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Practice Corner: Forty Years of Engagement Research in Children’s Mental Health Services: Multidimensional Measurement and Practice Elements

Practice Corner Author: Taylor N. Stephens, M.S., Palo Alto University

Article Title: Forty Years of Engagement Research in Children’s Mental Health Services: Multidimensional Measurement and Practice Elements

Article Authors: Kimberly D. Becker, Maya Boustani, Resham Gellatly, & Bruce F. Chorpita

Why is this article relevant to practice? While the dissemination of evidence-based treatments (EBTs) is growing, youth and family utilization of mental health services remains alarmingly low. Becker and colleagues propose that we can improve child and family mental health service engagement by actually measuring it in both research and practice. Highlighting the multifaceted, dynamic, and transactional nature of engagement in mental health services, Becker and colleagues look beyond mere session attendance, by introducing and applying a multidimensional measurement framework to better capture engagement: relationship, expectancy, attendance, clarity, and homework (REACH).  This “REACH” framework is relevant for youth-serving clinicians to consider key factors that may impact their clients’ engagement in treatment, while simultaneously challenging future research to further develop, and incorporate relevant domains and metrics.

Additionally, Becker and colleagues nicely distill the discrete clinical procedures (“practice elements”) pertinent to engagement across effective interventions. They identified the five most frequently included elements were: assessment (of client’s strengths and needs), psychoeducation (e.g., review of information on treatment in relation to the presenting problem), accessibility promotion (e.g., on-site childcare, taxi vouchers), eliciting barriers to treatment (e.g., scheduling, stigma, transportation), and goal setting (explicit selection of a therapeutic goal and plans to achieve it). Consideration of these factors in clinical settings may hopefully lead to a reduction in treatment barriers and increase engagement in treatment, while consideration of these factors in research settings may increase the relevancy and accuracy of engagement levels reported when examining a new EBT.

What are the key takeaways from the article?

  • Lack of engagement in mental health services remains a serious problem. 50% of youth and families that may need or benefit from services are not enrolling in treatment, and more than 50% of those that do enroll end up terminating early. While studies of novel evidence-based treatments (EBTs) in efficacy trials tend to report high attendance, these results do not translate to high engagement by actual clients in community settings.
  • Due to the multifaceted, dynamic, and transactional nature of engagement, there are additional factors beyond purely attendance that may illustrate engagement. The multidimensional REACH framework highlights five to consider:
    • Relationship: e.g., therapeutic alliance
    • Expectancy: beliefs that treatment will be helpful, and that one can participate successfully
    • Attendance: presence for treatment sessions
    • Clarity: “understanding about the treatment approach or the roles of each person involved in treatment” (p. 2)
    • Homework: “reflects multiple adherence/participation dimensions” such as homework completion and in-session participation (p. 2)
  • Five practice elements most commonly included in effective engagement are: assessment, psychoeducation, accessibility promotion, barriers to treatment, and goal setting. Assessment and psychoeducation are the top two that appear to be the most promising candidates for “promoting engagement universally across domains”
    • Assessment: guides case formulation, allows the clinician to learn the client’s story, enables the client to learn the clinician’s style, while prompting client participation which sets an expectation of involvement in treatment and sets the stage for psychoeducation
    • Psychoeducation: enables a clinician to share information relevant to the problem and treatment, delineate roles and responsibilities in treatment, introduce treatment rationale, and assess for clients’ understanding and expectancies
      • Both of these variables map onto multiple of the REACH factors

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Full Article Reference: Becker, K.D., Boustani, M., Gellatly, R., & Chorpita, B.F. (2018). Forty years of engagement research in children’s mental health services: Multidimensional measurement and practice elements. Journal of Clinical Child & Adolescent Psychology, 47(1). 1-23. doi: 10.1080/15374416.2017.1326121