Explaining engagement in outpatient therapy among adults with serious mental health conditions by degree of therapeutic alliance, therapist empathy, and perceived coercion.

Abstract

Objective: Adults with serious mental health conditions (SMHC) experience higher rates of disengagement from treatment. Factors associated with engagement in treatment in general for this population include therapeutic alliance, provider empathy, and perceived coercion. This cross-sectional exploratory study addressed the question: To what extent do client perceptions of therapeutic alliance, therapist empathy, and perceived coercion explain the degree of engagement in outpatient therapy for adults with SMHC? Method: An anonymous online survey measuring study variables was completed by 131 participants. The relationship between variables was tested using multivariate regression analysis with hierarchical blocks. Results: After separating therapeutic alliance and therapist empathy in the analysis due to multicollinearity and accounting for the influence of control variables, therapeutic alliance (B = .43, p < .01) and therapist empathy (B = .25, p < .01), but not perceived coercion, were associated with the degree of client engagement. Conclusions and Implications for Practice: For adults with SMHC enrolled in outpatient therapy, therapeutic alliance explained the greatest variation in the degree of engagement. Participants appeared to use outpatient therapy as a main strategy for pursuing recovery, and engagement in therapy may be increased if providers utilize strategies to strengthen expressions of empathy and bolster alliance. Additional research is needed to enhance understanding of engagement in therapy for this population and to develop more sensitive measures for evaluating these constructs. Impact and ImplicationsThis study found that greater degrees of therapeutic alliance and therapist empathy were associated with enhanced engagement in outpatient therapy for adults with serious mental health conditions (SMHC). Providers may improve the degree of engagement in outpatient therapy for adults with SMHC by strengthening expressions of empathy and purposefully incorporating strategies to foster alliance. Given the reliance on outpatient therapy as a main strategy to pursue recovery for participants in this research, engagement in therapy is a paramount goal to support overall well-being and promote personal recovery.

Recovery-oriented psychotherapy: Practical recommendations for psychologists in organized care settings.

“…This article offers an initial conceptualization of the overlay between recovery and the common processes of psychotherapy. The practical recommendations presented in this article extend research that demonstrates linkages between psychotherapy process and recovery outcomes of individuals living with mental health conditions and receiving psychological services (e.g., Mallonee et al, 2022; Neale & Rosenheck, 1995) by providing psychologists and other mental health providers with specific clinical recommendations. In doing so, this article helps to resolve practical confusion and misuses of recovery in practice that others have previously identified (Jaiswal et al, 2020; Slade et al, 2014).…”

“…Few studies in the recovery literature have examined process variables (particularly the working alliance) and their impact on functional and treatment-related outcomes among individuals living with mental illnesses. These studies find that a stronger working alliance is associated with reduced symptom severity and increased global functioning (Neale & Rosenheck, 1995) as well as increased engagement in outpatient mental health services (Mallonee et al, 2022). However, beyond noting the importance of process factors in recovery outcomes, no comprehensive attempts have been made to detail the ways in which the process of psychotherapy unfolds within a recovery-oriented framework.…”

Service user perspectives on social prescribing services for mental health in the UK: a systematic review

“…38 research consistently reports that care matched to a person's preferences and values leads to better engagement, adherence and satisfaction with treatment and services, 39,40 while also promoting self-determination, choice and autonomy, which are core components of recovery-orientated practice. 41,42 Principles of shared decision-making include a positive therapeutic alliance, which is a strong predictor of engagement in therapy 43 and outcomes in case management services in community mental health. 44 The development of supportive social environments, created by social prescribing services, allowed service users to build their own community and support network.…”

A model of the early therapeutic environment: Predicting client attrition.

“…In addition to empirical evidence for rapid change in alliance and distress, in conjunction with early attrition, research has also demonstrated empirical associations in expected directions among these constructs. Client attrition has been linked with alliance and distress as well as with client expectations, therapeutic dosage, motivation to begin therapy, and both client and therapist interpersonal skills (Clarkin & Levy, 2004;Garland et al, 2012;Holdsworth et al, 2014;Longo et al, 1992;Mallonee et al, 2021;McEvoy et al, 2013;Sun et al, 2021;Swift & Greenberg, 2012;Tracey, 1986;Tryon, 2002). Client attrition, for example, often occurs at roughly the same time the alliance fails to form (Sharf et al, 2010;Tryon & Kane, 1993).…”