When Practical Barriers Stall Therapy

Each Psychologist has their own version of this file: the client who has a good treatment, good alliance, and bad therapy. Sessions are cancelled on the morning of, attendance drops over a term, homework is never completed in the ways required, and things that have been accomplished in the session fade between sessions.

Training provides abundant frames of interpretation for non-attendance, ambivalence, avoidance, and rupture, and at times, a fit. But a wide-ranging appraisal of stymied treatments is increasingly revealing a more obvious first layer: the client was unable to reach the destination; unable to arrange the trip; no energy after a week to make the trip; or (most frequently) lives in an executive load which makes a Tuesday 2pm appointment a summit attempt. The least glamorous of all reasons why treatment doesn't work are practical barriers, and one of the most prevalent.

The four barriers behind the DNA pattern

Transport. The easiest and most clear-cut: no licence, no cheap path, an interaction of mobility and anxiety that establishes the hierarchy of exposures for public transport. Failure to transport results in precisely the attendance signature that reads ambivalence, and by asking directly what do you need to get here, and what has to go right, they differ in one question.

Executive load. With clients suffering from ADHD, brain injury, psychosis, severe depression or just too much in their life, the appointment is the tip of an unseen sequence, remember, plan, prepare, sequence the morning, leave on time. It typically means the sequence failed at step two, hours before the appointment, rather than at step five when they were considering whether to start or not.

Depleted capacity. Therapy is work and it takes up space in the system like all other work that life requires. On the day, the client who only just manages to keep a job, a family, and his or her self-maintenance may well have no other resources to spare, and not attending may just be a fact about the client, not a clinical one.

The between-session void. Gains occur with practice, activation, exposure, routine, and practice is initiated and structured by the presenting conditions that are impaired. The missed appointment is usually the same executive failure as the undone homework.

The clinical response: scaffold first, interpret second

This isn't the same as the interpretation being incorrect, it's the fact that it's too early to really have that interpretation while the logistics are still to be solved, so this series dovetails into the rest of this library because the logistics are solvable. Precisely the practical layer therapy needs can be provided by funded or privately arranged support work: transport and accompanying clients to sessions, the pre-session sequence (covered in detail in a later posting in this series) for clients who are anxious and executive impaired, and the between-session scaffolding, which will be covered in detail later in this series, which gives activation and practice a place to live on Tuesday morning when the client arrives to your waiting room. The funding is often already in place when someone is a part of the NDIS, or reachable through the simple doors this library maps for others. With the psychologist, it's a recognition and a referral conversation: to name the getting-here part, without shame, it's a real obstacle, it's fixable, and to point the client or family at the mechanism, in this case a platform such as Support Network, where a transport-and-support arrangement could be running within the fortnight.

Reading the difference honestly

None of this is to replace clinical judgement, it's merely to follow it. The client's attendance which normalises in the presence of transport has never been ambivalent; the formulation has to be adjusted. Now the client cancelling the sessions you support is saying something that can't be explained by the logistics, and you are moving forward with the interpretive work on clean data. Scaffolding, in this way, is differential diagnosis by intervention: solve the practical layer, and what is left is the clinical layer, which is seen for the first time.

How this plays out in practice

Imagine a client who is diagnosed with schizoaffective disorder, being referred for CBT for voices, warm towards engagement, 40 percent attendance and declining, on the verge of the discharge letter that would formalize each service's file on him. The direct question brings out one sequence, two buses, a transfer he dreads, and mornings when organising it defeats him by nine. The psychologist sends a brief note asking his coordinator to provide a support worker, and she is able to arrange this for Tuesday mornings, breakfast, the drive and the waiting room. The ambivalent paragraph in the formulation is quietly put aside, therapy builds up and attendance at ninety per cent inside a term. No change in treatment was made. The road to it did.

Next steps

For the three files that are the most problematic in terms of attendance, ask yourself at the next contact: how do I actually get here and what needs to go right? Then write the one paragraph note to the person who can construct the scaffolding.