To provide the basis for the development of the integrative framework, we conducted a scoping review (Levac, Colquhoun & O'Brien, 2010), which involved a comprehensive search of PsycINFO and PsycARTICLES for literature published in English from 2000 to 2012. An initial search using the terms Engagement, Mental Health, Intervention, Parent, Family, and Treatment yielded 1499 references. The titles and abstracts of these references were then scanned using the more refined search terms: Attrition, Adherence, Drop Out, Therapy, Process, Adolescent, Child, Youth, and Alliance. This process yielded 213 references. A detailed examination of the journal article abstracts reduced the number to 67 references. After reading these, a further 11 were excluded because they focused on entry or enrollment into treatment rather than engagement in the therapy process. Two additional articles were obtained from the reference lists of the identified articles, for a total of 58 relevant articles. We included articles providing a definition or conceptualization of child/youth/parent engagement in or with mental health services; articles that measured constructs such as attrition, dropout, and engagement; empirical articles examining predictors of participation or engagement; and articles discussing therapist expertise and client change processes.
In accordance with the aim of a scoping review (Arksey & O'Malley, 2005) and a ‘critical review’ approach to literature synthesis (Norman & Eva, 2008), our review was selective and critical, yet systematic in its approach in identifying relevant material. Scoping reviews involve the reconnaissance and interpretation of existing literature in a topic area (Arksey & O'Malley, 2005). The main strengths of a scoping review are its ability to extract the essence of a diverse body of evidence, thereby providing a sense of its meaning and significance, guidance regarding what remains to be understood, a new frame of reference, and a compelling stepping off point for new investigations (Davis, Drey & Gould, 2009). Although we followed a systematic approach in obtaining literature, there is some possibility that articles may have been missed due to the use of diverse terms referring to the engagement process; however, we do not believe that important theoretical articles have been missed.
In the following sections, we first briefly review conceptualizations of engagement in the literature, focusing on organizational, service provider, client, and relational perspectives. Adopting a relational perspective, we then propose a multifaceted definition of engagement in the intervention process and provide support for this conceptualization. Last, we outline directions for future research and clinical practice.
Conceptualizations and definitions of engagement
Engagement in mental health interventions has been conceptualized and defined in various ways, leading to inconsistent findings (McKay & Bannon, 2004). First, there is variation in what is considered to be engaged in or with, including service planning, decision making about intervention, therapy implementation, and/or the working alliance with the therapist (McCabe & Priebe, 2004). Second, there is variation in whether engagement is considered to be an outcome (such as service use); an event occurring at a specific stage of therapy (such as initial attendance); or a process characterizing individuals in their treatment journey (Yatchmenoff, 2005).
Third, there is variation in the signs of engagement given primary attention, with behavioral aspects given much more emphasis than definitions incorporating cognition or affect. Behavioral conceptualizations include attendance, appointment keeping, or adherence to treatment protocols, whereas cognitive conceptualizations include the extent to which expectations are met and treatments are believable, convincing, and logical (Nock, Ferriter & Holmberg, 2007). Affective conceptualizations include emotional involvement in sessions, a positive attitude, and trust in the therapist (Howgego, Yellowlees, Owen, Meldrum & Dark, 2003).
Fourth, there is variation in the perspectives taken on engagement, including organizational, service provider, client, and relational perspectives. The early engagement literature tended to adopt an organizational perspective (Yatchmenoff, 2005), focusing on whether the client remained in treatment or terminated treatment early. As indicated by Nock and Ferriter (2005), this literature considered variables such as dropout or premature termination (Kazdin, 1990), attrition (Armbruster & Fallon, 1994), retention (Chaffin et al., 2009), treatment adherence or attendance (Miller & Prinz, 2003), degree of compliance (McKay, McCadam & Gonzales, 1996), and length of stay in treatment (Liddle, Jackson-Gilfort & Marvel, 2006).
An appreciable number of studies have adopted the service provider view of client amenability or resistance to change, using trait-like terms such as ‘responsiveness to treatment’ (Moses, 2009), ‘resistance to change’ (Liddle et al., 2006), and the vaguer ‘readiness.’ The client perspective has been examined less often but indicated important factors affecting parents' engagement in mental health services for their children. Research focusing on the client perspective has examined client difficulties in participating in treatment (Kazdin et al., 1997); perceptions of treatment acceptability (Kazdin, 2000; Watson & Gresham, 1998); and the notion of ‘buy in’ (Yatchmenoff, 2005). These terms refer to alterable client states rather than traits or fixed attributes.
The relational perspective deals with various types of goodness-of-fit, including the fit between: (a) client needs and treatment (Hogue & Liddle, 2009), (b) client beliefs, priorities, expectations, and/or lifestyle and the treatment plan (Nock & Kazdin, 2001), and (c) the client and therapist on an interpersonal level (Wampold, 2001). Research on engagement in a therapeutic relationship exemplifies the relational perspective. Wampold (2001) has, for example, defined the therapeutic relationship as a collaborative partnership that motivates and engages the client. This extensive literature consistently indicates the importance of a sound therapeutic relationship (Day, Carey & Surgenor, 2006). The collaborative therapeutic relationship is consistently reported to be a robust predictor of treatment adherence and outcomes for individuals with a range of mental health problems (Howgego et al., 2003).