How to achieve client compliance (Proceedings)

One of my dear friends and colleagues – a veterinary cardiologist – often teases me that behavior can't really be that hard: a behaviorist's work rarely exceeds the advice to add another litter box. While it's true that implanting a pace maker is more impressive than 'adding a litter box', I like to emphasize that I'm able to keep more pets in their families and alive when we compare our case outcomes. This hasn't always been the case. Even if I was sure that I had the correct diagnosis and set up a well-designed treatment plan, including elaborate behavior modification programs, medications, and management recommendations, cases often failed to improve and many of my patients we surrendered, rehomed or euthanized. What went wrong?

I did what I was trained to do in vet school and during my specialty training. I gathered the information needed to diagnose, came to a diagnosis, recommended what I thought would best alter the problem, and sent the client home with explanations of the causes, behavior modification programs, and medications, assuming that they would implement the changes immediately.

But we all know that client compliance is an issue. Some owners fail to give antibiotics for the recommended number of days. Others may buy an expensive exclusion diet and still continue to feed treats. And few clients will really add another litter box (in the few cases in which I actually recommend it), especially if I ask to place the open box on the main floor of the house instead of the basement. More commonly, I see clients discontinuing abruptly the urine marking cat's prescription for fluoxetine despite my warning that this will lead to a relapse. Why?

We fail to develop treatment plans with the client. Instead we unilaterally create a tool and expect that it 'fits'. But because we are not trained to listen, to take into consideration a client's circumstances, their needs, strengths and limitations, the plan often won't work out. Clients are overwhelmed, not convinced, and provided with information that may not answer their questions or meet their needs.

"Dead end' communication takes place everywhere every day. To communicate effectively, it is essential to assess the client's motivation, her environmental system, physical environment, values, strengths and limitations. Based on these factors, the provider and client develop jointly (!) goals and formulate a 'contract'. This process requires that we explore and understand the client's reality and accept his or her 'framework' as it sets the stage for our work and the development of a plan that is completed jointly.

In many cases, we ask our clients to change their ways, adapt new strategies, and adjust their interactions with their pet. Clients are at different stages of readiness to make changes. Interactions must be non-judgmental, non-confrontational and non-adversarial. If a goal is set jointly, the client is part of the solution, is emotionally invested, and bought into the plan based on explicit and measurable terms.

Strategies focus on client's awareness of the potential causes, the resulting problems, consequences experienced, and risks faced as a result of the behavior in question. It is imperative to help clients think differently about their behavior as well as the behavior of their pet and ultimately to consider what might be gained through change.

The process relies of four simple principles: Express empathy to share your understanding of the client's perspective - Develop discrepancy to appreciate the value of change - 'Roll with resistance' and accept reluctance as it is normal in the process of change - Support client autonomy and self-efficacy

Empathy (don't confuse it with compassion) involves seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences. Expression of empathy is critical.

Your client, owner of an aggressive dog, says: "I don't see how you people can help me. I have read articles on the internet and watched the Dog Whisperer. I have done everything and you won't come up with something else."

Respond to the client empathetically in one sentence and show him that you understand him (be prepared to share your answer with us).

When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. Knowing details about experiences in depth allows you to assess when and where they need support, and what potential pitfalls may need focused on in the change planning process. Importantly, when clients perceive empathy, they become more open to gentle challenges about issues and beliefs without creating resistance. Clients become more comfortable fully examining their ambivalence about change and less likely to defend ideas.

Don't fight client resistance, but "roll with it" and resist the temptations to challenge the statements demonstrating resistance. Instead, use the client's "momentum" to further explore the client's concerns and opinions.

"Why shouldn't I allow the dog on the couch?! He bites me when I pet him when he eats – not when he sleeps."

Again, please respond to the client in one sentence and be prepared to share your answer:

Using this approach, resistance tends to be decreased rather than increased, as clients are not reinforced for becoming argumentative and playing "devil's advocate". Encourage clients to develop their own solutions to the problems that they themselves have defined. Thus, there is no real hierarchy in the client-nurse relationship for the client to fight against. In exploring client concerns, you may invite clients to examine new perspectives, but do not impose new ways of thinking on clients. The motivation for change occurs when people perceive a discrepancy between where they are and where they want to be.

Clients need to understand that the interaction with their pet somewhat resembles a 'dance': they are dancing a 'Rumba' and will not get to a 'waltz' unless they change the music and lead, allowing the dog to follow the new 'rhythm'.