FIFTY YEARS OF CHILD AND ADOLESCENT MENTAL HEALTH SERVICES RESEARCH
Engagement in therapy
One particularly significant barrier is a lack of client engagement in therapy, which has been shown to lead to worse treatment outcomes as well as to treatment dropout. On the other hand, greater engagement is linked to greater treatment effectiveness. One common way of talking about engagement is in terms of attendance in therapy. Attendance, however, does not correlate with positive outcomes. One can attend a therapy session and not be engaged in therapy, as well as be engaged yet not in attendance. Attendance is a poor measure of engagement.
An even more acute problem for children and adolescents
Lack of engagement is especially notable for children and adolescents, where dropout rates have been estimated to be as high as 75%. Many explanations have been offered as the reason, including child development limitations (e.g., the ability to understand and explain concepts such as `feelings’) and the multitude of obligations of modern family life that make consistent, on-going attendance at therapy a near impossibility.
What works?
Instead of focusing on the causes of dropout, researchers have turned to studying what works – what engages children and adolescents in therapy and keeps them motivated and coming back. Traditionally much of this research has been siloed (e.g., a particular engagement practice, such as doing homework, is studied within a particular treatment modality, such as Cognitive Behavior Therapy). But recently, researchers have started to systematically study engagement practices that work across all modalities and throughout the course of treatment. They’ve identified engagement practices that are dynamic (can address engagement challenges across clinical symptoms as well as the course of therapy).
Empirically supported engagement practices
Successful engagement practices fall into five domains: Relationship (or Rapport) Building (strategies in increase the quality of the therapeutic relationship), Expectancy (knowing what to expect in and from therapy), Attendance (which includes explicitly addressing potential barriers to treatment), Clarity (psychoeducation and modeling) and Homework (both assigned tasks as well as therapeutic practices). A more detailed look at these domains, and the particular practices that fall under them, is contained in the Table, below.
