What if I Can't Schedule Clients within 48 Hours?

By BRENDA J. WRIGHT, NANCY J. SMYTH and ELAINE M. MACCIO

Published January 2001

How can an addiction agency reduce "no shows" if the intake can't be scheduled within 48 hours?

As we reported in our last issue, Stasiewicz and Stalker (1999) found that clients were more likely to keep their appointments if they were to be seen within 48 hours of their initial contact with clinic staff. Those whose appointments fell outside the 48-hour range, even with reminder phone calls and mailings, were less likely to show for their intakes.

While the research clearly indicates that the best approach is to schedule intakes within 48 hours of an initial call, in reality, this may not always be possible. So, what can be done then to combat the problem of reduced show rates? The subject of client motivation for change has received increasing attention in substance abuse treatment research and literature (Hester & Miller, 1995). It has been shown that brief interventions designed to increase motivation for change can improve subsequent treatment outcomes. Therefore, to improve initial engagement and retention, we are proposing two possible interventions that are based on "motivational interviewing principles" and "readiness for change."

Clients will contact a substance use treatment facility for primarily one of two reasons: they want to or they have to. In the former scenario, the client is said to be in the contemplative or preparation stage of change; in the latter scenario, they may still be in the pre-contemplative stage (Prochaska & DiClemente, 1979). 

In either case, reminding the client why he or she originally sought help reiterates the importance of the initial appointment. It's easier to disregard a priority after the crisis or precursory motivation has passed. Simply said, "out of sight, out of mind."

Developed by Miller and Rollnick (1991), motivational interviewing (MI) has become a staple in the repertoire of proven substance abuse treatment approaches. MI is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. MI aids in the transition of clients through the stages of change. Its basic principles are: 

Avoid argumentation 
Express empathy 
Support self-efficacy (support and encourage client's belief that change is possible) 
Roll with resistance 
Use the client's language and avoid labels like "alcoholic" and "addict" (unless the client already identifies with them) 
Develop discrepancy (motivation for change occurs when clients perceive a discrepancy between where they are and where they want to be)

Gather key motivational information on the phone and personalize reminders. 

Expand the initial call (or have a receptionist schedule a brief phone appointment with a counselor within the next couple of hours) to include the following questions: 

     "What happened recently that led you to call today?" 
     "What are the good things about your alcohol/drug use? What are the not so good things?" 
     "How would you like your life to be different right now?" 
     "In what ways would changing your alcohol/other drug (AOD) use help or hurt you in terms of meeting those goals?" 
     "In what ways would keeping your AOD use the same help or hurt you in terms of meeting those goals?" 
     "What will happen if your AOD use continues?" 

All of the above would be conducted within a framework of empathy, concern and supporting the client's ability to make their own choices. 

Follow-up 

Having gathered this information, it can now be included in a follow-up letter to remind a client about their appointment. Something simple such as, "I know some time has passed since you called-this often makes people wonder if they really need an appointment after all. Some of what you told me that made you think it would be good to take a closer look your AOD was: [list key information from the phone questions]." 

A letter that includes this personal, motivational information, while acknowledging possible client ambivalence, might be more effective at motivating the client to follow through with the appointment than the general, "one size fits all" letters that are usually sent. 

Have counselors conduct motivational sessions on the phone. 

Contact the client within a day or two of their call and utilize MI techniques that promote/maintain the client's desire to change. When coupled with the informational questions noted in Strategy #1, these techniques might be especially effective. If necessary, schedule a "booster" call before the intake appointment. 

Scenarios: 

The Mandated Client 

How do you help someone keep an appointment that he or she didn't want to make in the first place? Avoid argumentation and express empathy. 

Client: "I don't see why I have to go to counseling." (pre-contemplation) 

Staff: "I can understand-this probably isn't where you want to be. It doesn't make sense to you. Is it that others are complaining about your drinking/drug use?" 

Client: "Everybody blows my drinking/using out of proportion." 

Staff: "That must be difficult listening to what might sound like criticism. I'm wondering if you don't see yourself drinking/using as much as others see you." (reflecting) 

Client: "You've got that right." 

Staff: "Tell me why you think others have concerns about your AOD use." 

Client: "My wife is afraid that I might lose my job. She wants me to get into treatment and deal with my problems." 

Staff: "Your wife must care a lot about you and your future together to tell you something that she feels is important to you, knowing that you might get angry with her." (reframing) 

The Voluntary Client 

Even clients who seek treatment under their own volition might be reluctant to surrender their addiction. Support self-efficacy and roll with resistance. 

Staff: "It couldn't have been easy making this first call." 

Client: "I have to try something." (contemplation) 

Staff: "Have you tried before to cut down or stop drinking/using?" 

Client: "Yeah, but it never worked." 

Staff: "But that doesn't mean it won't ever work." 

Client: "Sometimes I'm not even sure I want to stop." 

Staff: "There are a lot of people who feel that way." 

Whether clients are mandated or voluntary, drinking and drug use has undoubtedly affected their lives in negative ways (as well as perhaps some client-identified positive ways). Their addiction is interfering with their ability to attain their goals. Develop discrepancy. 

Staff: "Is your life turning out like you thought it would?" 

Client: "No! I'd started college right after high school. That seems so long ago." 

Staff: "Has any part of drinking/drug use gotten in the way of your goals?" 

Client: "I guess I probably would have been able to stay focused more if I didn't drink/use drugs."

Like any effective counseling method, becoming skilled in MI requires some training and practice, although 
Strategy #1 would probably be easier to implement without much background. Here are some places where you can find out more about MI: 

1. Visit the following websites for more information: http://views.vcu.edu/vattc/courses/reh681/index/html and  http://www.motivationalinterview.org/clinical/philosopy.html
2. Request a copy of TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment, BKD 342, available from the National Clearing-house for Alcohol and Drug Information (NCADI), 800-729-6686, http://www.health.org/catalog/catalog.htm

Hester, R. K., & Miller, W. R. (1995). Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed.). Boston, MA: Allyn & Bacon, Inc. 

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York, NY: Guilford Press. 

Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin. 

Stasiewicz, P. R., & Stalker, R. (1999). A comparison of three "interventions" on pretreatment dropout rates in an outpatient substance abuse clinic. Addictive Behaviors, 24, 579-582.

This summary has been made possible by the Northeastern States Addiction Technology Transfer Center (NSATTC), partnered with the University at Buffalo School of Social Work, 685 Baldy Hall, Buffalo, NY, 14260. Additional copies can be requested from the NSATTC office at 716-645-3381 x243. In part, the mission of the NSATTC is to increase the knowledge and skills of addiction treatment practitioners from multiple disciplines by facilitating access to state-of-the-art research, education and best practices.