Christina Schendel, Ph.D., Deployment Health Clinical Center on May 29, 2015
U.S. Army photo by Sgt. Luke Rollins
Christina Schendel, is a licensed psychologist and is special assistant for strategy integration for the Deployment Health Clinical Center. This article is written for providers and references scientific language and research.
As clinicians, we’ve all had patients who struggle to remain engaged in therapy, especially after a breakthrough, challenging session or even an alliance rupture. We know that almost half of patients leave psychotherapy too soon, which reduces the effectiveness of therapy. Taking a look at ourselves as therapists, and the therapeutic relationship, can help us find ways to stay engaged and keep patients as active participants in their therapy.
Consider these helpful reminders:
Maintain a collaborative alliance
Research indicates that a leading cause of disengagement and premature termination from therapy is miscommunication between the therapist and patient about therapy expectations. If your patient shows signs of disengagement, have an open discussion about the therapeutic relationship and collaboratively reevaluate the therapeutic goals. Using process comments, or interpersonal observations, to examine what is occurring between you and the patient brings immediacy into the relationship, allowing for an intimate and honest discussion. This may encourage the patient’s self-exploration and can foster greater therapeutic alliance.
Readiness for each therapy session starts before the patient walks into your office. Remind patients to arrive 10 minutes early for appointments. This will give them time to catch their breath, reflect on their week and mentally prepare for their session with you. Using mindfulness exercises to focus on the present moment is an excellent way to focus for therapy. Being fully present, or engaged in therapy, requires an active, collaborative relationship where both the patient and therapist are prepared to do the work.
Stick to your session time limit and allow for small breaks in between each patient to regroup, have a quick snack if necessary, and mentally prepare for the next session. Research indicates that 5-9 percent of therapy outcome variation is attributable to the therapist. Being fully attuned to each patient, either the first or the last of the day requires the capacity to be empathic and the ability to engage.
The therapeutic relationship is bi-directional, requiring the therapist to have insight into their feelings, thoughts and behaviors with a patient. One way to manage your countertransference reactions (the internal and external reactions rooted in past or present unresolved conflicts) is through self-insight.
Ask yourself whether you’re contributing to your patient not being engaged in the sessions. Are you engaged? Thinking broadly about countertransference, what are your positive or negative feelings and thoughts about this patient? Do you like him? Do you wish the session would go faster? Are you burned out or experiencing compassion fatigue? How is your experience playing out in the session? Take time to examine how you as the therapist are affecting the level of engagement in the session and then how you may use this insight to impact therapy with this patient and others.
Remember, your peers and supervisors are there to support you in your work. Consult others about your challenging clients and discuss your thoughts and feelings openly. A trusted colleague can offer clarity or insight into the therapeutic relationship.