You may have caught my recent post about why everybody hates rehab. It touched on an important point about what it means to receive referrals for clients from a 3rd party source and how it impacts the way we engage with our clients. Today I want to explore this idea a little further. If you've ever worked with a client who came across as resistant, unmotivated or disengaged - this post is for you. And if you've ever been frustrated by a client who never does any of the homework you agree on... read on.
The Rehab Checkout: Is Anyone Buying?
Jo Muirhead from Purple Co has written an excellent series on the different types of relationships that can play out in a rehab environment. One of them is the transactional kind - where we reduce clients down to their medical condition, chase down medical certification and eventually (we hope) get a client back to work.
What's wrong with this picture?
Boxes are ticked and everyone signs off, but the client is left somewhere in the middle and is thoroughly a passenger in this journey.
There is also a pretty good chance that no-one has stopped to ask the client what they hope to get out of this whole process - and whether they even want to be involved at all.
What this all means is that a transaction is happening that the client isn't even involved in.
Imagine if someone took you shopping and tried to talk you into buying a whole bunch of Pete Evans endorsed activated almonds you didn't want - they'd probably have to drag you to the checkout, and if it worked, you'd likely toss out the bag after they went home.
Conventional rehab can be a little bit like this sometimes. So it's no surprise that when we try to give homework to someone who hasn't bought in to this whole process (or has bought into a different goal than the one we're trying to pursue) that homework doesn't get finished, calls don't get returned and we label our clients as unmotivated, disengaged or resistant.
Visitors, Complainants and Customers
Before you can even think about developing an intervention or plan with your client, you have to figure out how willing your client is to (1) recognise and define a problem and (2) make a positive change around that problem.
Using a solution-focused framework is a great way to do this.
Prochaska, Norcross and DiClemente  break down behaviour change into three different stages:
- Visitor - someone who does not want help or see anything that needs to change
- Complainant - someone who wants help but feels that something or someone else needs to change
- Customer- someone who wants help and is motivated to change
*I don't really like the language about someone being a "complainant", mostly because I think that kind of language can place blame on the client even though their complaints are legitimate ones. Our job as health professionals is to encourage change while also addressing our clients' concerns instead of labelling them as complainers. Where this language comes in useful is in figuring out how willing someone is to change what is within their control.[/rescue_box]
In a rehabilitation environment, many of our clients do want change to happen but have lost hope that things can be better. Maybe they are used to relying on doctors, specialists and medication to fix or treat their problem. And maybe they've tried to do something about it themselves and are disappointed that it didn't work out.
This means that there is a high chance that your client falls into the second category, where they may no longer see themselves as part of the problem or solution. It's our job to amplify their hope that things can be better, and amplify the belief that they can be part of the answer. Our clients don't have to feel powerless anymore.
Meeting People Where They're At
Once you have a better idea of where people are right now in their journey towards change, you can start asking questions and helping them set appropriate goals based on what they can control.
I think it's really easy to fall into the trap of setting "homework" for people who aren't quite at the level where they're ready for it yet - particularly if that homework is based around working again for someone who just isn't quite there.
So here's your challenge - how else can you engage a person's desire for things to be different?
Maybe it's not time yet to start talking about going back to work. But most people we cross paths with do want something to be different - so ask - what would they like to see change?
What's already working in that direction?
What would it take for them to be just one step closer towards that picture?
That sounds like progress to me.
References and further reading:
Prochaska, J.O., Norcross, J.C., & DiClemente, C.C. (1994). Changing for good. New York: Morrow.
Bannink, F. (2006). 1001 Solution-Focused Questions. New York: Norton.