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Why Engaging with Carees Helps Healing

Mike Mackniak - July 03, 2017 01:00 PM

It is a well established tenet of Social Work and Human Services Practice, and indeed, is a basic principal in all courses of human interaction that rapport need be established in order to build and maintain any type of meaningful relationship. Barriers to rapport are many and varied. Likewise, establishing rapport has many different techniques and best practices (Hepworth, 1997). Nonetheless, engagement on a level that is comfortable to the individual is of paramount importance to the work of the social services fields.
In their comprehensive work on engagement O’Brien et al determined the following as possible barriers to engagement:

Gender – women tend to engage more than men
Age – young people seem to be harder to engage and more likely to drop services
Ethnicity – minorities tend to engage less with mental health services
Dual Diagnosis
Insight into illness
Stage of illness – “the most frequent outpatient appointment not attended is the first one”  (p 563, 2008)
Attitude/experience of caregivers
Low Income
Low social class
Lack of Health Insurance
Social deprivation
Living alone, separated, divorced, without family
Lack of communication skills or tools
Forensic History
Borderline Personality disorder is over-represented (40%) (Schizophrenia is actually the opposite especially if engaged within 6 months)

The term rapport, or more commonly “engagement”, has many definitions and can be quite subjective when viewed on a case by case basis. Indeed, a simple nod or smile may be a huge leap for one client while a friendly lunch or cup of coffee may be engagement in the mind of another. To be sure, engagement goes far beyond medication compliance, telephone conversations or allowing a caseworker into one’s home.

It can be agreed however that engagement encompasses all of the terms and concepts we commonly recognize in the therapeutic setting and more. Importantly, we should consider engagement based upon the willingness of a client to work on clearly identified goals along with a caseworker, counselor or other professional. Interestingly, the strong therapeutic relationship described herein is not only helpful in generating engagement, but, is also a by-product thereof.  (M. Gillespie et al, 2004) Here we see that engagement is not only a process but, must also be seen as a service provided (O’Brien et al, 2008). Still, it is common for one to be “engaged” as part of a process but maintain ill feelings toward the therapist or professional or the entire service system. Thus, a better working definition of engagement may be taken from O’Brien et al:

“[it] is a more complex phenomenon encompassing factors that include acceptance of a need for help, the formation of a therapeutic alliance with professionals, satisfaction with the help already received and a mutual acceptance and working toward shared goals” (p559, 2008).

In defining engagement, O’Brien et al recognize that “physical presence or attendance is necessary” to the process but, is clearly not the only element to the service associated with engagement. (p559, 2008)

O’Brien et al recognize the need for metrics to discern the appropriate level of engagement among and within certain demographics (2008). Some may have more socio-economic reasons for not engaging or dis-engaging while others may be experiencing clinical factors or socio-demographic factors which preclude engagement. Significantly, many may be experiencing the manifestations of their particular illnesses when they “choose” not to engage. In any event, “engagement is one of several ESSENTIAL components identified in case management approaches” ( A. Paget et al., p74, 2009).

Indeed, engagement or lack thereof has been cited as an indicator of the likelihood of involvement with more intensive services to include criminal involvement and hospitalization. Effective, early engagement has been found to indicate a likelihood of continued participation in therapy, mediation compliance and longer periods of stability. ((Gillespie et al, 2004) Further, engagement has been shown to increase over time and can remain stable for many years – clearly an important factor when, as discussed, the relationship and “service “ of engagement acts as a foundation for many other therapeutic approaches and interventions (A. Paget et al, 2009 ).


In a Recovery oriented system of care it is quite easy to say that an individual refuses to “engage” and, therefore, we can not, should not or, will not provide him/her with services. However, based upon the above cited research, this attitude is contrary to the terms of recovery as we have defined them. We must approach engagement as an integral piece of recovery. In other words recovery is not a by-product of engagement and neither is mutually exclusive of the other. For, not to engage is, by its very definition, the withholding of a service as much as it is the failure of a process. The evidence is quite clear that to withhold services from those most at need can have dire consequences to our constituents, our stakeholders and to the social return on investment we have made in our human service delivery systems.
Cited Sources

Gillespie, Morna et al, Clients’ engagement with assertive outreach services: A comparison of client and staff perceptions of engagement and its impact on later engagement, Journal of Mental Health, 2004.
Hepworth, dean H., Ronald H. Rooney, Jo Ann Larsen, Direct social work practice, theory and skills, 5th ed., Brooks Cole Publishing co., Pacific Grove, 1997.          
O’Brien, Aileen, Rana Fahmy, Swaran P. Singh, Disengagement from mental health services, Social Psychiatry & Psychiatric Epidemiology, 2008.
Paget, Andrew, Alan Meaden & Catherine Amphlett, Can engagement predict outcome in Assertive Outreach, Journal of Mental Health, 2009.

Michael Mackniak is an attorney, innovator and strategist. As a consultant for caregivers, decision-makers and fiduciaries, he is the nation’s foremost speaker on the value of interrelated service systems and developing efficient methods for delivering resources to our most at need populations. Michael lectures across the United States demonstrating the effectiveness of proactive planning and avoiding costly interventions. To learn more about Michael, please visit

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