An illustration of how to engage even the most challenging patients and clients
Jose: "Just read my record. I have nothing to say. You already have everything on me."
Wood: "Jose, thank you for coming to see me here today. I understand you have already told your story. I always prefer to hear it in your own voice, in order to record things accurately.
Jose: "Well, everything is there. It’s okay, just read it."
Wood: "You are right, everything is here. You see, I don’t start by reading any
of these things that are here, because I prefer to have some fresh eyes,
and I don’t want anything to bias or distort my judgment."
Jose: "Well, that’s okay. This is what you all do anyway. You all judge people and send false reports to the court about people. That guy at that other clinic messed up my court report and told the judge I wasn’t coming. Now I have to start all over again and spend another 6 months, just because of the lies from all of you people. All I want is to just finish my 6 months, get out of here, and go to work and do my life."
Wood, as he heard Jose talk about what he wanted, proceeded to join with him through his articulated goals. “You want to just finish your 6 months and get out of here. This is great. Let us do this together. I can see how important this is for you. Now, what needs to happen in order for you to reach this goal?” asked Wood. "Y’all just need to stop sending false reports to the court. That’s all. And if you don’t believe me, just talk to my girlfriend. She is the only one who has been there for me. No one else,” answered Jose. Wood followed Jose’s lead. He focused on what he was saying and what he was not saying. And, while this was the right thing to do, he was still unsuccessful. Wood was doing his best but to no avail, and he needed to find another way.
Up to this point, Jose had been playing with his phone, looking at it, and avoiding making eye contact with Wood. As everything else had failed, so far, Wood seized the opportunity to focus on Jose’s interest.
"Your phone,” said Wood, who then paused, waited for a response from Jose, but again to no avail. Wood, after a pause of ten seconds (which felt like an eternity) stated, "Jose, your phone." This time gesturing to Jose about how he was well absorbed with his phone.
This still was not enough to move things forward with Jose, who reacted, “What?” Wood remained patient and understanding, believing there was always a way to engage even the most challenging patient and client. He made his third attempt for this. Pairing his words with a gesture, Wood said, “Jose, the phone. You seem to be into it a lot. What’s going on?” “Oh, it’s nothing. Even if I tell you, you won’t be interested. You’ll think I am crazy,” responded Jose while smiling, the first indication that engagement was beginning. Wood had to capitalize on Jose’s smile and use it to help move things forward.
Feeling accomplished for a brief moment, Wood thought to himself, “I seem to have finally reached a significant place here. But I am not going to mess it up, and I am going to do my best to build upon this, engage Jose, establish trust, and move things forward.” He then followed the affect, vaguely commenting on Jose’s smile, building positive reinforcement, and as the session continued, went from telling Jose that he was interested in his story, to showing Jose that he was interested in his story. Now, how did he really do that?
Wood, for the first time during this visit with Jose, stepped away from behind his desk. He took his chair, put it next to Jose’s chair, positioned himself at his level, and said nothing.
Don’t tell, show, I often say, and “actions speak louder than words” is indeed true.
When Wood changed his position, now removed from behind his desk, and at the same level as Jose, while remaining silent, Jose appeared surprised and skeptical.
Nonetheless, and perhaps despite himself, Jose smiled, and this was the start of a connection and therapeutic relationship, which both Jose and Wood needed in order to take their work to the next level—together.
In two previous articles on engagement, I described ten principles on how to engage our patients and clients. I outlined the first five principles as:
(1) Meet them where they are at;
(2) Instill trust;
(3) Include them in all decisions;
(4) Establish concrete goals with clear metrics; and
(5) Identify Barriers and Problem Solve.
I then outlined the next five as:
(1) Involve family members, the community and use them as allies;
(2) Use motivators;
(3) Focus on the patient and client;
(4) Start the process early; and
(5) Have an overall engagement strategy around engagement.
I would like to echo that knowledge is power only when it is in use. While these ten principles that I outlined above are part of the art and science of engagement in daily practice, we often come across challenging situations that may make the application of these principles less straightforward. Hence the reason for this additional series entitled, When Everything Else Fails.
When everything else fails, these same principles will apply, but some form of creativity will be required, and this encounter between Wood and Jose illustrates just that.
For more in this series of articles, check below!
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.
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