Jacob, a 12-year-old boy, goes in with his mother to see Dr. Darby, because: "The school counselor wants him to see a psychiatrist. He covers his head each time his teacher approaches him, and he barely pays attention in class." Jacob’s mother, Marie, tells the story how her older son, Mike, was once held in a psychiatric hospital, against the consent of his parents. “We refused to sign any forms of consent for treatment and managed to get Mike discharged from the hospital.” They stopped receiving outpatient treatment, but they are here now, because like Jacob’s brother, "The school is pressuring us to see someone."
Patient and client engagement is a challenge across all aspects of clinical care and more so in mental health, especially for those who feel forced into treatment. There is no single best definition for patient or client engagement, but I usually describe it as the active patient and client involvement in his or her care for best outcomes. Jacob and his parents see their previous experience with mental health as negative. Understanding Jacob's condition and crafting a treatment plan with him will require engagement—trust, listening, and dialogue. Below we will discuss 5 tips for fully engaging your patients and clients, and achieving the best possible outcomes.
1. Meet them where they’re at
Meeting patients and clients where they are at means speaking their language, listening to their own explanatory model of the illness and, at least, attempting to address their most immediate concerns. Use their language, listen but do not judge, do not confront too early, educate when needed, but always ask permission first.
A 24-year-old male, Amack, was admitted to the inpatient psychiatry unit and on evaluation, he, with a “textbook” diagnosis of schizophrenia, reports: "These are bad spirits making me weak and distracted. I want them to go away." In the engagement process, the physician told Amack, “We have pills that can make you stronger and fight the bad spirits." He agreed to take Risperidone and started to improve about a week later.
Amack's language and explanation were "the bad spirits." Our specialty language was schizophrenia, but using Amack's language fostered engagement and achieved an optimal outcome in his care. This speaks to the power of “meeting them where he was at.”
2. Instill trust
Patients and clients come to us with all types of preconceptions, either conscious or subconscious, and they may look for “signals” to reinforce their beliefs.
Darlene, a 52-year-old woman, was referred to a dual diagnosis clinic for treatment of her alcohol use disorder and post-traumatic stress disorder, as part of a reunification plan for her children, who were in foster care. After a successful reunification process, she brought her children to meet her psychiatrist to whom she said, while sobbing: "I came in here with a mistrust for the system, hating doctors who reported me to child welfare and admitted me to the hospital against my will. I came in only because I had no other options, but I learned to trust you. You made me trust you, and I am very grateful." The doctor paused, smiled, and said: “Darlene, it’s only because you allowed me on the journey with you.
You do not always know your patients and clients' presumptions when they first seek treatment with you; all you may have is yourself, your training, your experience, and more importantly, your compassion, which drove you into healthcare, to start with. Making use of all these is a genuine and authentic way to instill trust.
3. Include them in all decisions
Whether you are dealing with your children, your spouse, or your staff, including people when making decisions that impact them is a sure way to achieve buy-in. This is certainly true and important when dealing with patients and clients, too. This level of inclusion needs to be across the board. From the appointment day and time, to whether the patient or client wants to hear a diagnosis, and from frequency and type of treatment modality, to anticipated length of treatment. Even when it is about hospitalization or involving others in the patient’s care, or having to call child welfare, because the patients' children may be in danger, if you include your patients in the process, you will see the difference it makes.
Darlene's doctor had the task of consistently being in touch with her probation officer and child welfare agency. He often reminded her of that responsibility and always made sure to go over any reports with Darlene before sending them to child welfare or probation.
Including your patients and clients in the decision-making adds collaboration and partnership. You will be surprised how your partner will go out of their way to help make things work.
4. Establish concrete goals with clear metrics
Engagement is a process, and we can use engagement to establish concrete goals and achieve the best results. Some concrete goals may be to return to school, to obtain a job, to make new friends, or to start dating. Further, people can feel discouraged unless they have concrete ways to measure their progress. Take a few minutes to get a baseline score for your patient’s level of depression, anxiety or symptoms of PTSD. After a few weeks of treatment, re-administer the scales and talk with your patient about the meanings. There are lots of instruments available, simply choose one, stick to it, and help give your patients something concrete to go by.
When Darlene went to her doctor, there were many goals, but reunifying with her children was the most palpable, the most pressing. Other goals for Darlene were sobriety, and maintaining stable mood, but reuniting the family was one that she lived and breathed for.
In a world where treatment plans are done most of the time because, "we need to get paid; we don't want to get cited," one powerful way to engage your patients is to meaningfully include them in the development of something concrete and palpable that can be measured and achieved through a stepwise process.
Remember, "meet them where they are at," include them when making decisions, and appeal to their sense of purpose when developing the treatment plan.
5. Identify barriers and problem solve
Research shows that barriers to engagement can be placed into three categories- structural, attitudinal, and cultural. Structural barriers to engagement include all those social determinants of health, which require attention for successful treatment outcomes. Attitudinal barriers encompass all attitudes your patients have about treatment, which at times, can be based on previous experiences. Having an idea of what these experiences have been for a particular patient can therefore be an important tool for the engagement process. Cultural barriers are not the least of these categories. Besides the broad cultural differences based on religion, language, race, or ethnicity, sub-cultures are equally as important and include family, neighborhood, peers, addiction, gang affiliation, and jail or prison subcultures.
Jay, a 21 year-old male, after six months of remission from opiate use disorder, once told me: "Now that I don't use, and I don't hang out with my old friends, I don't know who I am anymore. I don't feel like I belong anywhere, because all I knew was being an addict, since using when I was 14."
Cultural sensitivity is essential in the engagement process with your patients and clients, and remaining curious, non-judgmental, while attempting to join-in will surely take you a long way.
Are you ready to make engagement a part of daily practice?
As stated above, engagement is a process, it does not happen overnight, and it requires patience, flexibility, and a different mindset. As a result, to be successful you will need to see the importance of all that’s involved in the engagement process and decide to make them a priority.
Thank you so much for reading!
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Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, coaching, and management, experience. Some of his passions are public speaking, leadership, entrepreneurship, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past-Medical Director for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.