Increasing Engagement for AIM Clients

Background

“Motivation” is not the same as “Engagement” and sometimes clinicians inadvertently assign a value judgment and think of client as “unmotivated”. Engagement is probably a more valid and useful term and refers to a deliberate effort to work toward a goal of rehabilitation intervention. I like theLequerica and Kortte (2010) model for thinking about engagement during rehabilitation. According to these experts,the following factors are critical for productive engagement in the therapy process:

  1. Perceived need (client has to have an awareness of attention being a problem and be able to understand potential benefits of exercises)
  2. Positive outcome expectancies (client has to believe that exercises and program will be useful at improving attention and, if attention is improved, something important to them-such as doing better in school-will be impacted)
  3. Perceived self efficacy (client has to believe s/he is capable of doing the program as assigned.

So if an AIM client seems “unengaged” the first challenge is to figure out why. It may be due to the fact they don’t think they need the program. Perhaps they feel it won’t help or make a difference, or maybe they don’t feel they can do what they are supposed to do to complete the program. The Goal Attainment Process used in AIM is often a good indicator of which of these issues may end up lowering engagement.

If a client’s perceived need for program seems low, some up front brain injury education may be useful using some of the on-line videos/vignettes of kids talking about attention problems for those students that have awareness issues.

If client does not feel the AIM program will be useful, then the client may benefit from revisiting the Goal Attainment process. “We need to make sure that your effort is going toward something that is important to you. Let’s look at what you hope will get better by doing the AIM program”. Alternatively “vicarious experience” can be helpful for these issues. (Maybe I can make video of other students who have gone through the program. The point is that we have to help them link the program to things that are important to them.)

If the client has low self-efficacy, the clinician can figure out why. If discouraged by exercise performance, we may want to back up to easier, higher accuracy and boost confidence. If homework feels burdensome, we may want to look at scheduling or rewards.

Some general dos and don’ts

In general it does NOT help to “convince” client that program will be good for them. Verbal persuasion is rarely effective. Most of the “don’ts” have to do with convincing or pseudo scolding/reminding. We want to make sure we are not parental, but instead make the program be something the student wants. Below are some examples of how to do this depending upon which of the aforementioned three issues seems to be the core cause of the lack of engagement.

Affirming progress (but not over the top praise) that is tied to effort and engagement and that is varied can be helpful in increasing engagement.

“I can see you are tired today. It’s impressive you are here doing this when you’ve got a lot going on. Good job.”

“We’ve been increasing the difficulty level of your exercises. I’m impressed”

“How does it feel to see your scores improving?”

Reassuring when self-efficacy or performance is low can also increase engagement. Common examples I use:

“No worries, it was a busy week for you. Let’s just figure out when you can practice this week”

“The score doesn’t matter as much as making your brain work hard. You are doing the exercises and that’s what will make the improvements”

Using Humor and Clinician Engagement can be powerful. I try to ask myself—did I find a spark and make the session fun or at least interesting? Did I ask about events important to the student before and after the session and connect with the student? The idea is to build a therapeutic alliance so they want to come back and this may get them over the hump if there outcome expectations are wavering.

Techniques from motivational interviewing are often the most effective.

“Sounds like it’s important to you to get better grades. Would the AIM program be worth it, if it helped this?

“Let’s look at your goals again. Are these still important to you?”