What is client involvement? - Chapter 5

What is therapeutic involvement and therapeutic cooperation?

Therapeutic involvement is essential for the effectiveness of treatments. Involvement is defined in two ways: engagement (a behavioural component: he/she does the homework, he/she shows up) and loyalty to treatment (an attitude component: how does he feel about the treatment, is there emotional investment and dedication). Both components are important for effective treatment.

Secondly, involvement can also be seen as a process in which the two factors (engagement and loyalty) are promoted by establishing a therapeutic cooperation relationship. According to Karver and colleagues (2005), this relationship consists of three ties:

1. An emotional-affective bond (in which concepts such as trust and acceptance are central, among other concepts).
2. A cognitive bond (like having the same goals).
3. A behavioural bond (including working on tasks together).

Adolescents often do not seek out therapy on their own. Also, more than 50% of them end the treatment prematurely. In addition, 50-77% are not loyal to their treatment outside the treatment room. Also, 25-50% of all adolescents who end up in a crisis department do not return for a second appointment.

What factors influence adolescent involvement?

Adolescent-related factors:

• An older child.
• Male sex.
• Belonging to an ethnic minority group and low socio-economic status reduce adolescent involvement.
• Also, slightly serious problems and good general functioning decrease engagement, except in the case of substance abuse or a behavioural disorder.

Family-related factors:

• High stress at home.
• Parents who have low expectations of treatment.
• Low socio-economic status.
• Parents' views on practical barriers (transport, financial burden, scheduling) reduce the child's involvement in treatment.

Therapy-related factors:

• The barrier to client involvement is mainly the unknown social situation in which he/she feels uncomfortable and incompetent.

Therapist-related factors, factors that increase engagement are:

• Therapeutic behaviour that invites participation.
• The willingness to make contact with the child in a real, realistic, honest way, respecting their perspective.
• Dodging highly emotional topics in the first sessions.
• A good cooperation with the (supportive) parents.
• Emphasizing the confidentiality of what is said.
• Using simple, clear words.

The effect of a good relationship between a practitioner-adolescent and the outcome of treatment is stronger in behavioural therapies than in non-behavioural therapies.

What interventions can increase engagement?

The two main interventions to increase engagement is through a therapeutic assessment (TA) and through  motivational interviewing (MI).

Therapeutic assessment (TA)

The first session is often important for creating engagement. Therefore, the book calls for a so-called therapeutic assessment (TA) during the first session. First, the psychosocial history is mapped and a risk assessment is made (approximately 1 hour). After a 10-minute pause, another half-hour follows in which the following is done: identifying the main problems, creating a diagram that represents the vicious circles that maintain symptoms, increasing the motivation to change this, analysing the existence of the vicious circle, and describing this diagram and the exits in a clear letter.

Motivational interviewing (MI)

It is unlikely that anyone is 0% or 100% motivated. Motivation varies over time, can be very specific and is interpersonal (motivation stemming from others). The principles of MI are as follows:

• Show empathy through reflection (not with "good" or "bad" judgments).
• Create discrepancy between how things are now and what the child would want.
• Motivate self-efficiency by focusing on previous successes and self-reliance.
• Play with resistance: If the child resists, avoid the subject and change your strategy. Take a break if necessary. Dodge discussions!

Useful responses for the therapist are as follows:

• Empathetic reflection: “It seems that if you are angry about how today has turned out.”
• A reinforced reflection (exaggerate the comment made). Child: “Most of my friends smoke weed.” Therapist: So if you quit, there wouldn't be any friends left?
• A double reflection on both the positive and negative side of something: you're frustrated that you had to wait a long time, but you also decided to wait until I got there.
• Reframing. Child: “My mother constantly whines about that I have to stop cutting myself”. Therapist: It sounds like your mother is very worried about you.
• Ask an open question: what are you experiencing right now?
• Change the subject: “I notice that you find it hard to talk about your feelings. Let’s talk about something else. Tell me, what do you like to do after school?”
• The components of MI can remembered with the use of the acronym BROS: confirm strengths and attempts to change, reflect, (ask) open questions, and summarize.

Psychoeducation

Providing information about the causes, symptoms, risks, clinical course and treatment options of a disorder also increases involvement in the treatment process.

Naming the barriers to treatment

Simply naming things that stand in the way of effective treatment can also increase the level of engagement.

Jointly establish a partnership

By allowing the child to bring as much of his own life as possible into the CBT (by involving boyfriends or girlfriends and their own hobbies) you increase the involvement.

Therapeutic involvement is essential for the effectiveness of treatments. Involvement is defined in two ways: engagement (a behavioural component: he/she does the homework, he/she shows up) and loyalty to treatment (an attitude component: how does he feel about the treatment, is there emotional investment and dedication). Both components are important for effective treatment.