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Clinicians in naturalistic settings regularly modify the delivery of trauma-focused treatments to enhance client engagement and retention. However, what types of modifications are made in clinical settings, why, and when, and their impact on client outcomes has seldom been examined. As an initial step to address this, the current study applied elements of the updated Framework for Reporting Adaptations and Modifications—Expanded (FRAME; Wilstey Stirman et al., 2019) to examine content-level modifications documented in the delivery of posttraumatic stress disorder (PTSD) treatment to veterans via medical records review in an urban PTSD clinic. Results indicated that the updated FRAME suited the data well, and that modifications occurred in most veteran–clinician pairs over the course of treatment. The four most common modifications documented were spreading (27%), repeating (24%), drift with return (22%), and integrating (21%). Three composite case examples are discussed that describe the application of the most common modifications observed in medical record documentation. This is an important first step toward understanding the real-world modifications of evidence-based trauma-focused interventions that in turn will lead to critical recommendations for improving treatment implementation.

To examine goal attainment, engagement, and the stances used by coaches providing a solution-focused coaching intervention (SFC-peds) for young people with cerebral palsy pursuing friendship goals.The case study involved two clients with cerebral palsy (a young child and his mother, and a youth) and their service providers. An interpretive descriptive approach was used to analyze quantitative and qualitative data. Friendship goal attainment was assessed by the Canadian Occupational Performance Measure and goal attainment scaling, and client engagement was assessed using the Pediatric Rehabilitation Intervention Measure of Engagement-Service Provider version. Information from post-intervention client interviews was used to identify coach stances and relationships with client engagement.Participants met their friendship goals and were considered to be highly engaged by their coaches. Four coach stances were identified: Respectful Inquiry, a Strengths Presupposition, Implementation Curiosity, and Inspiring Commitment. These stances, and aligned tactics, engaged clients on affective, cognitive, and behavioral levels, and impacted the client's stance toward their goal.SFC-peds appears to be an effective and engaging approach for young people with disabilities working on friendship goals. The findings illustrate how the coach's stances and tactics engage clients, thus impacting the client's own stances toward change.

IntroductionQuitlines are standard care for smoking cessation; however, retaining clients in services is a problem. Little is known about factors that may predict dropout.AimsTo examine predictors of retention while in-program and at follow-up for clients enrolling in a state quitline.MethodsThis was a retrospective analysis of quitline enrolled clients from 2011 to 2017 (N = 49,347). Client retention in-program was categorized as (a) low adherence to treatment (receiving zero coaching calls), moderate (1–2 calls), and high adherence (3+ calls). Dropout at follow-up included participants who were not reached for the 7-month follow-up.ResultsMore than half the sample dropped out during treatment; 61% were not reached for follow-up. Women (odds ratio (OR) = 1.21; 95% confidence interval (CI) = [1.16, 127]) and those with high levels of nicotine dependence (OR = 1.03; 95% CI = [1.02, 1.04]) were more likely to have moderate adherence to treatment (1–2 coaching calls). Dropout at follow-up was more likely among clients who used nicotine replacement therapy (OR = 1.14; 95% CI = [1.09, 1.19]) and less likely among those who had high treatment adherence (OR = 0.41; 95% CI = [0.39, 0.42]).ConclusionGiven the relapsing nature of tobacco use and the harms related to tobacco use, quitlines can improve their impact by offering tailored services to enhance client engagement and retention in-treatment and at follow-up.

This pilot study used a prospective mixed methods approach to examine predictors of retention in services during the transition from pregnancy to postpartum. Home visiting programs that serve pregnant women are an important means of improving child and maternal well-being. Providing services to women during the transition from pregnancy to postpartum is particularly important, because children under the age of 1 are at high risk for mortality. Morever, mothers face amplified levels of stress during the postpartum period. Unfortunately, home visiting programs in the United States that support pregnant and postpartum women suffer from high rates of attrition. General research on home visiting engagement suggests that the client-provider relationship is an important factor in predicting client engagement in services; however, few studies have examined factors related to maternal engagement during the transition from pregnancy to postpartum. Measures administered during pregnancy for 39 pregnant women were used to predict attrition up to 15 months postpartum. Semi-structured interviews were conducted at 3 months postpartum with 33 of the original 39 women to qualitatively assess factors related to engagement in services during the transition from pregnancy to postpartum. Both quantitative and qualitative analyses indicated that clients’ perceptions of the client-provider relationship was a critical factor in maintaining mothers’ engagement in services. Both types of analyses indicated that perceived provider reliability was related to mothers’ engagement in services. Quantitative analyses also found that perceived provider cultural competence predicted engagement in services. Other findings from qualitative analyses indicated that mothers’ perception of the home visitor as trustworthy/supportive, personable/having good communication skills, knowledgeable, and collaborative/flexible, were factors that mothers noted when discussing engagement in services. These results advance the literature on engagement in home visiting services by overcoming some of the limitations of previous literature and may have implications for home visitor training.

Client engagement in behavioral and mental health services has been strongly linked to improved outcomes and treatment completion. Animal-assisted interventions (AAIs) are increasingly used to improve client engagement, for example, by involving a dog in therapy to support a client's sense of safety. Although existing research suggests that human-animal interactions may promote engagement, further research is needed to understand the underlying mechanisms, identify procedures needed for treatment fidelity, and determine the populations in which this intervention would be most effective. The aim was to identify the existing knowledge base to inform future research and practice in these areas.A review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines to answer three questions: What research has been completed regarding the use of animals to affect client engagement, including measurement of potential processes of change? How have interventions that use animals been structured and protocolized? How is engagement operationally defined by these studies?Ten studies were identified for review. Preliminary evidence indicates that AAIs may support client engagement in behavioral and mental health services. A wide range of conceptualizations in which populations and settings could benefit from AAIs were identified, but it remains unclear who would benefit most. The review did not substantively address the efficacy of AAIs for increasing engagement or factors that may drive engagement.Further research is needed to quantify the impact of AAIs on service engagement and to identify mechanisms of change.

Tackling street gangs has recently been highlighted as a priority for public health. In this paper, the four components of a public health approach were reviewed: (1) surveillance, (2) identifying risk and protective factors, (3) developing and evaluating interventions at primary prevention, secondary prevention, and tertiary intervention stages, and (4) implementation of evidence-based programs. Findings regarding the effectiveness of prevention and intervention programs for street gang members were mixed, with unclear goals/objectives, limited theoretical foundation, and a lack of consistency in program implementation impeding effectiveness at reducing street gang involvement. This paper proposes that the Good Lives Model (GLM), a strengths-based framework for offender rehabilitation, provides an innovative approach to street gang intervention. Utilizing approach-goals, the GLM assumes that improving an individual’s internal skills and external opportunities will reduce the need to become involved in street gangs. Wrapping the GLM framework around current evidence-based interventions (e.g., Functional Family Therapy) increases client engagement and motivation to change, which is notably poor amongst those at risk of, or involved in, street gangs.

Women who use drugs during pregnancy are required to intersect with numerous services in relation to their and their unborn child’s well-being. The purpose of this article is to stimulate practitio...

Objectives Although turnover, defined as when a therapist leaves his/her organization, occurs frequently in public mental health organizations, its impact on clients is understudied. This study examined the effects of turnover on client engagement among youth receiving services in one public mental health agency. Methods Data were abstracted through a retrospective chart review of 76 clients who initiated outpatient trauma-focused treatment with 30 therapists between June 2013 and January 2016 at one agency in Philadelphia. Client demographic information, client session attendance, and therapist for each session was abstracted from each chart. The dependent variable (i.e., client engagement) was operationalized as client attendance to scheduled sessions. Mixed-effects regression analyses were used. Results Youth who experienced therapist turnover were 86% more likely to miss a future scheduled therapy session. When exploring this effect by diagnosis, youth without a Post-Traumatic Stress Disorder (PTSD) diagnosis were more likely to miss a scheduled session following therapist turnover than those with a PTSD diagnosis (p Conclusions Therapist turnover is a strong predictor of client engagement among youth receiving trauma-focused treatment, and a PTSD diagnosis may be a protective factor against missing sessions. Implications for treatment planning in the face of therapist turnover are discussed.

Parent engagement is an important intermediate outcome in Family Drug Treatment Court (FDTC) and child welfare services. This study explored the utility and reliability of a client satisfaction and engagement survey designed to measure interim outcomes of a Mentor Parent Program, operating in conjunction with a FDTC. Findings suggest the survey is a useful, parsimonious and reliable tool for measuring key dimensions of parent mentor services including client engagement; client-centered support and empowerment; and help with systems navigation and accessing resources. The survey may be adapted for use in other FDTC or parent mentor contexts.

Sudden gains-substantial stable symptom improvements between consecutive therapy sessions-are a common phenomenon. As condensed points of change, examination of sudden gains can provide insight into mechanisms of therapeutic change. This study investigated the association between sudden gains and cognitive change, therapeutic alliance, and/or client engagement in transdiagnostic group cognitive-behavioural therapy for anxiety disorders. Of 58 treatment initiators, 21% (

A recent study of two Community Care Access Centres in Ontario was conducted to look at how clients can be involved in their own care while, at the same time, enhance their experience overall. This article describes that study and looks at ways of developing a new client engagement strategy moving forward.

The aim of the study was to develop and validate measures of client engagement in aged homecare. The Homecare Measure of Engagement-Staff questionnaire (HoME-S) is a self-complete measure of six dimensions of client engagement: client acceptance, attention, attitude, appropriateness, engagement duration and passivity. The Homecare Measure of Engagement-Client/Family report (HoME-CF) is a researcher-rated interview which obtains client and/or family perspectives regarding frequency and valence of conversational and recreational engagement during care worker visits. Care workers (n = 84) completed the HoME-S and a measure of relationship bond with client. Researchers interviewed clients (n = 164) and/or their family (n = 117) and completed the HoME-CF, and measures of agitation, dysphoria, apathy and cognitive functioning. The HoME-S and HoME-CF demonstrated good test-retest and inter-rater reliability, and showed significant negative correlations with apathy, agitation and non-English-speaking background. Controlling for client and care service characteristics, a stronger care worker-client relationship bond and English-speaking background were independently associated with higher HoME-S scores, and apathy was independently associated with higher HoME-CF scores. In conclusion, the HoME-S and HoME-CF are psychometrically sound engagement measures for use in homecare. Clients who are apathetic or from non-English-speaking backgrounds may be less responsive to traditional care worker engagement strategies. Engagement may be augmented in clients who have stronger relationships with their care workers.

The present research investigated the use of a Smartphone App as an adjunct in the treatment of a range of anxiety disorders. The primary aim of the App was to increase client adherence to between session therapy tasks, involving homework practice of a range of skills and tasks known to be associated with successful treatment of anxiety disorders. Homework is an important component of many therapeutic approaches, allowing clients to practise therapeutic skills between sessions, as well as providing continuity between sessions (Freeman & Rosenfield, 2002). Greater client adherence to homework tasks has been associated with improved treatment outcomes, and may be particularly important for reducing the risk of relapse (Scheel, Hanson, & Razzhavaikina, 2004). However, despite the benefits of engagement with homework tasks, client adherence to these activities can often be a significant barrier to treatment (Addis & Jacobson, 2000; Burns & Nolenhoeksema, 1991; Detweiler & Whisman, 1999; Detweiler-Bedell & Whisman, 2005). It is also one area in which the use of adjunctive technologies may have the greatest impact. The aim of this paper was to describe the development and pilot testing of a therapeutic Smartphone application, namely, PsychAssist. This application was designed as an adjunct to face-to-face therapy in the treatment of anxiety disorders among adults. The App was developed with the purpose of enhancing client engagement and adherence to between session (homework) tasks to improve maintenance and generalization of therapeutic behaviours.

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.

Acceptance and Commitment Therapy (ACT) has emerged over the last twenty years within the context of the Third Wave of Cognitive Therapies, and has been utilised with reported success in a range of therapeutic and mental health settings. Social and self-stigma related to seeking assistance for mental health and other concerns has been shown to reduce client engagement with therapeutic support. Numerous studies have been undertaken that support ACT as an empirically validated framework for engaging stigmatised client groups. This paper provides a review of the key philosophical underpinnings and prominent techniques employed in ACT. Further, the paper highlights the utility of ACT in treating mental illness and other conditions by encouraging therapeutic participation through a use of techniques that inherently reduce the self and social stigma related to psychological disturbance and disability.

Purpose: Within supervised rehabilitation programs, Lent and Lopez (2002) proposed that clients and therapists develop a “tripartite” network of efficacy beliefs, comprising their confidence in their own ability, their confidence in the other person's ability, and their estimation of the other person's confidence in them. To date, researchers have yet to explore the potential relational outcomes associated with this model in rehabilitation contexts. Method: In Study 1, we recruited 170 exercise clients ( Mage = 63.73, SD = 6.46) who were enrolled in a one-to-one aerobic exercise program with a therapist as a result of a lower-limb musculoskeletal disorder. Clients reported their tripartite efficacy beliefs and perceptions about the quality of their relationship with their therapist, and respective therapists rated each client's engagement in his or her exercise program. In Study 2, we recruited 68 separate exercise clients ( Mage = 65.93, SD = 5.80) along with their therapists ( n = 68, Mage = 31.89, SD = 4.79) from the same program, to examine whether individuals' efficacy perceptions were related to their own and/or the other person's relationship quality perceptions. Results: In Study 1, each of the tripartite efficacy constructs displayed positive direct effects with respect to clients' relationship quality appraisals, as well as indirect effects in relation to program engagement. Actor−partner interdependence modeling in Study 2 demonstrated that clients and therapists reported more adaptive relationship perceptions when they themselves held strong tripartite efficacy beliefs (i.e., actor effects), and that clients viewed their relationship in a more positive light when their therapist was highly confident in the client's ability (i.e., partner effect). Conclusion: These findings underscore the potential utility of the tripartite efficacy framework in relation to motivational and relational processes within supervised exercise programs.

Individuals with severe disability exiting school are likely to be enrolled in day activity and sheltered workshops at least as often as in supported employment. Such facilities are often staffed by paraprofessionals who may not have the skills to engage clients in meaningful activities. This article describes a 3-phase staff training project designed to increase client engagement in an adult habilitation centre.The first phase of the project was to develop curriculum guidelines. The second phase was conducting a series of training for paraprofessional staff. And the third was the implementation of the clinical experience. The first author conducted a graduate level methods class on site at the adult habilitation centre. Staff participants (paraprofessional staff, supervisors, and graduate students) learned the components of systematic instruction and developed and implemented activities for clients. Engagement was measured before and after the 5-week clinical experience.The engagement of clients increased with the implementation of systematic instruction following staff training. The implications are discussed.

The unique challenges associated with providing substance abuse treatment in rural settings with publicly funded clients are examined. Solution-focused strategies have proven particularly well suited to these settings. Strategies and techniques discussed include a strong focus on client engagement and use of client feedback, focus on “wellness,” use of the “miracle question,” and exception periods.

Although there is widespread acceptance that services should be evaluated there is little evidence that evaluations have much influence on services. This study reports an evaluation which was designed specifically to influence development in a residential service for adults with mental handicap. A rationale is provided for the design of the evaluation and the subsequent evaluation process and methodology is described. Results are presented which show that ‘second generation’ services can achieve levels of performance similar to those reported by ‘exemplary’ projects on such measures as client engagement and staff interaction. Equally, the marked variability in results across the district-wide service indicated both the need and the scope for significant improvements. The consequences of feeding back this information to management are described. Finally the practicability and usefulness of this type of evaluation are discussed.

Behavioral health treatment agencies often struggle to keep clients engaged in treatment. Women clients often have additional factors such as family responsibilities, financial difficulties, or abuse histories that provide extra challenges to remaining in care. As part of a national initiative, four women-focused drug treatment agencies used process improvement to address treatment engagement. Interviews and focus groups with staff assessed the nature and extent of interventions. Women-focused drug treatment agencies selected relational-based interventions to engage clients in treatment and improved four-week treatment retention from 66% to 76%. Process improvement interventions in women-focused treatment may be useful to improve engagement.

Home visitation programs have exhibited modest impact in promoting maternal and child health outcomes; therefore, formative research is necessary to examine whether home visiting program models or actual implementation need to be modified. In particular, client engagement and retention have been identified as areas in which program implementation can be enhanced. This study assessed home visiting clients' reasons for entering home visiting programs and their perception of programs' response to these identified needs. We asked newly enrolled home visiting clients ( n = 123) to identify reasons for entering their home visiting program, including their first and second most important reasons. The most frequently cited reasons for enrolling were wanting information about job training, completing one's education, keeping in good health during pregnancy, and learning about infant growth and development. Home visiting programs' response to clients' identified needs varied. Needs more closely related to home visiting program goals of providing parenting education and promoting prenatal health were most often met, whereas needs less closely related to program goals (e.g., life course needs such as information about job training or education) were less often met. Our findings suggest that home visiting programs in urban contexts should consider modifying their program protocols to better respond to employment- and education-related issues facing their clients.

To meet the needs of clients, mental health clinics must offer responsive, organized intake procedures. Clients who receive rapid intervention when they request therapy services are more likely to attend and benefit from therapy. The present study examined the effects of implementing a web-based scheduling program on treatment delays and first session attendance. Results indicated that the use of a web-based scheduling system significantly reduced the number of days clients waited for a first appointment and increased the number of kept appointments. Additionally, clients provided with an immediate response to their request for treatment successfully terminated from therapy after fewer sessions.

Two nonspecific organizational factors-consensus, defined as agreement within staff and client groups, and concordance, defined as agreement between staff and client groups-were shown to influence client engagement in treatment in a national sample of 80 residential substance abuse treatment programs including 595 staff and 3,732 clients. Agreement was tested using a combined therapeutic community, cognitive-behavioral therapy, and 12-step treatment scale completed by staff and clients. Treatment engagement was measured by the combined scores on the three scales completed by the clients, including engagement, rapport with the counseling process, and confidence in treatment. Within-group consensus was measured by the standard deviations of the mean scores, whereas between-groups concordance was measured by the standard error of the difference between staff and client mean scores. Regression analyses showed that staff consensus was a significant independent predictor of client treatment engagement (p.05), whereas client consensus approached significance (p.10). Concordance was also a significant predictor of client engagement (p.002) after controlling for staff and client consensus. The potential contribution of the findings to a better understanding of program quality and effectiveness of programmatic interventions is discussed.

Client return for post-intake therapy is one indication of client engagement in the therapy process. A therapist's verbal responses from seven engagement and four nonengagement interviews were classified using the 12-category Hill Therapist Verbal Response Category System (Hill, 1993). In engagement interviews, the therapist provided the client with more information than in nonengagement interviews. Therapist information utterances increased and therapist use of questions decreased throughout engagement sessions. In nonengagement interviews, therapist information declined and therapist questions increased during the sessions. Results suggest that clients returned for further therapy after intake when their problems had been clarified through the use of questions and work on the problems had begun with the therapist providing information.

African-Americans have, without their knowledge and consent, been used as human guinea pigs in scientific and medical experiments by private and governmental organizations. As a result many African-Americans approach the health care industry with caution and apprehension. African-Americans are admonished to remember the atrocities they once experienced and to approach participation in clinical studies with skepticism. This paper presents an historical overview of conspiracy theories, discusses various health issues that affect African-Americans, identifies for whom participation in clinical trials could prove beneficial, and recommends methods that can be used to attract African-American clients as active participants in clinical studies.

Delivering pediatric rehabilitation services to immigrant parents of children with disabilities requires the practice of culturally sensitive care. Few studies have examined the specific nature of culturally sensitive care in pediatric rehabilitation, especially the notions of effective communication and client engagement.Interviews were held with 42 therapists (10 social workers, 16 occupational therapists and 16 speech language pathologists) from two locations in Canada (Toronto and Quebec City). Data were analyzed using an inductive content analysis approach.Study themes included the importance and nature of effective communication and client engagement in service delivery involving immigrant parents. Participants discussed using four main types of strategies to engage immigrant parents, including understanding the family situation, building a collaborative relationship, tailoring practice to the client's situation and ensuring parents' understanding of therapy procedures.The findings illuminate the importance of effective, two-way communication in providing the mutual understanding needed by therapists to engage parents in the intervention process. The findings also richly describe the engagement strategies used by therapists. Clinical implications include recommendations for strategies for therapists to employ to engage this group of parents. Furthermore, the findings are applicable to service provision in general, as engaging families in a collaborative relationship through attention to their specific situation is a general principle of good quality, family-centered care. Implications for Rehabilitation Effective communication permeates the delivery of culturally sensitive care and provides mutual understanding, which is fundamental to client engagement. The findings illuminate the nature of "partnership" by indicating the role of collaborative therapist strategies in facilitating engagement. Four main strategies facilitate effective communication and client engagement, including understanding the family situation, building a collaborative relationship, tailoring practice to the client's situation and ensuring parents' understanding of therapy procedures. Engaging families in a collaborative relationship through attention to their specific situation is a general principle of good quality, family-centered care.

In the last decade Drug Courts have been developed in hundreds of American communities. Little attention in the research has been given to the retention of diverse client groups who have been subject to legal inducement for treatment through Drug Courts. This article examines a Drug Court that offered culturally specific programming as a strategy to enhance retention in the treatment of female and African-American male substance abuse offenders. The study found that mandating treatment is insufficient to foster client engagement. Retention was significantly enhanced by treatment that recognized cultural differences among client populations.

Client engagement in drug abuse treatment is associated with favorable treatment outcomes, but it is not completely understood why some clients are more likely to engage in treatment. This study examines a wide array of client characteristics and treatment experiences potentially associated with engagement. Findings from the Los Angeles Target Cities Project, funded by the Center for Substance Abuse Treatment, indicate that the predictors of treatment engagement are generally confined to current treatment experiences. For both women and men, the perceived utility of treatment, ancillary services, and the client-counselor relationship are the strongest predictors of client engagement in treatment. Client characteristics are generally not strong predictors of treatment engagement. Concerning the client-counselor relationship, the findings suggest that women may respond more favorably to an empathic counseling style, whereas men may respond to a more utilitarian style. The findings contradict popular stereotypes about the treatment-"receptive" client, identify possible directions for treatment improvement, and highlight the need for more research examining the treatment experience of the client. Other research, clinical, and policy implications are discussed.

Integrative models containing client and treatment components were tested in a sample of 396 daily opioid users from three methadone maintenance treatment sites. Measures included client motivation at intake as well as repeated assessments of therapeutic engagement (relationships between clients and their counselors, session attendance, and results of urine testing) during the first 6 months of treatment. There was a positive effect of pretreatment motivation on greater engagement and a reciprocal positive relationship between components of engagement and their effects on lowering drug use throughout treatment. Further analyses addressed differential effects of group versus individual counseling and showed that group session attendance was associated with higher rates of drug-negative urines.

In her article, Frimpong1 studied the availability of on-site HCV testing in a sample of opioid treatment programs (OTPs) and found that nearly 68% of these programs required staff for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly in OTPs with a greater number of injection drug users (IDUs) among the clients. The author noted that the limited HCV testing services in OTPs is a key challenge to reducing HCV in the United States where HCV has surpassed HIV as a cause of death and is particularly prevalent among IDUs. The literature suggests that it is not only lack of availability of services but also factors such as stigma, low-perceived priority of health care, and convenience that determine IDUs’ access to health care.2,3 Drug use, particularly injection drug use, is a highly stigmatized activity. Thus, it is desirable to offer essential care to this group from venues where social stigma is less of an issue. OTP clinic and syringe exchange program (SEP) are two such venues where drug use is acknowledged with no or little judgment.4 This atmosphere increases IDUs’ willingness to disclose risk behaviors.5 In addition, regular attendance at OTPs and SEPs offers valuable opportunity for offering essential care. Because IDUs often view health care as being low priority compared to other needs such as obtaining food, housing, and drugs. If health care cannot be obtained when finally sought, then it may become low priority by the scheduled appointment time. Health services subsequently miss a valuable opportunity to provide care to this group at an early stage of need, which can then result in potentially harmful consequences for the individual and the broader community.6 Moreover, offering on-site HCV testing and other essential services may foster a therapeutic environment, client engagement, and OTP retention.7 Together these observations highlight the importance of a strategic and consistent approach to successfully offering essential care to this group, preferably from venues of convenience and less stigma. In every setting, different groups will have different health care needs, mandating provision of services that are appropriately differentiated to meet a target group’s priorities. OTPs and SEPs are well positioned to offer on-site testing for HCV, other blood-borne viruses, sexually transmitted infections, and for providing associated care. In fact, these venues increasingly represent targeted primary health care sites.5,8

Motivational interviewing is increasingly being integrated into existing treatments for major mental health problems in order to enhance client engagement with treatment. This chapter outlines the critical importance of resistance in therapy and discusses two forms of it: intrapsychic resistance (fear of change) and interpersonal resistance (opposition to the therapy/therapist). Motivational interviewing can be thought about as a way of managing and working with resistance (either type) to enhance client intrinsic motivation and collaboration in the therapy process. Thus, it is argued that a major contribution of motivational interviewing is in the provision of a framework for viewing and responding effectively to resistance. The basic philosophy and principles of motivational interviewing are discussed in this context and clinical examples of using motivational interviewing to work with resistance are detailed. Keywords: motivational interviewing; resistance; cognitive behavioral therapy; motivation; collaboration

An implementation analysis conducted as part of a 2-year experimental study of residential and nonresidential treatment programs for the dually diagnosed homeless found significant differ ences in client engagement and retention, as well as unexpected variations in the treatment conditions. Fully 40% of subjects assigned to either treatmentfailed to become engaged for even one day, although a significantly higher percentage of those assigned to the residential program than the nonresidential program graduated from the first 3-month phase of treatment. The analysis revealed significant differences in the type and amount of services provided by the two treatment programs, as well as potentially important difficulties in program management. Such process data are valuable toolsfor understanding client outcomes and interpreting experimental results.

This study examined the relationship between clinically significant symptom change (rated by youth and parents), severity of client-defined primary presenting problems (i.e., Target Complaints), and perceived change in therapy. Participants were 117 adolescents receiving outpatient therapy and their parents. Participants completed the following measures at intake and 3 months into treatment: Ohio Scales, Target Complaints, and Perceived Change. Results indicate significant correspondence between clinically significant symptom change and other outcomes, offering preliminary evidence that global symptom measures represent change that is meaningful to adolescent clients. However, the modest magnitude of the correspondence also suggests that such measures as perceived change and individualized Target Complaints may offer unique utility in capturing the multidimensional nature of outcomes in youth therapy and provide useful avenues for future research focused on enhancing client engagement and retention. Recommendations for outcome assessment in community mental health centers are provided.

The present paper describes client engagement issues encountered in a research demonstration program that provides treatment for homeless polydrug users in Philadelphia. To better understand the reasons for premature program disengagement, various points of attrition in the subject recruitment and program sequence were identified, process evaluation data were used to closely monitor attrition, client interviews with program dropouts were conducted, and feedback was solicited from staff. In response to the problem, a multi-pronged strategy was formulated to reduce the number of clients leaving prior to completing treatment, and to increase the number who reengage with the program.

Mental health clinicians and program administrators must implement effective strategies for engaging and retaining clients in care. At a recent series of forums open to providers from clinics in New York City that was sponsored by the city and state public mental health authorities, high-performing providers described their client engagement strategies. In this column the effective strategies reported are summarized in four areas: the first session, staff training and expertise, productivity measures, and engaging families and support persons. The approaches should be of use to administrators to improve programs' ability to engage and retain clients in community-based clinic care.

Bibliotherapy is a form of self-administered treatment in which structured materials provide a means to alleviate distress. Although the treatment has evidence of effectiveness, evaluations of bibliotherapy have typically focused on outcomes, and the perspectives of both the client and the service provider have been understudied. In the present study, eleven users of a bibliotherapy scheme were interviewed regarding their experiences of bibliotherapy. In addition, five referring practitioners to the scheme were also interviewed. Thematic analyses revealed three super-ordinate themes in the transcripts: participants' personal experiences of the bibliotherapy scheme factors that facilitate change and the influence of the professionals involved. The implications of these findings for bibliotherapy schemes are considered. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: • In primary care, bibliotherapy can be useful for early intervention with people experiencing mild to moderate psychological problems. • Referring practitioners actively involved in bibliotherapy can benefit from the feedback obtained from recipients in terms of monitoring progress. • There is a relatively high level of patient acceptability for participation in bibliotherapy schemes. • The role of allied professionals in bibliotherapy delivery requires consideration as it impacts on client engagement with the scheme.

This article discusses a two-phase demonstration project focused on the implementation of the Network for the Improvement of Addiction Treatment model of process improvement among substance abuse treatment providers in Los Angeles County, California. A total of 30 Change Teams from 12 county-contracted treatment agencies planned and executed one or more rapid-cycle change projects to reduce wait time to treatment, reduce no-shows to scheduled appointments, increase admissions, or improve continuation in treatment. The findings and lessons learned illustrate the importance of a concrete and straightforward methodology and consistent peer-to-peer interaction provided in a learning collaborative environment. In addition, both ongoing technical assistance and coaching are essential for successful implementation of this innovative, low-cost, evidence-based process improvement strategy.

This paper describes reconstructive group therapy with people affected by AIDS. It begins with the therapeutic need as we defined it in the AIDS-affected community and the practicalities of the group therapies we offered. The reconstructive perspective, based on personal construct theory, is then explored and applied to interpret both the psychosocial functioning of AIDS-affected people and group therapy. The group therapy process is described: client engagement and group beginnings, goals, group rules, leadership roles, group experiments, group issues and endings. Some problems that arose are then identified; and a sample of group process is provided. Finally, the appropriateness of the reconstructive perspective and of group therapy for these clients is discussed, together with the identification of the major ethical issues and some recommendations for its use.

This investigation explored the relationship of client engagement variables (client expectations, therapeutic/working alliance, and session attendance) with treatment satisfaction and posttreatment drinking-related outcomes using data from 2 outpatient alcohol treatment studies (N=208). Path analysis was used to test a model in which engagement variables jointly influence client satisfaction with treatment and subsequent drinking-related outcomes. The proposed model fit well with the data and accounted for 14-23% of the variance in posttreatment outcomes. The relationships in the model suggest that the link between treatment satisfaction and outcome is clarified by examining client engagement variables, which relate indirectly to outcome by means of client satisfaction.

Client attendance at individual counseling sessions in community-based methadone treatment programs was more frequent among clients with self-reported psychological problems at intake. These problems included anxiety, depression, suicidal ideation, and other symptoms suggesting psychopathology (hallucinations, difficulty controlling violence, etc.). The sample consisted of 462 clients in treatment at least 90 days, divided into two groups of no psychological problems reported at intake (no problems group, N = 341) and two or more problems reported (high problems group, N = 121). The high problems group was twice as likely to attend the treatment program's recommended minimum number of individual counseling sessions (two per month) than was the no problems group, and was more likely to discuss psychological issues in their individual counseling sessions. The high problems group showed significant decreases in drug use and illegal activity in the first 3 months after admission and did not differ significantly from the no problems group on drug-positive urines or illicit activity at month 3. Within the high problems group, clients who attended at least two individual sessions per month reported less cocaine and speedball use during treatment than those who attended fewer sessions.

In a previous study (Felce, de Kock and Repp, 1986), appropriate client activity was found to be considerably higher in two community homes for severely and profoundly mentally handicapped adults than in a number of institutions. Client activity was also shown to be related to the extent of staff interaction. The method of this study was replicated in a two-year follow-up to investigate whether these desirable levels of staff interaction and client activity were maintained. Client engagement in appropriate activity remained similar for five subjects but had fallen slightly for a further five. The duration of instruction given to the majority of subjects by staff had declined but so too, for a variety of reasons, had staff–client ratios. Overall, the follow-up data give a general impression of the maintenance of client activity with some subjects engaging with greater independence. However, interpretation is dependent on the role that staff–client ratio may play in determining staff performance and in particular their level of interaction with clients.