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Keywords:

  • Within-treatment engagement;
  • mental health;
  • conceptual model;
  • therapy process

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

Background

This article proposes a conceptual model of child and parent engagement in the mental health intervention process.

Method

A scoping review was performed of articles on predictors of engagement in mental health interventions, the effectiveness of engagement interventions, and interpersonal aspects of care. A comprehensive search of PsycINFO and PsycARTICLES was performed for literature published in English from 2000 to 2012.

Results

Based on the review, a motivational framework is proposed in which engagement is defined as a state comprised of a hopeful stance, conviction, and confidence, brought about when therapists optimize engagement processes of receptiveness, willingness, and self-efficacy.

Conclusions

Implications concern the need to help clients understand what to expect from the therapy process, and to educate therapists about engagement strategies.

Key Practitioner Message
  • Child and parent engagement in mental health treatment can be considered to be a multifaceted state of affective, cognitive, and behavioral commitment or investment in the client role over the intervention process
  • In an engaged state, the client is enthusiastic about intervention, believes that the offered or chosen treatment will be effective, and sees the intervention plan as manageable
  • Practitioners may benefit by considering whether clients have a hopeful stance, are convinced about the appropriateness of intervention goals and processes, and are confident in their ability to carry out the intervention plan
  • Practitioners can play a key role in optimizing client engagement by maximizing the client's receptivity, willingness, and self-efficacy

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

High dropout rates are significant concerns in outpatient mental health services (Nock & Kazdin, 2001). Approximately one half of families who begin treatment for their child or adolescent with a mental health issue drop out prematurely (Nock & Ferriter, 2005). Other engagement issues can arise, including lack of connection with the therapist, lack of willingness to offer information or otherwise participate actively in the sessions, resistance to recommendations, and lack of follow through. These affective, cognitive, and behavioral aspects of engagement influence the outcomes children attain. Engagement is essential for optimal service delivery and in achieving clinical outcomes (McKay & Bannon, 2004).

The present article examines client engagement in the intervention process (as distinct from treatment entry). We define engagement as a multifaceted state of affective, cognitive, and behavioral commitment or investment in the client role over the intervention process. We view engagement as both a child and family level construct. For younger children or youth with intellectual disabilities, the focus is most often on parent engagement, whereas adolescents with typical intelligence are usually the primary focus of engagement efforts.

The diverse literature on client engagement is comprised not only of research on predictors of engagement and the effectiveness of engagement interventions in mental health but also research on adherence and client participation in treatment, and studies of the therapeutic relationship, the skills of effective or expert therapists, and family centered and relationship-based care. The aim of the present article is to present an integrative, evidence-based framework for conceptualizing the engagement of children and parents in the mental health intervention process. To set the stage, we first discuss the importance of engagement as a precursor of client change, and the need for a conceptual framework by which to understand the nature of engagement and the processes by which it fosters client change.

Research on client change processes

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

Although it is widely assumed that engagement is necessary for optimal client outcomes, there is a surprising lack of research on how engagement is related to the processes by which clients change, which is unfortunate because the question of how therapy works is an important research agenda (Doss, 2004). Client change processes are the active ingredients of the therapy process (i.e. the client behaviors or experiences that occur during the treatment session or from therapy homework assignments), which result from therapy interventions and strategies (Doss, 2004). Little attention has been paid to client change processes, although they are considered to precipitate treatment gains (Hogue & Liddle, 2009) and may provide parsimonious explanations of the roles played by multiple client, therapist, and treatment factors, thereby eliminating an overly detailed (and confusing) approach to understanding client engagement.

The need for an integrative conceptual approach

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

There is a clear need for conceptual approaches that allow us to understand engagement and the processes by which it brings about client change. Past research on engagement in child and adolescent treatment has lacked a unifying conceptual approach (Nock & Kazdin, 2001). Noteworthy frameworks that have been proposed include a Barriers-to-Treatment model reflecting a risk and protection viewpoint (Kazdin, Holland & Crowley, 1997), an attributional framework focusing on cognitions affecting engagement (Morrissey-Kane & Prinz, 1999), and a framework of attitudinal and behavioral components (Staudt, 2007). Drieschner, Lammers and van der Staak (2004) recently proposed a model of treatment motivation that views behavioral engagement as resulting from cognitive and emotional determinants. According to Karver, Handelsman, Fields and Bickman's (2005) therapeutic process model, therapist relationship factors influence the client's affective, cognitive, and behavioral reactions to the therapist/therapy, and thereby actual participation in mental health treatment.

These frameworks emphasize different predictive factors, aspects, or dimensions of engagement and generally focus on reducing barriers to treatment rather than optimizing engagement. They do not consider the role of the therapist in creating optimal motivational conditions for change, the principles at play, or how engagement works to bring about change and better client outcomes. Although transactional frameworks are most appropriate to understand how therapists set up conditions to optimize engagement, most existing frameworks are not transactional [exceptions are Karver et al.'s (2005) therapeutic process model and Littell, Alexander and Reynolds's (2001) client participation model]. There has also been little consideration of insights provided by other literature, including contextual factors influencing treatment adherence and engagement, and interpersonal aspects of caregiving, which has examined the importance of communication, enablement, collaboration, and the customization of service delivery to meet unique client needs. These literatures support a view of engagement as a multifaceted process occurring over the course of intervention.

Objective

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

This article provides a conceptual review and synthesis of literature relevant to the engagement of children/youth and families in mental health services. The specific aims are to (a) provide a comprehensive conceptualization and definition of client engagement in the intervention process and (b) present an integrative framework of engagement in the clinical change process. Our focus is on affective, cognitive, and behavioral involvement and how therapists engage clients after entry into the service delivery context.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

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).

A motivational framework of client engagement in the intervention process

Here, we provide our definition of engagement and present an evidence-based conceptual framework that describes the nature of client engagement and how engagement can be optimized by therapists. The framework is based on a synthesis of the reviewed literature and is meant to guide empirical study rather than be a predictive model per se.

Definition of engagement

We believe that it is most appropriate to view engagement from a relational perspective involving client-therapist interaction. We therefore define client engagement as a multifaceted state of motivational commitment or investment in the client role over the treatment process. The notion of ‘role’ acknowledges the importance of a negotiated and changeable client–therapist relationship.

Conceptual model of engagement

As shown in Figure 1, we propose that engagement in the intervention process has three components: (a) affective involvement (emotional involvement in the process and with the therapist), (b) cognitive involvement (beliefs about the need for intervention and therapy effectiveness), and (c) behavioral involvement (in-session participation; behavioral collaboration; and beliefs about personal self-efficacy to carry out agreed-upon intervention outside of treatment). These are separate facets of engagement. For example, a client can be emotionally invested in the process but not believe in the usefulness of the offered intervention, or can collaborate behaviorally while having serious doubts about the utility of the intervention.

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Figure 1. Client engagement in the clinical change process

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Behavioral involvement includes participation in problem identification and goal setting, shared decision making, and mutual endorsement of tasks (Littell et al., 2001), along with beliefs about self-efficacy. Self-efficacy refers to implementation-related beliefs. Parent self-efficacy is viewed as key in promoting out-of-session changes in the child's emotional state, self-perceptions, thinking processes, and actual behavior.

As shown on the right in Figure 1, an ‘engaged client’ has a hopeful stance (an optimistic attitude, as well as trust in the process and therapist); is committed to intervention goals and convinced about the need for treatment (conviction); and feels able to carry out intervention tasks (confidence). In this optimal state, the client is enthusiastic about intervention, believes that the offered or chosen treatment will be effective, and sees the intervention plan as manageable. Whether or not this optimal state leads to actual change will depend on situational constraints, but the client is receptive, willing, and able to invest in making desired changes.

This optimal client state is brought about when the therapist uses three engagement processes: client receptiveness, willingness, and self-efficacy (Figure 1). Receptiveness refers to client belief in the ability of the therapy process and the therapist to bring about a positive outcome, an openness to receiving help (Yatchmenoff, 2005), and the expectation that things will change for the better. Willingness refers to client desire to invest effort in the intervention. Willingness is reflected in the state of conviction, which refers not only to belief that intervention is needed (Treasure & Schmidt, 2001) but also to the individual's evaluation of how believable, convincing, and logical a given treatment is, and that the treatment will lead to certain improvements (Nock et al., 2007). Self-efficacy refers to client belief in his/her ability to carry out the intervention plan in real life.

As shown in Figure 1, the skilled therapist harnesses these engagement processes by providing hope and support, providing coherence to the intervention plan, and ensuring treatment manageability. The skilled therapist modifies explanations, strategies, and his/her behavior depending on how the client reacts to what is being said or done. The therapist's intention is for the client to be receptive (‘I believe in the therapist and have trust and optimism regarding the therapy process’), willing (‘I believe this intervention will work and am willing to invest effort’), and able (‘I believe I can do this, with the supports and resources I have’).

This framework is unique in viewing engagement as a process involving affective, cognitive, and behavioral components. Other frameworks focus on entry into treatment, emphasize only one or two components of engagement, are not transactional or relational, and do not explain the mechanisms by which skilled therapists create a change-oriented intervention atmosphere. The present framework contributes to the field by conceptualizing engagement as a multifaceted client state optimized by therapist use of engagement principles. The client's hopeful stance, conviction, and confidence are instrumental in bringing about longer term changes in attitudes/emotions, cognitions, and behavior. In the following sections, we discuss engagement as a state of motivation, and link our framework to client change processes.

Engagement as a state of motivation based on attitudes and beliefs

Motivation is influenced by attitudes and beliefs that create behavioral intentions, and is considered to be the key determinant of behavioral change (Thelen & Smith, 1994). We propose that motivation to engage in therapy is based on (a) belief that the therapist can help (hopeful stance), (b) belief that the problem is sufficiently important to warrant intervention and that the treatment will be effective (conviction), and (c) belief that one can bring about desired change (confidence). Others have proposed motivational assessment frameworks that view readiness as comprised of conviction and confidence (e.g. Treasure & Schmidt, 2001), but do not include a distinct affective component (hopeful stance).

We view within-treatment engagement as an interconnected set of positive attitudes and beliefs about the roles of treatment, the therapist, and the self in bringing about change. These beliefs wax and wane over the course of the intervention, as clients receive new information, develop therapeutic relationships, and come to understand the service context in which they may/may not receive the interventions they expect. Clients can experience setbacks and be distracted by life events, leading to lower receptiveness, lower commitment to therapeutic goals, and/or feelings of hopelessness. They can become more receptive as they experience successes, more willing to invest effort as they develop more realistic expectations, and more confident as they marshal resources and develop skills.

The three engagement components reciprocally influence one another, with no one component necessarily preceding another. Emotional involvement with the therapist and the therapy process clearly influence client commitment or willingness as well as confidence in carrying out the treatment plan. In addition, clients who have a hopeful stance are more likely to be behaviorally involved in the treatment session (e.g. ask more questions, give more information) and therefore more likely to understand the treatment rationale (be cognitively more involved). The result is a strong network of interconnected beliefs, required for out-of-session changes in attitudes, cognition, and behavior.

Client change processes

Our framework highlights processes of client change that occur through optimal client–therapist interaction, and it also distinguishes engagement processes from longer term life outcomes. In our view, engagement is a primary client change process. Client change processes refer to covert and overt activities and experiences that individuals engage in when they attempt to modify problem behaviors (Prochaska, DiClemente & Norcross, 1992). According to a process viewpoint, a set of empowering and adaptive processes, residing largely in the client, are mobilized by therapy and client–therapist interaction (Doss, 2004). These in-session processes carry the power to improve clients' lives. Instilling hope and self-efficacy are, in fact, considered to be common mechanisms of change generalized into the client's life, brought about by in-session change processes (Doss, 2004).

Support for a multifaceted framework

Support is provided by literature on interventions designed to increase family engagement in mental health services (e.g. Miller & Prinz, 2003); research on parent beliefs about treatment credibility and expectancies about treatment effectiveness as predictors of treatment participation in mental health care (e.g. Nock et al., 2007); the ‘therapy process’ literature (e.g. Oetzel & Scherer, 2003); and literature on therapy change (Staudt, 2007). The components and processes in the engagement framework appear repeatedly in different literatures. In the sections below, we provide supportive conceptual and empirical evidence for the framework from various literatures.

Literature on predictors of behavioral engagement

This extensive literature has studied pretreatment factors limiting adherence in mental health services, including stigma, hopelessness, and parent factors (e.g. marital problems; Shriver & Allen, 2008); distrust of ‘helping institutions’ (Armbruster & Fallon, 1994); language and cultural barriers (Chaffin et al., 2009); and parents' lack of acceptance of the child's diagnosis (Oppenheim et al., 2007). This literature has also examined predictors of behavioral engagement (i.e. adherence) once the client is in treatment. The variables found to be important to adherence to treatment recommendations include (a) characteristics of the client (e.g. lack of understanding, beliefs about problems, and expectations and attitudes toward treatment), (b) characteristics of the treatment protocol (including client perception of treatment effectiveness, and the complexity, inconvenience, and experience of the treatment), and (c) the nature of the client–therapist relationship (inadequate communication, poor rapport; Littell et al., 2001).

Belief systems have been found to play a much stronger role in parents' perceived barriers to treatment than socioeconomic disadvantage or the severity of the child's dysfunction (Kazdin, 2000). Furthermore, parental perceptions of treatment barriers (including a poor relationship with the therapist and treatment demandingness) significantly predict treatment dropout beyond variation explained by logistical barriers (Kazdin et al., 1997). Perceptions of treatment relevance and demandingness have been found to be salient dimensions contributing to the relation between perceived barriers and therapeutic change (Kazdin & Wassell, 2000).

Literature on intervention engagement

This literature strongly supports the view that parental cognitions are crucial to engagement. Studies suggest that parent engagement rests on attitudes about services and service providers (McKay & Bannon, 2004), beliefs about the cause of their child's problems (Miller & Prinz, 2003), perceived ability to handle such problems, and expectations of the ability of therapy to help them (Morrissey-Kane & Prinz, 1999). These beliefs about therapy outcomes, treatment processes, and the self correspond to our constructs of hopeful stance, conviction, and confidence.

Parents and children enter treatment with expectations about the help they will receive, including how the therapist will interact with them, the procedures that will be offered, and the outcomes they will achieve (Day et al., 2006). When parents view treatment as valuable (leading to a hopeful stance), and have expectancies that mirror important service delivery characteristics (leading to conviction and commitment to particular intervention), there is greater likelihood they will continue in treatment (Miller & Prinz, 2003). Furthermore, their pretreatment attributions about the child's problems can play a role in how confident they are in their parenting ability and in their use of new child-management strategies (confidence), thereby influencing engagement (Miller & Prinz, 2003). For example, a parent who believes medication to be the answer to their child's difficulties would not see learning parent management skills as useful (lower conviction) and would be less willing to invest effort in this intervention (lower willingness).

parents' initial beliefs about treatment have been found to predict their behavioral adherence to treatment (Nock et al., 2007). Furthermore, parents' conceptualization of their child's problems has been found to be associated with their attitudes and experiences with mental health treatment (Moses, 2009). In a study of a motivational orientation intervention designed to improve parenting program retention, Chaffin et al. (2009) proposed that the motivational factors affecting retention include readiness to change parenting behaviors (receptiveness), recognition that there is a problem requiring intervention and attitudes toward the program (willingness), and self-efficacy perceptions (self-efficacy).

Literature on the therapeutic relationship

The therapeutic relationship is considered to be essential to the quality of mental health care (Oetzel & Scherer, 2003). In a study of youth dropout from outpatient mental health treatment, Garcia and Weisz (2002) found therapeutic relationship problems to be the most important factor distinguishing treatment completers from dropouts. The therapeutic relationship is considered to be the vehicle by which the therapist hopes to engage with a client and effect change through empowerment processes (Howgego et al., 2003). Various conceptualizations have been proposed, including ‘therapeutic alliance,’ ‘client-provider relationship,’ and ‘collaborative partnership.’

The therapeutic alliance is commonly defined as a relational connection with the therapist, involving three aspects: emotional connection with the therapist (affective involvement), the cognitive connection that underlies willingness (cognitive involvement), and behavioral collaboration (behavioral involvement; Karver et al., 2005). Karver et al. (2005) have proposed a therapeutic process model that links therapist characteristics and behaviors to client cognitive and affective reactions to the therapist/therapy, and client participation in treatment. This model differs from our process-oriented model, which considers affective, cognitive, and behavioral involvement with the therapist/therapy as equally important aspects of engagement that the skilled therapist seeks to maximize. We therefore seek to explain not only what engagement is but also how it brings about longer term change in beliefs, attitudes, and behavior.

When a client has a different explanatory model than their therapist about a disorder (etiology, course, prognosis, and appropriate treatment), this has a major impact on adherence (Nock & Ferriter, 2005). As clients often conceptualize their problems in lay terms and dysfunctional ways, a primary function of therapy is to provide an adaptive explanation, which bolsters conviction that treatment will be efficacious. In addition, researchers have emphasized the importance of emotional involvement, proposing that a positive attitude toward treatment is the ‘heart of engagement’ (Staudt, 2007). Others have stressed behavioral collaboration (e.g. shared decision making), along with affective aspects of the relationship such as trust, empathy, personal liking, and valuing (Howgego et al., 2003).

A recent meta-analysis of therapeutic relationship variables in child and adolescent treatment indicated that the best predictors of youth outcomes included the therapist's interpersonal and direct influence skills (factors influencing receptiveness), youth/parent willingness to participate in treatment (willingness), and youth and parent behavioral participation in treatment (Karver, Handelsman, Fields & Bickman, 2006). Therapists' direct influence skills were prominent predictors of outcomes, suggesting that youth are responsive to therapists who present information clearly and with an understandable rationale (providing coherence).

Literature on the skills of effective or expert therapists

The treatment adherence literature consistently indicates the importance of practitioner skills that maximize the client's sense of control, understanding, and feeling of being respected and supported. Behaviors such as a supportive style, providing clear explanations, and demonstrating respect are considered to promote client self-actualization and self-direction in treatment (Cormier & Nurius, 2003), and they reflect the principles of providing hope and support, providing coherence, and ensuring manageability.

Similarly, the literature on effective therapists indicates the importance of engaging clients through listening, empathy, interpersonal skills, and emotional presence (Calhoun & Rider, 2008). Studies of expert therapists indicate that they work hard to establish rapport and relationship (optimizing receptiveness), ensure clients understand the treatment rationale (optimizing willingness), and empower (optimizing self-efficacy; King et al., 2007). In essence, expert therapists endeavor to create optimal conditions for change by enabling and customizing strategies that maximize the likelihood of engagement (King, 2009).

Literature on family centered and relationship-based care

These literatures consider the client–therapist relationship to play a major role in creating motivational conditions for change. The development of positive, supportive relationships with parents is considered to be a key component of effective collaboration in family centered practice (McWilliam, Tocci & Harbin, 1998). Specific attitudes and behaviors required for supportive partnerships have been identified, including sensitivity and responsiveness to parent concerns, providing information about resources and options, and listening to and encouraging parents (Hanna & Rodger, 2002). The literature on relationship-based care provides similar evidence concerning therapist behaviors that create motivating conditions for change. In a relationship-based approach, practitioners focus on client preferences, use active and reflective listening, and display empathy, warmth, and trustworthiness (Dunst, Boyd, Trivette & Hamby, 2002).

General conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

We have presented a conceptual framework that provides coherence to the literature by proposing that engagement is an optimal state comprised of a hopeful stance, conviction with respect to the appropriateness of intervention goals and processes, and confidence in personal ability to carry out the intervention plan. This state maximizes client change processes necessary for positive outcomes—the client is receptive, willing, and feels able to change (self-efficacy). To be effective, therapists need to create conditions for an empowering client mindset—trust, belief in treatment effectiveness, and personal power to bring about change. Expert therapists understand that actual change is in the hands of the client; however, they can reasonably expect to influence motivation. The role of the therapist is to support, guide, and enable, thereby instilling empowering or motivating attitudes and beliefs.

Directions for research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

It is important to develop reliable and valid ways to measure various indicators of engagement: client receptiveness, willingness, and self-efficacy. Prospective mixed method designs could then be used to follow the treatment journey of families, chronicling their emotions, thoughts, and experiences, including changes in the patterns of engagement indicators. This descriptive work would more clearly elucidate the processes that influence changes in engagement over time. Studies could then examine which engagement processes are most instrumental in improving client outcomes.

Several directions stand out as particularly worthy of future research. Parent willingness to participate has not been the subject of much research (Karver et al., 2005) and acceptability of treatment procedures in mental health service delivery deserves greater attention (Kazdin, 2000). Treatment acceptability is likely influenced by how treatment is presented and delivered, and how client expectations are managed (Kazdin, 2000), suggesting the importance of examining therapist persuasiveness (Karver et al., 2006).

Implications for intervention

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

The common denominator of many interventions is the science of persuading and motivating people to commit and sustain commitment to treatment (Morrissey-Kane & Prinz, 1999). Training service providers in engagement principles and strategies is therefore important, especially for first face-to-face meetings with clients (McKay & Bannon, 2004). Engagement can be facilitated by directly addressing clients' expectations as they begin treatment, addressing perceptions of treatment demandingness, and ensuring clients understand connections between treatment procedures and the processes by which change will occur (Kazdin & Wassell, 2000). When therapists understand the nature of optimal engagement and engagement principles, they can customize their use of engagement strategies to fit client needs for hope and support, understanding of intervention rationales, and manageable intervention tasks.

In conclusion, this article has outlined the conceptual and evidence base for a motivational framework of client engagement consisting of processes of receptiveness, willingness, and self-efficacy. Clients will be most engaged when they trust the therapist and believe in the value of therapy; believe in the relevance of the treatment offered; and believe that they have the skills, resources, and support to bring about desired changes.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References

There was no financial support for this work. The authors have declared that they have no competing or potential conflicts of interest. We gratefully acknowledge the contributions of Madhu Pinto and Michelle Gibson who assisted with the literature search.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Research on client change processes
  5. The need for an integrative conceptual approach
  6. Objective
  7. Methods
  8. General conclusions
  9. Directions for research
  10. Implications for intervention
  11. Acknowledgements
  12. References
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