Whenever you feel you are doing more work than the patient and are more invested than he is, something has gone wrong in collaborative care.
With resistant or hostile patients, fight the urge to move quickly into clinical assessment and to prescribe what you think should be worked on and how. Instead, spend more time—especially when building the treatment alliance in the first 15 minutes (Box1)—exploring their ideas on how, when, and where they feel they can achieve what is most important to them (Table 12).
Resistant patients may have different agendas, but taking a pragmatic approach can merge their goals with yours.
Building the all-important alliance
More than 2,000 research publications in the last 30 years prove the clinical importance of the therapeutic alliance.1 When working with resistant patients, keep these points in mind:
Develop a strong alliance early in treatment. “Early” is relative to the length of therapy, but evidence suggests sessions 3 to 5 are a critical window.
The patient’s experience of being understood, supported, and provided with hope depends on the strength of the alliance early in therapy. His or her interpretation of what you do can be different from what you intend. You may be a great clinician but not necessarily for this particular individual at this time, doing the kind of work you do.
Progressively negotiate the quality of the relationship. The patient’s perception of the alliance—not yours—is most influential. Ask specifically if the treatment relationship is working for him or her.
Early in treatment, the alliance itself contributes more to outcomes than do therapeutic techniques and models. First develop a collaborative agreement on the goals and strategies to be used in the therapeutic work.
Table 1
How to merge the reluctant patient’s goals with clinical needs assessment
| Questions to prioritize patient goals | Questions for clinical needs assessment | Merging patient goals with assessed needs | |
|---|---|---|---|
| What? | What does the patient want the most? What undesired consequences will occur if s/he does not get help? | What does the clinical assessment indicate s/he needs? What obstacles/assets do you need to address to help her/him get what s/he wants? | What treatment contract will drive the treatment plan and organize treatment priorities? |
| Why? | Why did s/he seek help now? Has s/he realized or been told s/he is at risk to lose freedom, health, a relationship, or a job? How committed to change is s/he? | Why are the assessed obstacles and resources important to include in a treatment plan? What diagnostic, function, or severity problems do assessment data reveal? | Is the treatment plan linked to what s/he wants? Does s/he accept that the treatment priorities will help her/him get what s/he wants? |
| How? | How will s/he achieve the most important goal? Must you try her/his preferred treatment before s/he accepts methods you prescribe? | How will you develop patient buy-in and get her/him to accept the plan? | Does s/he believe your strategies will help get what s/he wants? Will s/he be actively invested or passively compliant in treatment? |
| Where? | Where is s/he willing to be treated? Does s/he have strong preferences (such as about group treatment or residential programs)? | Where is the appropriate setting for treatment? What is indicated by the placement criteria? | Refer her/him to the level of care that merges his/her preferences with what is clinically indicated and likely to be effective |
| When? | When does s/he want to begin treatment? Is s/he feeling pressure to start? How badly does s/he want treatment, or is s/he just complying? | When should treatment begin, based on your assessment? What are realistic expectations and milestones in the process? | How urgent is treatment? What is the process? What is expected from referral? |
| Source: Adapted from reference 2, Table 3. | |||
What does the patient want?
When a patient is difficult to engage, begin by listening for the most important concern that brought him to your office.
He may be depressed, anxious, or tired, but exploring why he decided to seek help now (“My wife said she would leave me if I didn’t get help”) reveals what is most important. The “treatment contract,” then, is helping this patient save his marriage.
Initial engagement
Collaborative treatment begins with a genuinely interested dialogue about what prompted the patient’s visit.
Therapist: “Thank you for choosing to work with me. How may I serve you? What is the most important thing you want me to help you with?”
Mr. L: “I didn’t choose you; they made me come.”
T: “I didn’t see anyone drag you in. What would happen if you had not come today?”
Mr. L: “I might lose my job. I came because my boss told me to.”
Focus on what the patient wants, not just what others have said he or she needs (treatment for substance abuse, angry outbursts, conflict at work). The patient may want to stay out of jail, keep his job or relationship, regain custody of his or her children, obtain housing, or get people to “leave me alone and quit locking me up against my will.” Although the patient’s problem may be obvious to us, he needs “discovery” work, not “recovery” work.