We’re Not Gonna Take It Anymore

Or, Why We Need to Stop Calling Clients

“Non-Compliant”

By: David Baker, LPC
Clinical Director
Georgia HOPE

I know it’s probably dangerous to quote the title of a song recorded in 1984 by a band called Twisted Sister in a blog about mental health related topics because 1) it certainly dates me a bit (though I promise you I wasn’t really a Twisted Sister fan in my youth) and 2) as a protest song (and I know you’ve probably heard it and maybe even sung along with it) it makes some pretty strong statements. But I think the title and the sentiment behind the lyrics of the song make a pretty good point about not trying to force people to fit into a box they don’t belong in.

I can already hear you asking “So what does that have to do with non-compliant clients?” My response is: “A lot!” Let me explain. Most of the time when we identify a client as “non-compliant” what we are saying is “They aren’t doing what I or someone else thinks they should be doing.”

For example:

  • “They aren’t keeping appointments”
  • “They aren’t taking their medicine”
  • “They aren’t returning my calls”
  • “They aren’t using the skills I’m teaching them”
  • “They aren’t getting anything out of the therapy I’m providing”
  • Or you fill in the blank

Usually “non-compliance” has more to do with what I think my client’s unmet needs are than with what my client thinks their unmet needs are.

At the risk of giving Twisted Sister more credit than they might deserve for brilliant therapeutic insights, think about these lines in the context of the clients you work with who you think of as “non-compliant”:

“We’ve got the right to choose it/There ain’t no way we’ll lose it/This is our life, this is our song”

and

“We’ll fight the powers that be just/Don’t pick our destiny ’cause/You don’t know us, you don’t belong”

While these sentiments may be somewhat overstated (and I’m probably stretching these lyrics way beyond their intended purpose…), I think these lines make the point that people have the right to choose their destiny and when this is challenged or disregarded the response is usually to fight or flee from whoever is trying to force us to do something we didn’t choose.

So when your client is “non-compliant” maybe what they’re telling you is there’s something about the help they are getting that they don’t want to “take.” If we are accurately reflecting in treatment the unmet needs our clients have asked us to help them to address, than “non-compliance” is a non-issue as a client can’t be non-compliant with themselves.

I think these lines make the point that people have the right to choose their destiny and when this is challenged or disregarded the response is usually to fight or flee from whoever is trying to force us to do something we didn’t choose.

So, what do we as therapeutic helpers do when we our clients become disengaged from treatment? I think the first and best thing we can do is to listen. Sometimes the listening is easy because our clients are singing as loud as Twisted Sister letting us know that they don’t want what they’re being offered by us – “We’re  not gonna take it!” More often than not though the listening requires a little more skill because the communication isn’t so “in your face.”

In an article on addressing resistance in therapy the following statement was included: “…resistance is a signal that the client views the situation differently.  This requires that [staff] understand the client’s perspective.  This is usually a signal for [staff] to change direction or to listen more carefully” (http://rssw705.tripod.com/id15.html).

The point is in order to better align treatment with the client’s unmet needs we need to make sure we understand our client’s unmet needs. For our clients to stay involved in treatment we need to create the positive motivation for them to stay involved in treatment. If we haven’t asked them why they aren’t engaged, we need to. If we haven’t given them the freedom to have a different point of view than ours and express that point of view, than we need to give it. If we haven’t put ourselves in our client’s shoes as best we can and tried to understand the challenges they are facing from their point of view, than we need to. And we need to be willing to acknowledge that while we may have a lot of experience and education in providing help to other people, our clients are still the experts on their own unmet needs even if they don’t always know it. So we need to make sure that we are developing the skills to hear in all the various ways our clients are expressing those unmet needs and then help our clients tell us how we can assist them to most effectively and positively meet those unmet needs.

And we need to be willing to acknowledge that while we may have a lot of experience and education in providing help to other people, our clients are still the experts on their own unmet needs even if they don’t always know it.

Finally, there will be times when our clients continue to tell us straight up “We’re not gonna take it anymore!” and our response will have to be “OK” because our clients have the right to make that choice. It’s their treatment. Hopefully that will be after we have made every effort we can to listen and have exhausted every possible avenue for creating motivation to access the help we have been trained and want to provide.

Oh and if you’re feeling lost without the word “non-compliance” in your vocabulary, I guarantee you if you put yourself in your client’s shoes and try to see things through their eyes you’ll probably come up with something more positive to use.

 


 

Dr. Seuss and the Individual Recovery Plan:
Oh the Places You’ll Go!
By: David Baker, LPC
Clinical Director
Georgia HOPE

When I graduated from graduate school a friend of mine gave me the Dr. Seuss book “Oh the Places You’ll Go.”  Some of you may be familiar with this book. The book is about a character who is at the beginning of a journey and it emphasizes the destinations on that journey he will reach and the experiences he will have along the way. The story is all about moving forward even if there are experiences like the “slump” and the “lurch” or places like The Waiting Place and The Alone Place that create problems or slow our hero down. The point of the story is that the character is moving forward toward a positive (and even exciting!) destination. The story ends with the promised excitement of what you’ll see when you make it to the top of the mountain you’ve chosen to climb.

Our job in working with clients is to help them identify the destinations they want to reach – the “mountains” they want to climb. Think of a time when you were planning a vacation or trip to somewhere. Usually when we do this we are thinking about the destination we want to reach – Bora Bora, Destin, the Smokey Mountains. Usually we aren’t just thinking about what we are getting away from. Ok, sometimes we are thinking “I just want to get away from it all” – work pressures, family pressure or some other discomfort. But we usually have a picture in mind of where we want to be instead – walking on a beach in Maui, sitting on your deck with a cool breeze blowing, curled up on the couch reading a great book, climbing a mountain with a Dr. Seuss character.

The role we can play with our clients is to help them identify those mountain summits they want to reach in life.

The role we can play with our clients is to help them identify those mountain summits they want to reach in life. They’re not usually physical mountains. Sometimes the “summit” is being able to get to the end of the day and say I’m proud of something or many things I did today. Sometimes it’s being able to say when I felt myself getting anxious today I knew what to do to return to my chosen sense of calm and peace. Sometimes it’s being able to say when I thought about the loved one I lost I was able to remember something positive about them and smile instead of breaking into tears. So while it may be very important for little Johnny to stop having temper tantrums at school or Sally to stop injuring herself when she feels afraid or anxious, it’s also just as important to help Sally and Johnny identify what they want instead. Maybe Johnny’s and Sally’s mountain to climb is developing a comprehensive sense of safety that they can call on when times are difficult.

Some mountains may seem big and some may seem small, but the thrill of getting to the top is usually the same and you almost always have a better view. Sometimes getting to the top of a small mountain gives a view of the next mountain you want to tackle. Not everyone wants to reach the same mountain top and not everyone climbs the same mountain the same way. So as tempting as it is for helpers like ourselves to think “I know the way to go and I’ll tell you how to get there” it’s probably more helpful for us to help our clients decide where they want to go and then help them decide what way there works best for them. Then our job is to simply cheer them along the way to the places they want to go.

So as tempting as it is for helpers like ourselves to think “I know the way to go and I’ll tell you how to get there” it’s probably more helpful for us to help our clients decide where they want to go and then help them decide what way there works best for them.

So the next time you look at or write an Individualized Recovery Plan see if it passes the Dr. Seuss test. Is it about “Oh the Places you’ll Go”? Do the “mountains” it identifies for climbing look exciting and positive? Or is it only about staying out of the “slump” or avoiding The Alone Place? And does it sound like something that your client thinks would be a good place to get to instead of the “slump” or The Alone Place? If it doesn’t pass the Dr. Seuss test, than have your client help you change it! As important as it is to prepare for the “slumps” and to know what to do about the “Alone Place”, it’s equally important to decide where you want to be once you get beyond those places. Our job as helpers is to keep that phrase in the back of our minds and to keep reminding our clients of it – “Oh the places you’ll go!”