primary obstacle to moving forward with any meaningful intervention. Resistance is a barrier to be overcome by the worker, not an excuse to prevent successful service from occuring. The primary issue of overcoming resistance is understanding what purpose it serves and what it means to the client.
The worker is the primary tool of engagement. The worker's prior training, life experience, and creativeness join forces in an irresistible therapeutic alliance which allows the client to feel less anxious and defensive about the counselor and what he or she has to offer. In the end, each worker knows there will be some difficult and nonvoluntary clients they will never engage.
Critical worker skills necessary to be successful in engaging difficult and nonvoluntary client include an understanding of the engagement process, a personal feeling of safety and willingness to be creative, different, and irresistible, and a genuine interest in wanting to know and engage the client. One has to genuinely want to do the work and have an appreciation for the absurd, unacceptable and sometimes disgusting. Anything less will get in the way of the client experiencing the worker as one who can be helpful.
To modify one of Minuchen's thoughts, "Beyond technique there is the wisdom which is knowledge of the interconnectedness of things...when techniques are guided by such wisdom's, then (therapy) interventions become healing".
References
Barker, J.A. (1992). Paradigms: The business of discovering the future. New York, NY:
Harper-Collins Publishers, Inc.
Bell, J.E. (1963). A theoretical position for family group therapy. Family Process,
2(1),:1-14.
Fest, J. (2005). Positive youth development: Your questions answered. The Prevention
Researcher, 12 (Supplement, December),: 3-6.
Hartman, C., Reynolds, D. (1987). Resistant clients: Confrontation, interpretation, and
alliances. Social Work: 68(4):205-213.
Gitterman, A. (1983). Uses of resistance: A transactional view. Social Work: 28(2):127-
31.
Jelsma, B. (1990). Risky business. The Family Therapy Networker, 14(4):48-51
Jurick, A.P. (1990). The jujitsu approach. The Family Therapy Networker, 14(4):42-47.
Kaplan, L. (1986), Meeting with multiproblem families. Lexington, MA: D.C. Heath.
Matthews, J., Robertson, R.M. (1993). A promise of family: A practical guide to
understanding family preservation and home based programs. Allentown, PA:
Valley Youth House.
Minuchen, S., Fishman, H.C. (1982). Family therapy techniques. Cambridge, MA:
Harvard University Press.
Riebel, L. (1992). On with the show. Family Therapy Networker. 16(5):33-37.
Robertson, R.M. (1997). Walking the talk: Organizational modeling and commitment to
youth and staff development. Child Welfare, 76(5):577-589.
Robertson, R.M. (1989). The diagnostic - intervention paradigm. Allentown, PA: Valley
Youth House.
Robertson, R.M., Sweinhart, J. (1993). Ground zero and therapeutic creativity.
Allentown, PA: Valley Youth House.
Schlosberg, S., Kagan, R. (1988). Practice strategies for engaging chronic multi-
problem families. Social Work: 69(1).
Shulman, L. (1984). The skills of helping individuals and groups. Itasca, IL: F.E.
Peacock Publishers, Inc.
Waters, D., Lawrence, E. (1993). Competence, courage, and change: An appoach to
family therapy.
Waters, D., Lawrence, E. Creating a therapeutic vision. Family Therapy Networker.
17(6):52-8.
Wylie, M.S., Markowitz, L.M. (1992). Walking the wire. Family Therapy Networker.
16(5):19-30.
Mindreading 101: It’s Not What You Think
- Think of a number between 1 and 10
- Multiply that number by 9
- Add the 2 digits of that number together
- Subtract 5 from that number
- Translate that number to a letter of the alphabet (example: 1=A, 2=B, etc)
- Think of a country that begins with that letter
- Think of an animal that begins with the letter E
- Think of a common color that describes that animal
- “That’s funny/weird/etc. because there are no grey elephants in Denmark”
* Special thanks to Eric Anderson, magician, for sharing/teaching this simple mindreading activity.