Learning Objectives
By the end of this section, you will be able to:
- Describe client engagement in mental health care
- Discuss how client engagement improves outcomes and promotes recovery
- Describe challenges to and strategies for improving client engagement
According to NAMI (2016), 70 percent of people who start mental health-care treatment drop out after the first or second visit. The initiation of a therapeutic relationship and the degree of support that the client feels during the first interaction with a mental health professional can determine the client’s level of engagement in the recovery process.
Client Engagement in Mental Health Care
Compliance is the term frequently used when discussing people following their mental health treatment plan. Adherence is a more positive and appropriate term because it does not imply a power imbalance in the clinical provider-client relationship. Alliance is an even better term, focused on recovery and the team approach of client and clinician. Engagement is actually the best term in that it describes the client and the health-care team participating together in the services provided (NAMI, 2016). Client engagement includes having the client at the center of the treatment decision-making process and working in collaboration with the health-care team (Graffign & Barello, 2018). There are factors that can impede an individual’s ability to engage with the health-care team. These include: “age, ethnicity, level of education, level of income, personal dispositions and beliefs about the patient’s role in managing health care” (p. 1262), as well as the nature of the disease, the details of the therapeutic regimen, and culture. The health-care team should review all of these factors in an effort to have the most information as they collaborate with the client in planning their care.
Engagement Defined
NAMI’s (2016) definition for engagement is the “strengths-based process through which individuals with mental health conditions form a healing connection with people that support their recovery and wellness within the context of family, culture and community” (p. 6). This definition shows belief in the person, beyond symptom management.
Theories Related to Client Engagement in Mental Health Nursing
Nurses base their care on theories that help guide their knowledge and practice. Nursing theories provide a framework for nurses to understand the how, what, and why of their professional role (Wayne, 2023). There are three types of nursing theories: grand theories, middle-range theories, and practice-level theories (Wayne, 2023). Grand theories provide a broad overview for a general nursing framework. Middle-range theories focus on a particular nursing phenomenon. Practice-level theories are those that are used to form interventions and outcome planning in specific client populations.
As described previously, Hildegard Peplau is a very important part of the process of client engagement. Her theory of interpersonal relations helps nurse to understand the importance of the nurse-client relationship. In psychiatric nursing, this is especially critical as that relationship is what guides practice. Imogene King also had a theory related to the development of the nurse-client relationship. Her theory of goal attainment was based on the nurse and client working together to set goals and the nurse being there to help the client attain those goals (Wayne, 2023). Her theory includes three interacting sections—personal system (perception and self-growth), interpersonal system (interaction and communication), and social system (organization, authority, and decision-making). And Prochaska’s transtheoretical model, or stages of change model (see 5.1 Psychiatric-Mental Health Treatment Settings) is focused on the decision-making of the individual and how it occurs in a cyclical manner (LaMorte, 2022). All of these theories help a nurse to assess a client’s ability and level of engagement in care.
McAllister et al. (2021) suggest that nurses and other practitioners use the five techniques of the principles of engagement model: “(1) understand the person and their illness; (2) facilitate growth; (3) therapeutic use of self; (4) choose the right approach and; (5) emotional versus restrictive containment” (p. 2). This model was derived from the behavior change theory with the idea that client and provider engagement is influenced by “capability, opportunity and motivation to engage” (Celestine, 2021, p. 2). Nurses need to be able to determine how capable the client is of making a change, if they have the opportunity in their environment to make the change, and whether or not they have the motivation to perform the change. These components are important in helping a client to change their behavior, thus increasing their engagement.
Client Engagement Improves Mental Health Recovery
According to SAMHSA (n.d.-a), the definition of recovery is a “process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential” (para 2). For recovery to work, the process for achieving it must be appropriate to the individual’s age, culture, and stage of life. As discussed in 6.3 Peer Support, peer support is a key component of client engagement in the recovery process. The support and understanding that someone else has had the same experiences assists the individual to engage in treatment choices that are right for them, where they are. Collaboration between the client and the health-care professionals is considered a foundation of recovery because of the trust formed in this relationship as everyone works toward the same goals (Ness et al., 2014).
Reduction of Stigma
A stigma is a cluster of negative attitudes and beliefs that motivates the general public to fear, reject, avoid, and discriminate against people with mental health disorders (Substance Abuse and Mental Health Services Administration, n.d.-b). The general public, relatives of those with mental illness, and even health-care professionals can possess stigmatizing beliefs and attitudes (Zamorano et al., 2023).
Nurses and other health-care professionals need to look for ways they can help to reduce the stigma surrounding mental illness. Zamorano et al. (2023) identified that there are higher levels of stigma in general nursing and medical practice than in psychiatry, and that this resulted in poorer client outcomes, including higher mortality rates. Having contact with people who have mental health concerns actually is one of the best ways to lower stigma. Interactions with people with mental health diagnoses allow nurses to understand and have empathy for the person, seeing beyond the symptoms. It also provides evidence for recovery and hope for people with mental health conditions. Education and training are other effective tools.
Improved Client Outcomes
The World Health Organization (WHO) defines interprofessional collaborative practice as multiple health workers from different professional backgrounds working together with clients, families, caregivers, and communities to deliver the highest quality of care (World Health Organization, 2010). Effective teamwork and communication reduce medical errors, promote a safety culture, and improve client outcomes (AHRQ, 2015). The importance of effective interprofessional collaboration has become even more notable as nurses advocate to reduce health disparities related to social determinants of health (SDOH). In these efforts, nurses work with people from a variety of professions, such as physicians, social workers, educators, policymakers, attorneys, faith leaders, government employees, community advocates, and community members. Nursing students must be prepared to collaborate interprofessionally after graduation (National Academies of Sciences, Engineering, and Medicine, 2021).
Strategies for Improving Client Engagement
Early intervention is one strategy for increasing client engagement (Becker et al., 2017) because if clients are part of the entire process from the start, they will be more likely to understand the nuances of the options and be central to the decision-making process. Moreover, in a study completed by Becker et al. (2017), the most important client points identified that would lead to them having a higher level of engagement were twenty-four-hour crisis services, having a variety of treatment choices, involving family/support people, and availability of addiction services. One intervention that has been studied and found to increase client engagement in mental health care is protected engagement time (PET) (McAllister et al., 2021). PET encourages nurses and other health-care professionals to set aside a specific amount of time to spend engaging with their clients in inpatient units. Research by Ness et al. (2014) found that consumers want their health-care providers to take the time and effort to know them by showing their availability.
One example of a strategy used to keep young adults engaged in their mental health treatment is called “Just Do You.” This intervention includes two 90-minute sessions with a licensed clinician and a peer recovery role model (NYU, 2022). The sessions are interactive with music, visual arts, psychoeducation, and peer mentorship. Its design empowers youth in making informed decisions about their mental well-being (Narendorf et al., 2020).
REACH Model
During the assessment phase of the nurse-client interaction, nurses must ask open-ended questions about the client’s level of engagement. Do not make assumptions about why clients may seem disinterested in pursuing further treatment. Becker et al. (2021) suggest that providers often project the blame onto client factors instead of realizing the problems may be attributed to their own lack of performance in developing a therapeutic rapport. The REACH model is one that practitioners can use to assess the level of engagement in their clients. There are five parts to this treatment model: relationship, expectancy, attendance, clarity, and homework (Becker, 2021). A trusting therapeutic relationship should be the basis of interactions with clients. What is the expectancy of the interaction? Is the client attending their appointments? Does the nurse ask the client or caregiver to state their understanding/clarity of what is going to happen in treatment? Is the client completing homework or participating in the treatment sessions? Awareness of and meeting each of these steps helps determine the likelihood and strength of engagement.
Barriers to Client Engagement
Some barriers exist that reduce client engagement in their mental health recovery. A barrier is anything that blocks the ability of an individual to get the care that is appropriate for their needs. According to NAMI (2016), barriers include outdated policies and procedures, lack of care coordination, negative treatment of people in mental health crisis, lack of respect from the providers, high caseloads, and following very rigid rules when treating a person in crisis. Additional barriers include turnover of providers, lack of transportation, cost of care and treatment, scheduling difficulties, school, work, and implicit bias (Becker et al., 2021). These barriers can make it difficult for clients to access providers in a timely manner, or to be able to continue with a provider once a relationship has been established.