What can you do when basic compliance fails?
In a previous blog, compliance 101, we discussed the basics for addressing non-compliance. Here we will go even further and try to provide tips for what to do when the basics fail. As usual, you first need to identify the reason for non-compliance. Then you can try to match and adapt any one of these strategies:
Sometimes deeper education is needed. Modeling in clinic is one way. Home / school visit is often another more effective one. Often you may find that not understanding what to do is merely an excuse for not being truly motivated to actually do. Educating about the rationale of the home program and direct relationship to the caregivers’ goals will then be more effective (Segal & Beyer, 2006).
Often handouts get left behind. Links to Pinterest boards stay in email boxes and paper handouts stay on the shelf, while real life situations happen in neither of these places. Sadly (or not…) most life experiences are accompanied and shared by our trusted selfie taker – the smartphone. Use that to get your assignments in the right hands at the right time. Families admire therapists who keep up to date with technology in their field (Blue-Banning, Summers, Frankland, Nelson, & Beegle, 2004).
Failure to match assignments to routines means no habituation of assignments. And without habituation, the assignments will not last for long. Identify what can trigger a new habit loop and what’s the reward of the habit. Try to match the reward of the routine (e.g. getting dressed) with the reward of the interventional activity (e.g. calm down). You can read more on how to create habit loops in therapy here.
Motivation fluctuates and may vary across caregivers. You can try to use motivational interviewing techniques to evoke motivation for change. For example, you can ask open ended questions that help envision better future and become motivated to achieve it. You can work in partnership with your client to resolve ambivalence, evoke change readiness and plan practical steps (Miller & Rollnick, 2012).
Start every session with a few minutes to review the compliance since last session. This is the single most important thing therapists can do to increase compliance (Bryant, Simons & Thase, 1999). You need to be consistent about this. Your consistency will be reflected in your clients’ consistency in complying. If you see they are not taking their homework assignment seriously, you should examine whether you are… If you don’t give up on reviewing their compliance together with them at every session, there is a good chance they will not give up on doing it!
If you are hearing complaints about the ‘fun’ element you can work on mutual enjoyment. Remind the parents that it’s not just about the child’s fun, it is just as much about their own fun. Help them choose activities they can personally enjoy (that are within scope of intervention, of course).
For some clients and caregivers control is paramount. If giving them a small sub-set of activities to choose from feels too confined, you can try a more family-centered coaching approach to therapy (Dunn, Cox, Foster, Mische-Lawson, & Tanquary, 2012). Coach caregivers to come up with their own contextual interventions and solutions.
If you hit a road block here, it most likely means you did not start small enough or you moved up the intensity curve too fast. It’s best to take a step back and look for quick-wins. Small achievements that may not be the ultimate therapy goal, but are desired enough by the caregivers, to be appreciated when achieved. Make sure to structure an agreeable and short term plan that cannot fail to achieve a very clear and measurable (even if small) target.
Bryant, M. J., Simons, A. D., & Thase, M. E. (1999). Therapist Skill and Patient Variables in Homework Compliance: Controlling an Uncontrolled Variable in Cognitive Therapy Outcome Research. Cognitive Therapy and Research, 23, 381-399.
Blue-Banning, M., Summers, J. A., Frankland, H. C., Nelson, L. L., & Beegle, G. (2004). Dimensions of family and professional partnerships: Constructive guidelines for collaboration. Exceptional children, 70(2), 167-184.
Dunn W., Cox J., Foster L., Mische-Lawson L., Tanquary J. (2012). Impact of a contextual intervention on child participation and parent competence among children with autism spectrum disorders: a pretest-posttest repeated-measures design. American Journal of Occupational Therapy, 66, p. 520-8. doi: 10.5014/ajot.2012.004119
Miller, W.R., & Rollnick, S. (2012). Motivational Interviewing, 3rd ed. Guilford Press. ISBN 978-1-60918-227-4.
Segal, R., & Beyer, C. (2006). Integration and application of a home treatment program: A study of parents and occupational therapists. American Journal of Occupational Therapy, 60(5), 500-510.
Oren Steinberg is co-founder of SensoryTreat, providing a carryover empowerment platform for pediatric therapists and caregivers of children with Autism and other developmental disabilities.