Managing Poor Engagement

Definition

Our definition of poor engagement includes individuals who fail to attend their first appointment (sometimes called ‘non starters’), those who attend sporadically, or those who drop out. Poor engagement might also be a reference to statutory supervision or to treatment interventions.

Who are the ‘poor engagers’?

This can be a common problem across a number of personality disorders. In psychiatric services, community non-attendance is approximately 19%; in personality disorder patient populations it is higher at around 33%. For personality disordered offenders, non compliance – failing to complete a period on licence or a community order, or dropping out of treatment – is linked to raised risk of further offending (and recall to prison). Poor engagement, although not exactly the same as non completion, is likely to be very closely linked. So improving engagement is likely to improve completion, and potentially reduce risk.

However, it’s important to remember that absolutely refusing to engage (for example, never starting treatment at all) does not necessarily raise the risk of future offending. It does, however, make it really difficult to follow a sentence plan.

 

Why do service users have problems with non- attendance?

Attendance and engagement problems can be viewed as a form of communication. Remember the service user may have had difficult early experiences of being abused or neglected by those in authority; they are likely to expect relationships with practitioners to involve a repetition of previous patterns of rejection, abuse, or deception. Service users may avoid any closeness in their interaction with staff, or set ‘tests’ to see if the staff are trustworthy or truly care about them. For those with substance misuse problems or who are emotionally volatile, they are more likely to lead chaotic lives which makes attending appointments a hit and miss affair.

Using the personality disorder table detailed in the PD Guidance, we can see how different personality types/traits can leads to different types of poor engagement.

Personality type Interpersonal strategy Attitudes behind the engagement problems
Paranoid Suspicious or provocative ‘All information from sessions will be used maliciously. Don’t give anything away, do the bare minimum to get through.’
Schizoid Isolated or unengaged ‘There’s no point in talking ‘just for the sake of it’; your questions about thoughts and feelings make no sense – why are you asking them? Just let me get on with my usual routine.’
Antisocial Deceive or manipulate ‘Life is a jungle, and therefore, never trust anyone or rely on anyone. Reject any invitation to open up.’
Borderline Attach or attack ‘I thought you were the one to really help me, but now I see you’re no better – perhaps worse – than the others. I can’t spend time talking when there are so many crises in my life which need to be sorted out now.’
Narcissistic Compete or exploit ‘Of what interest can you or your supervision possibly be to me? I am more than capable, and you have nothing to teach me.’

 

Impact on the practitioner

Service users who engage poorly have an impact on the practitioner. You might feel:

Frustrated – just as felt you were making progress and the service user was opening up, they don’t show up. You wonder what you did wrong.

Relief – You may in part be pleased when sporadic attenders miss appointments; you have plenty of paperwork to get on with, they cause extra work due to their demands and chaotic lives.

Indignant – You may question why you should care, if they can’t even be bothered to contact you.

Anxiety – you wonder if they have been re-arrested, or have self harmed or had an accident.

 

The practitioner’s stance   – do’s and don’ts (for chaotic clients, also refer to the tips in the Managing Self Harm section )

DO DON’T
Be firm about boundaries when you need to Send a warning letter in the heat of the moment, without contacting the service user first.
Assume engagement will be poor this time if there’s a previous pattern of problems Assume it was the previous practitioners’ mistakes which were the cause of the poor engagement
Be open to exploring the non- attendance problems Let any sense of strong negative emotion enter into your enquiries
Show you noticed/care by phoning or texting the service user immediately, to see what has happened. Just wait for the next appointment and then demand answers
Discuss non-attendance with the service user, and be honest about what the consequences will be. Avoid talking about the consequences of non attendance, or worse, imply a threat of action that you don’t want or can’t carry out.
Use phone calls or texts to remind the service user of their appointments in advance. Set a long sequence of appointments by letter, and expect the service user to attend them.
Work out what the service user worries about/wants help with, and focus on that issue Insist that the service user focuses on your agenda (or the Court’s) exclusively.
Actions speak louder than words: be useful! Expect the service user to value thoughtful conversation and reflection on its own
Use letters and video conferencing, or visits to family members, whilst the service user is back in prison. Close the file as soon as the service user returns to prison, expecting to resume contact on release.

 

Managing poor engagement issues

There are three steps to manage poor engagement, set out in the Figure below.

managing-engagement-issues

Identify the service user’s history of engagement with services. For example, review whether this is a historical problem when in the community or custody previously, how quickly it occurred, whether it was worse with male or female practitioners, and so on. Reviewing the file may give you an indication of this.

Analyse, the patterns of poor engagement in terms of the underlying reasons, in order to work out what are the triggering events. Examples of triggers to poor engagement can be

  • thoughts (why should I be told what to do, this person doesn’t like me)
  • feelings (anger, fear of showing the need for help)
  • behaviour (the pattern of non-attendance )
  • relationships (fear of intimacy with females or competitiveness with males)

Ideally, these patterns should be thought about with the service user, in collaboration, and the timeline could also be developed together. This assists with the development of the series of events that occurred before and after the poor engagement that reinforces this behaviour.

 

Timeline

timeline-engagement-issues

 

Intervene

Having explored the problem by identifying and analysing the non-attendance, you need to work in collaboration with the service user to develop a plan. The key task is to try and identify in advance the problems that might occur, and work to avoid them proactively. This could take the form of a conversation, or recorded in a sentence plan, or even a letter to the service user. Some service users will respond well to a contract – a simple agreement – which anchors the contact in mutual expectations and helps the service user and practitioner work towards agreed goals. Please download our example contract sheet if you are interested.

 

Tips for planning

tips-for-planning-engagement-issues