Working with Non-Compliant Clients: A Stages of Change Approach for Engaging Clients in Treatment
Jeremy M. Linton, PhD, LMHC, LCAC
Associate Professor
Director, IU South Bend Community Counseling Clinic<
Counseling and Human Services Department, School of Education
Client non-compliance in counseling has long been discussed in the literature (e.g, Miller & Rollnick, 2012). This is especially true in the areas of addiction, assaultive behaviors, and extrinsically motivated reasons for seeking treatment (Lee, Sebold, & Uken, 2003; Linton, Bischof, & McDonell, 2005). There are, though, many other explanations for client non-compliance with counseling interventions. In this article, client non-compliance in counseling is conceptualized and methods for working with that non-compliance are discussed. First, client non-compliance is defined as it pertains to participation and follow-through with treatment recommendations. Following this, suggestions for addressing client non-compliance in counseling are offered. These discussions are framed within Prochaska and DiClemente’s (1984) Transtheoretical model, also known as the Stages of Change approach. These suggestions will focus on techniques for use by counselors designed to increase client compliance with treatment. A case vignette is provided to enhance this discussion.
Client Non-Compliance
For the purposes of this discussion, a non-compliant client is any individual who has been offered treatment options for a condition or diagnosis but is unmotivated to follow-through with those options. Clients’ non-compliance with treatment may arise for a variety of reasons, including certain qualities of the treatment process, personal or cultural bias, lack of knowledge about treatment, low motivation, depression, hypochondriasis or issues stemming from the manner in which treatment is introduced (Maschauer, Fairley, & Riha, 2017). Additionally, non-compliant clients may desire change but may be ambivalent about the counselor’s ability to help with their concerns. It is important to note that the non-compliant client is different from the resistant client. While the resistant client can be defined as an individual who is “unwilling or opposed to change” (Gladding, 1997, p. 385), the non-compliant client may simply lack the motivation and/or knowledge to engage in change activities.
The following case vignette illustrates client non-compliance:
Jon’s scheduled an appointment with his primary care physician (PCP) at the request of his wife. At his initial PCP appointment Jon described feelings of agitation, fatigue, and depression. Jon also reported a loss of appetite, increased alcohol use, and isolation from co-workers, family, and friends. While Jon did not readily acknowledge these symptoms as a problem, he did note that his wife was becoming more and more worried about his behavior and tired of his constant changes in mood. Because of these symptoms, Jon’s physician diagnosed him with depression and wrote him a prescription for an anti-depressant. Jon was not thrilled about this course of treatment and only took his medication sporadically. When discussing his non-compliance with medication therapy, Jon indicated that he simply could not remember to take it on a regular basis because it “didn’t work.”
As a result of his non-compliance with medication, Jon’s PCP suggested that he seek out counseling. Jon was not happy about this idea either but his physician told him that this would be the next intervention that they would try before considering any other forms of treatment. Since Jon desired to address his symptoms for the sake of his marriage, he decided to attend counseling.
During his counseling intake session Jon stated that he did not believe counseling could help him. Jon reported that his negative perceptions about counseling came from friends’ descriptions of the process and media portrayals of counselors as “touchy-feely know it alls.” After the intake interview, Jon sat back in his chair and said to the counselor in a cynical tone, “Okay, do your magic.” At his second counseling appointment Jon and his counselor completed a treatment plan to address his presenting symptoms. Jon missed his third appointment and did not reschedule.
This vignette clearly illustrates several important aspects of client non-compliance. First, Jon was unsuccessful in his attempts to take medication to address his depression because of a perceived lack of effectiveness. This was noted by his PCP as non-compliance with treatment. Second, Jon was referred to counseling but did not follow-through beyond the first two session, which can also be described as non-compliance. In fact, as described in the vignette, the client appears to have only sought counseling as a way to appease his wife. Finally, the client’s non-compliance, as presented in the vignette, stems from inaccurate perceptions of the mental health counseling field and lack of knowledge on how counseling could help. The case of Jon will be revisited below as a way to demonstrate methods for addressing client non-compliance.
Reconceptualizing Non-compliance
As mentioned, the reasons for client non-compliance are many. In a major study of patient non-compliance, Krousel-Wood, Kegan, Whelton, and Lahey (2014) identified 6 “hidden motives” behind patient non-compliance with treatment interventions for chronic disease. These were to: (a) avoid interference with other priorities, (b) avoid losing control, (c) avoid a negative identity, (d) be one’s own doctor, (e) keep an arm’s length relationship to the medical establishment, and (f) avoid unpleasantness. All of these reasons, along with a multitude of others, can have a negative impact on the effectiveness of treatment interventions.
Prochaska and DiClemente’s (1984) Transtheoretical Model, also known as the Stages of Change, may help to understand client non-compliance. This widely accepted model has been used to study many phenomena including addiction, weight loss, exercise, and follow-through on New Year’s resolutions (Ahmed, Horwath, & Bernard, 2017; Garcia & Benavidez, 2016;
Johnson, Fallon, Harris, & Burton, 2013; Mastellos, Gunn, Felix, Car, & Majeed, 2014; Prochaska & Norcross, 2003; Reed, Pritschet, & Cutton, 2012). The effectiveness of this model has been established in the literature (e.g, Norcross, Krebbs, & Prochaska, 2010). The theory conceptualizes change as occurring in a five stage sequence with clients falling into one of the five stages at any point in time based on thoughts, behaviors, beliefs, and other related factors.
The first stage of Prochaska and DiClement’s (1985) Transtheoretical model is precontemplation. In this stage, clients are either unaware of the need for or lack the desire to change. In the second stage, labelled contemplation, clients are ambivalent about change; sometimes they see the need for it and other times they don’t. Following contemplation is the planning or preparation stage. Here, clients have accepted the need for change and have begun creating plans for the change process. It is important to note that clients in the planning stage do not have to commit to any of the plans they develop; they are simply thinking of ways to make change occur. After the preparation stage clients enter the action stage of change. As the name implies, clients in the action stage begin to engage in their planned change activities. It is during this stage that actual behavioral changes occur. Finally, in the last stage of change, maintenance, changes clients made in the action stage become part of their daily life. In essence, clients have created a new lifestyle where the presenting problem is now absent or greatly reduced for six months or more (Prochaska & DiClemente, 1984; Prochaska, Redding, & Evers, 2013).
Important to the process of counseling from the Transtheoretical model is the idea that clinician must match their counseling interventions to the client’s stage of change (Center for Substance Abuse Treatment, 1999; Prochaska & DiClemente, 1984; Prochaska & Norcross, 2003). In fact, the “mantra” of the Transtheoretical counselor is, “different interventions for different times.” For example, a clinician working from the model with a client in the precontemplation stage would not address ideas for client actions. Clients who do not see the need for change likely are not ready to try new things to address a problem and the clinician may therefore be frustrated with the client’s non-compliance with clinical interventions. The concept of matching a client’s stage of change will be further delineated in the case discussion below.
It is important to note that, while the Transtheoretical model of change is linear in nature, it is not unidirectional. Ideally clients progress through the stages in a forward motion until they reach maintenance. However, while engaging the change process clients may regress to previous stages based on circumstance, motivation, or other factors. For example, in the case study above, Jon could be described as being in the contemplation stage when it comes to taking his prescribed medication. As time progresses, Jon may decide that he doesn’t really have a problem worthy of medication therapy and thereby regress to the pre-contemplation stage. Likewise, Jon may find himself in the action stage and having little success in implementing his plan. Accordingly, he may regress to the preparation stage to develop new plans to be implemented into action.
Addressing Client Non-compliance
Having now defined non-compliance and a method for conceptualizing it, the discussion will turn to ways to address non-compliance in in counseling. These methods include assessing client motivation, addressing Stages of Change, and implementing interventions consistent with clients’ stage of change (Prochaska, Redding, & Evers, 2013). The case of Jon will be used to discuss these techniques and approaches to working with non-compliant clients.
Working with the Stages of Change
The first step in working with non-compliant clients is to assess their motivation and determine their stage of change (Prochaska, Redding, & Evers, 2013). Below, each stage of change is outlined as they related to Jon’s case. The discussion will proceed as if Jon is working his way through the Stages of Change and specific ideas for aiding clients in this progression will be offered. Within each stage interventions to be avoided will also be discussed.
Precontemplation
As noted, in the precontemplation stage, clients do not acknowledge a problem or see a need for change. Jon exhibits low motivation to engage in counseling as well as non-compliance with his PCP’s treatment directives. In addition, Jon only presented for treatment at the request of his wife and does not appear to be intrinsically motivated to seek treatment. Accordingly, with regards to his motivation to engage in counseling, Jon can be firmly placed into the precontemplation stage of change.
Rather than the elimination of the presenting problem, or in this case the problem that the client was referred for, the goal for the counselor and client in any stage of change is to move their client to the next stage. Consequently, the counselor in this case should focus on moving Jon to the contemplation stage of change. The initial case presentation illustrates how the counselor did not match the client’s stage of change. While Jon was steadfastly precontemplative, the counselor worked in the second session to create a treatment plan, which is an intervention best suited for the planning stage of change. Not surprisingly, because the counselor suggested plans for change to a client who did not see a problem, Jon did not report for his third counseling session.
Several interventions are suggested to help clients move from precontemplation to the contemplation stage (Center for Substance Abuse Treatment, 1999; Prochaska & DiClemente, 1984; Prochaska & Norcross, 2003; Prochaska, Redding, & Evers, 2013). The three interventions mentioned most in the literature are (a) consciousness raising, (b) environmental re-evaluation, and (c) emotional arousal. Consciousness raising involves educating the client on their symptoms and situation. Environmental re-evaluation pertains to taking a look at the environment surrounding the client and taking in feedback that the client is getting from that environment. Finally, emotional arousal includes interventions to get the client to emotionally engage with their presenting symptoms in hopes of getting them to break through any cognitive barriers pertaining to their unacknowledged problems.
With regards to the case, Jon presented for a third counseling session after being contacted by the counselor. At the start of the session the counselor apologized to Jon for any miscommunication that may have occurred in the first two counseling sessions. The counselor then set out to engage Jon in a way that moved him to the contemplation stage. The first intervention used with Jon was to provide him with some education and reading materials on depression (consciousness raising) with the goal of getting him to at least consider that he might have some symptoms of depression. The counselor also engaged Jon in a discussion about his wife’s perceptions of his behavior and her concern for his wellbeing (environmental re-evaluation). Here the goal was to get Jon to consider another point of view. Lastly, the counselor had a discussion with Jon about his level of trust with his wife and what might happen if she didn’t see any changes in his current behavior. To do this the counselor engaged Jon in a role-play discussion where Jon played his wife and the counselor adopted the role of Jon (emotional arousal). The motivation behind this intervention was to get Jon to see the potential outcomes of not acknowledging and getting help to alleviate his symptoms. At the end of the third session Jon stated that he would at least consider the thought that he was experiencing symptoms of depression and agreed to seek out further information on the symptoms of the disorder.
Contemplation
In the contemplation stage of change clients begin to consider the idea that they have a problem. Sometimes they believe they have a problem and other times they believe they don’t. Following his third appointment Jon began educating himself on the symptoms of depression. In addition, he had a long discussion with his wife about his symptoms and discussed his trust in her judgment. After reading several items on depression and having these discussions with his wife, Jon began to question his initial assessment of his situation. While there were times when Jon began to believe that he had a problem with depression, there were other points of his day where he thought any discussion of him having depression was “crazy talk.” Jon’s ambivalence about his potential problem is the hallmark characteristic of the contemplation stage (Center for Substance Abuse Treatment, 1999; Prochaska & DiClemente, 1984; Prochaska & Norcross, 2003).
From the Stages of Change perspective the goal of the counselor with clients in the contemplation stage if to engage them in a way that will resolve clients’ ambivalence and help them settle on the idea that they do, indeed, have a problem. The overall plan here is to engage clients in such a way that will move them to the preparation stage of change. Interventions designed to move clients to the planning stage include (a) self-reevaluation, (b) dramatic relief, and (c) decisional balance.
During Jon’s fourth counseling session the counselor began to engage Jon in a way that would resolve his ambivalence. Building on the interventions from the previous session, and Jon’s progress to the contemplation stage, the counselor utilized several in session techniques. The first of these was to assist Jon in engaging in some self-reevaluation. Here the counselor talked to Jon from the side of his ambivalence indicating that he did, indeed, have a problem. Role play was utilized wherein Jon played himself from the perspective of “I do have a problem with depression” and the counselor taking the position of Jon stating, “I do not have a problem.” Following this, Jon and the counselor continued the discussion taking the perspective that a problem with depression does exist and talking about what would happen if his symptoms would dissipate (dramatic relief). For example, Jon identified that his wife would be happier if his mood and behavior changed which would give him relief from his worries about upsetting her. Finally, the counselor led Jon through a decisional balance exercise where he developed a list of positive and negative aspect of change and positive and negative aspects of not changing (Miller & Rollnick, 2012). At the end of the fourth session Jon was instructed to have another discussion with his wife about the possible effects of him changing and to spend the next week further developing his decisional balance list.
Planning
In the third stage of change, planning, clients have resolved the ambivalence from the contemplation stage and readily acknowledge that they do have a problem. Jon presented to his fifth session having resolved his ambivalence. He developed a new perspective on his problem and readily embraced that he struggled with symptoms of depression. This admission placed Jon resolutely in the planning stage of change.
While in the planning stage clients and counselors work to develop a treatment plan for addressing the newly embraced presenting problem (Center for Substance Abuse Treatment, 1999; Prochaska & DiClemente, 1984; Prochaska & Norcross, 2003; Prochaska, Redding, & Evers, 2013). The goal of this stage is to help clients agree on a plan for change and to move them to the action stage of change. Techniques involved here include, (a) brainstorming, (b) self-liberation, and (c) counterconditioning.
During the fifth counseling session the counselor started by describing the brainstorming process to Jon. The counselor explained that their task in brainstorming was to generate as many options as they could for addressing Jon’s symptoms of depression without evaluating or committing to any of the ideas that were created. Following brainstorming, Jon and the counselor evaluated the options they developed and came up with a specific list of things that Jon could do to relieve his depressive symptoms (self-liberation). Finally, Jon and the counselor developed a list of alternative actions that he could take that ran counter to behaviors he engaged in while experiencing depression (counter-conditioning). At the end of the session Jon was instructed to take the ideas and lists generated during the meeting and to add any other items that may arise during personal reflection. Some of the ideas Jon included on his plan were to discuss the strategies he developed with his wife, continue to evaluate some of the items included on the plan, make another appointment with his primary care physician to discuss his depressive symptoms, and exercise.
Paramount to the planning stage is insisting that clients do not commit to any of the strategies they create during the stage. Suggesting that the client follow through on these strategies is better left for the action stage. Creating a plan may lead to anxiety as clients think about actually following through on the ideas they have generated and experiencing this anxiety may be enough to drive them backwards to a previous stage. Therefore, it is imperative that counselors do not push clients to follow through on their plans until they are ready.
Action
Clients embedded in the action stage of change present as ready to engage in the plans that they created in the previous stage of change. In the author’s experience, it is not uncommon for clients to reach the action stage between sessions and to begin acting on the items that they created in their plan prior to meeting again with their counselor. With regards to Jon, by the time of his sixth session he had joined a gym that was close to his house and scheduled an appointment with his PCP.
When working with clients in the action stage counselors should support their clients’ new behaviors and engagement with their plan. In essence, counselors are working with action stage clients to help them maintain their motivation and enhance the plans that they are fulfilling. Techniques utilized here include: (a) stimulus control, (b) reinforcement management, and (c) helping relationships.
During the action stage Jon and his counselor refined the plan to include methods for avoiding any situations or circumstances that might trigger his symptoms of depression (stimulus control). Some ideas here were limiting sleep to seven hours per day and making sure to take his medication once it was re-prescribed by his PCP. Second, Jon and his counselor decided to create a rewards system by which Jon treated himself to a desired item after following through on his exercise plan (reinforcement management). Lastly, Jon and his counselor identified helpful people and institutions he could seek out should his symptoms of depression emerge (helping relationships). Some of the supports Jon identified were his wife, best friend of 20 years, and counselor. Jon was also thinking about joining a depression support group. Jon attended two more sessions during which he and the counselor continued to work on the actions he was taking and refined his plan as necessary. Jon terminated counseling after his eighth session and agreed to seek out help from the counselor if needed.
Maintenance
In the final stage of change, maintenance, clients have been living either symptom free or with drastic improvements in their presenting issues for a time period of six months or more Prochaska, Redding, & Evers, 2013). In Jon’s case, the counselor conducted a routine six month follow-up to assess his progress. Jon was still enjoying greatly reduced symptoms of depression and reported that he and his wife were happy with the outcomes of his treatment.
Interventions for use with clients in the maintenance stage are similar to those used during the action stage of change. During the follow-up phone call with Jon, the counselor encouraged him to keep seeking out social supports (helping relationships) and work on diversifying his reward system for exercise (reinforcement management). Termination of counseling was confirmed but, true to the helping relationship technique, Jon agreed to seek out counseling as needed.
Conclusion
In conclusion, client non-compliance with counseling continues to be an issue affecting counseling outcomes (Miller & Rollnick, 2012). There are many reasons for client non-compliance and engaging clients where they are “at” in terms of their problem can be an effective tool for addressing non-compliant behaviors. One such model is Prochaska and DiClemente’s Transtheoretical Model of the Stages of Change. While this article serves as a brief summary of the Transtheoretical approach, readers are encouraged to consult the references used in this article to learn more about this long standing and effective model of counseling intervention.
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