Engagement from the Get-Go: Frontiers Friday #152 ⭕️
A Q&A from Advocate, The eMagazine of the Network of Alcohol and other Drugs Agencies (NADA).
In 2021, I did a talk for Network of Alcohol and other Drugs Agencies (NADA), the peak organisation for the non-government alcohol and other drugs sector in New South Wales, Australia. The topic was “Engaging the Edges: Connecting with people before they dropout from therapy.” (You can watch the video below).
NADA’s Senior Program Manager, Michelle Ridley did a follow-up Q&A with me about this. The following appeared just this week in the eMagazine, Advocate.
Michelle Ridley (NADA): In your book The First Kiss you talk about undoing the Intake Model and using an Engagement Model first. Why?
The way we are trained to conduct a clinical intake assessment does not engage clients. This is not an exaggeration. The cumulative evidence suggests that, on average, about 20–30% of clients attend only one session and prematurely drop out of treatment.
You can see this being played out further, particularly in larger service settings. In the attempt to solve a waitlist issue, they have an ‘intake officer’ do the initial assessment, then subsequently transfer to a treating psychologist or counsellor. However, the unintended consequence is that when a client is transferred to someone else after initial assessment, they are 2–3 more likely to discontinue treatment.
Overvaluing a clinical intake assessment may result in obtaining ‘true but useless’ information.
Here's a snippet from the book, The First Kiss:
The Intake Model schools us this way: Step 1: Figure out the ‘clinical’ background, who’s who in the system. Step 2: Develop a rigorous case formulation. Step 3: Slay our clients with our latest evidence-based interventions.
We do not need to conduct a ‘thorough psycho-social assessment’ before we begin therapy.
Our urge is to gather all the necessary facts from the person. One eminent psychiatrist once said to a room of more than a hundred mental health professionals during a grand ward round, ‘we must seek the truth out of our patients.’ I gather he was extolling us to become Sherlock Holmes. While his forensic approach appealed to me, imagine if we adopted this idea in our first sessions in therapy.
Have we earned the licence to pry?
If we start a first session like a truth seeker, we run the risk of three problems. First, as we try to dig the past and gather all the facts, we may inadvertently re-traumatise our clients. For example, I was once referred by my client’s general practitioner (GP) to help him with his post-traumatic stress disorder, regarding a significant event of abuse that happened in his teenage years. Even though it was clearly defined as PTSD by his GP, my client wasn’t prepared, nor interested in talking about it in the first session. If I had pushed, insisting that this was the primary concern, I would have caused emotional injury. He might have dropped out from therapy.
Second, even as we attempt to gather all the facts in the first session, even if your client responds to your questions, we may not have a consensus to delve into a particular area of their life.
In short, the Intake Model values information, the Engagement Model prioritises connection. We should focus more about what we are giving than what we are ‘in-taking.’
Our training over-emphasises on what is eliciting information. Instead, we need to focus more on developing a shared focus, that is, figuring out where a person is, where they need to go, and what they deeply care about.
NADA: In your keynote presentation at the NADA Conference 2021, you spoke about accessing a counsellor when you were young in Singapore. You said it was a profound experience because this person listened—he let you talk and didn’t have an agenda. You spoke about the importance for practitioners to be personal over professional. Can you explain more?
This is vital. There is a strange paradox at hand. Our drive to be ‘professional’ can lead us to become clinical and cold.
If you stop to think about it, the helping profession, especially those that fall under talk therapies, is a strange profession. Our tools of healing are not tools, but our personhood. If we detach our personhood from the process--our experiences, knowledge, feelings and idiosyncratic nature of being--we risk creating distance in the space between us.
In this profession, the most professional thing to do is to be personal.
NADA: You’ve spoken before about the need for practitioners to create a climate of emotional safety for people accessing treatment/therapy? How do they do this?
Here's what not to do.
The Quaker writer Parker Palmer says,
‘If we want to see a wild animal, we know that the last thing we should do is go crashing through the woods yelling for it to come out. But if we will walk quietly into the woods, sit patiently at the base of a tree, breathe with the earth, and fade into our surroundings, the wild creature we seek might put in an appearance. We may see it only briefly and only out of the corner of an eye--but the sight is a gift we will always treasure as an end in itself.’
~ From Hidden Wholeness
Simply telling someone that ‘you are safe here’ isn't going to cut it. The challenge is neither to be invasive or evasive.
We might come across as invasive when we aren't cognisant of ‘true but useless’ information, and if we remain too distant from the human endeavour of deep conversation, we inadvertently evade from painful, stirring and traumatic topics. Healing can only begin when we approach the things that wound us, with the guidance of someone with whom you can relate with, someone who cares about you.
Safety is cultivated in the presence of a healing connection.
For more on this, see this post, Safe me
NADA: What are your top 3 practice tips for workers to increase engagement with their clients right from the first meeting?
Here's my top three principles that guide me, especially in my initial connection with someone.
1. Follow the pain and follow the spark
I talked about this in the book.
When I think about ‘follow the pain’, I think about my father-in-law who is a traditional Chinese medicine physician. He will ask his patients, ‘Where does it hurt?’ and when he ascertains the location and quality of pain, he would start to apply specific pressure to aid in their healing.
There are some parallels in the emotional realm. We need to figure out what are the inner struggles the person is facing on the inside. Often, these are unspoken. It takes a warm and inviting climate for these aspects to surface.
If you are hurried and clinical, don't expect these parts to show up.
I sometimes hear from clients that entering the therapy room was all it took for them to feel things that often get bypassed in daily living. I suspect that's because the environment is cloistered, slowed down and all parts of oneself are welcomed in the spirit of exploration.
However, following the pain needs to be balanced with following the spark.
These aren’t ice-breaker questions. They are fire-starters. I want to learn about what this person sitting in front of me cares about. What interests does this person have? Why? What about it? How do they share these parts of their lives with, etc.
2. Significant events
Second, I want to find out about significant things that have happened in their lives so far.
Though significant events often relate to traumatic incidents, significant events also entail threshold moments––a sort of bridge-crossing from one place to another––when a change so drastic alters the course of one’s life. This could be a move to another country, falling in love, a surprising life-affirming feedback from a teacher, or any other happenstance that wouldn’t have ordinarily led to transformation of the self.
Sometimes, when appropriate and relevant, as a therapy homework, I would ask clients to draw up a timeline and take time to reflect on what were the significant moments in their lives and why.
3. Significant people
Finally, I want to fully appreciate who are the people that this people loves, who loved them into being, who played an important role in their early years and adult life. It is as if we are invited a community of others into the therapy room, even though it is just two of us in the healing conversation.
Some years ago, I met a woman in her mid-30s who was struggling with relationships and alcohol dependence. I asked her to take a moment and think about people in her life who have shaped her. She became quiet for a while. She came from a well-to-do family, but her parents were often absent due to work travels. She then went on to talk about her nanny. Her nanny was her mother-figure. Her attachment to her nanny became a secure base for her, until the day that she was told to leave. It devastated her. There was little pre-warning about her departure.
She was shocked that her parents made that decision so abruptly. Maybe her parents become fearful of the bond that she is having with someone who is not in the family. She had no further contact with her nanny; she wasn't allowed to.
As my client was sharing this story, I asked her to picture her nanny. She fought the tears, because she was surprised by the floodgates of this memory. Instead of running away from this, I asked if she would permit herself to simply feel this memory, to feel this connection she had to her nanny, who was her guiding light.
This access to her memory, her connection with someone so significant to her, was a life-giving force for her. Though no longer in physical connection, the emotional connection was palpable.
We exist in a web of relationships. It is only sensible to understand others around your clients in order to understand your client.
For more on this, I talked about 4 perennial factors you should figure out about your clients:
Watch now: Daryl Chow's keynote from the NADA Conference 2021.
Notice Board
Thank you to Jan Dybkjær and his team of therapists from The Danish Red Cross Asylum for having me. My hopes is that more agencies think in terms of developing a culture of a “learning environment” like theirs.
1-Day Training in Denmark 26th of Oct 2023:
I’m teaching a 3-day supervision course in Copenhagen this October. Thereafter, the organisers are opening up an intimate 1-day training in deliberate practice.
If you are interested to join us, you can register here.
(Note: The website is in Danish, but the course will be in English. If needed, drop the organiser’s an email. And if it helps, here’s a google translate of the details.)Online Training for Clinical Supervisors:
Our status quo approach in clinical supervision does not consistently translate to better outcomes for clients, and it doesn't help therapist improvement over time. I believe that we can fix that. We need to reimagine the practice clinical supervision in order to yield actual improvement.
If you are a clinical supervisor, I invite you to join us.
Two more weeks before we kick off the 14th Cohort of the Reigniting Clinical Supervision (RCS) online training.
For more details, see this Substack Note (Don’t miss the discount code inside).Here’s the central idea for RCS:
And here are the 7 pitfalls that we will address in our orthodoxy of clinical supervision, and its antidotes:
If you have questions about the course, feel free to drop me an email.
Warm Welcome to New Folks on Frontiers of Psychotherapist Development (FPD)
Thanks to those who have introduced themselves so far. I really appreciate hearing from you. This is one of the ways for an introvert like me to socialise.
If you are new here, I just want to say a big hello to you and would love to hear from you. Tell me a bit about you and where you are from. Drop me an email info@darylchow.com
Click here to see more resources about Frontiers of Psychotherapist Development and Frontiers Friday.
Daryl Chow Ph.D. is the author of The First Kiss, co-author of Better Results, and The Write to Recovery, Creating Impact, and the new book The Field Guide to Better Results .
