Strategies to Predict, Measure, and Improve ...

PERSPECTIVES Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence Robin E. Gearing, PhD, Lisa Townsend, PhD, Jennifer Elkins, PhD, Nabila El-Bassel, PhD, and Lars Osterberg, MD, MPH Abstract: Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians’ recommendations. Empirically supported, evidencebased, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.

Keywords: adherence, discontinuation, dropout, nonadherence, premature termination, psychosocial treatment, treatment compliance, treatment noncompletion

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onadherence to psychosocial treatment is a significant public health problem that presents a barrier to recovery and symptom improvement. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians’ recommendations.1–5 Psychosocial treatment nonadherence, also called premature termination, discontinuation, or dropout, is a fundamental challenge in the treatment of mental disorders. Psychosocial treatment nonadherence is associated with poor recovery, symptom relapse, medication nonadherence, impairment, and inefficient use of mental health resources.1,4,6–10 Similar to medication adherence, completing recommended psychosocial treatment regimens is a critical component of recovery from many mental health disorders and is recognized as an essential ingredient for successful interventions.8 Psychosocial treatments include forms of psychotherapy, behavioral treatment, or talk therapy to assist, help, or support individuals with their mental illness, symptoms, or presenting problems. Psychosocial treatments involve active collaboration between clients and their mental From Columbia University School of Social Work (Drs. Gearing and El-Bassel); Johns Hopkins University Bloomberg School of Public Health (Dr. Townsend); University of Georgia School of Social Work (Dr. Elkins); and Stanford University School of Medicine (Dr. Osterberg). Original manuscript received 15 March 2013; revised article received 19 July 2013, accepted for publication 17 September 2013. Correspondence: Robin E. Gearing, Columbia University, 1255 Amsterdam Ave., New York, NY 10027. Email: [email protected] © 2014 President and Fellows of Harvard College DOI: 10.1097/HRP.10.1097/HRP.0000000000000005

Harvard Review of Psychiatry

health providers over a period of time and number of sessions. Psychosocial treatments are guided by a range of approaches from structured, manualized, empirically supported interventions or evidence-based practices with a contracted number of sessions, to more open client-provider collaborations based on a specific theoretical or eclectic approach. The last few decades have witnessed an explosion in the empirically supported psychosocial and behavioral interventions available to treat an increasingly wide range of mental health conditions. A core underlying assumption of most, if not all, evidence-based interventions is that clients will fully and actively engage in the treatment protocol.11 Psychosocial interventions are likely to be ineffective with clients who drop out of treatment prematurely or who fail to adhere to intervention protocols. Despite annual investments of millions of dollars to develop and disseminate these interventions, nonadherence remains a significant threat to treatment effectiveness.12–17 Although the influence of medication adherence on health outcomes has been widely investigated, psychosocial treatment adherence has received less scientific attention. Treatment adherence is a critical factor associated with positive outcomes in the following areas:18 changing symptom course; reducing episode recurrence and rehospitalization; and lessening the illness burden, disability, and impairment associated with mental health diagnoses. Adherence to psychosocial treatment also promotes medication adherence and improvements in social, psychosocial, and family functioning.1,19 Nonadherence to psychosocial treatment is associated with increased societal burden, including elevated health care, occupational, and academic www.harvardreviewofpsychiatry.org

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costs. For example, treatment expenditures are higher for individuals who do not adhere to outpatient treatment (medication or psychosocial); nonadherence is associated with increased use of inpatient services.20–23 Drawing extensively from existing research, this comprehensive review aims to (1) conceptualize and categorize psychosocial treatment adherence, (2) examine predictors that influence adherence to psychosocial treatments, (3) identify treatment-response patterns that relate to adherence, (4) summarize measures of adherence, and (5) describe existing interventions to enhance psychosocial treatment adherence. This review provides clinical practitioners and researchers a guide to identifying and measuring predictors of psychosocial treatment adherence, and it describes intervention strategies to enhance adherence.

METHODS Peer-reviewed publications on psychosocial and behavioral treatment adherence were searched using Medline and PsycINFO electronic databases. All searches were limited to peer-reviewed studies published in English between 1 January 1980 and 1 January 2013 that matched the MeSH and search keywords across three areas: psychosocial treatment, mental health, and adherence. Psychosocial treatment area keywords included the following: behavioral treatment, psychosocial treatment, evidence-based practice, empirically supported, case management, and psychotherapy. Mental health area keywords included: mental health, mental illness, mental disorders, and psychiatric disorders. Adherence area keywords included: adherence, adherent, treatment compliance, compliance, compliant, treatment dropouts, dropouts, premature termination, treatment termination, discontinuation, and nonadherence. Exclusion criteria included: (1) non-English publications; (2) publications prior to 1980; (3) training or fidelity studies; (4) treatment focus on medication; and (5) editorials, letters, comments, and conference or congress abstracts. Excluding duplicates, 463 articles were initially identified. A separate review of the associated abstracts by two of the research team (RG and JE) resulted in the inclusion of 40 articles. The research team then notably broadened the search by reviewing and incorporating studies and publications from reference lists from the identified articles. ADHERENCE AND PSYCHOSOCIAL TREATMENT Epidemiological studies suggest that more than one-third of individuals who seek psychosocial and behavioral treatment for mental health conditions terminate prematurely.2,9,24–30 Conceptualization of psychosocial treatment nonadherence focuses primarily on session attendance, degree of engagement within sessions, and completion of therapeutic tasks between sessions. Nonadherence in each of these domains carries different implications for therapeutic outcomes. No single, generally accepted definition of psychosocial treatment adherence is available; rather, a wide variety of 32

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definitions has been used to describe the construct, and multiple measures have been developed to characterize it. The following three core elements need to be included in any potential definition of psychosocial treatment adherence: (1) session attendance (i.e., intervention dosage); (2) intrasession involvement (i.e., intervention participation within sessions); and (3) inter-session involvement (i.e., homework completion). Research on temporal patterns of symptom improvement has found that 35% of psychotherapy clients, including both adults and adolescents, experience rapid early response31,32 or sudden session-to-session reductions in mental health symptoms early in treatment.33 These sudden improvements occur on average by the fifth session,34–36 with participants achieving most of these gains by the tenth session.33 Research has also identified that 40%–70% of premature terminations take place early on in treatment—notably, the first two sessions.28,37–41 Thus, it is not surprising that clients who remain in treatment longer have been shown to have superior outcomes compared to those with who drop out prematurely.18 Laurenceau and colleagues42 note that treatment takes a certain amount of time to exert its effect on participants; consequently, although overall treatment adherence is essential, early treatment adherence can be decisive. Notwithstanding these different patterns of treatment response, adherence to the early phase of psychosocial treatment is exceptionally critical to, and often reflects, the majority of the overall treatment gains. Adherence to psychosocial treatment needs to be evaluated not only preand post-treatment, but at multiple assessment points throughout the intervention, especially within the early phase of treatment. Proactive screening to predict which clients are at risk of premature termination is not, however, a standard part of clinical practice. And no gold standard is currently available for measuring psychosocial treatment adherence; the methods in use range from simple calculations of physical attendance to more complex ratings of clients’ engagement during clinical interactions. That said, improving clinicians’ capacity to identify clients who are likely to disengage from psychosocial treatment may help clinicians to target engagement efforts in ways that enhance clients’ persistence with treatment and that also conserve limited agency resources.

TYPES OF NONADHERENCE Session Attendance The most commonly reported form of nonadherence is missed or sporadic session attendance, including premature dropout. Session attendance, or intervention dosage, is most commonly characterized and reported as the ratio or percentage of sessions that clients attend in relation to the total number of sessions recommended or expected4,11 (though many studies, instead, simply count the number Volume 22 • Number 1 • January/February 2014


Psychosocial Treatment Adherence

of sessions attended or canceled).11,43 Intervention dosage measures are a popular choice for clinicians and researchers due to their relative ease, low cost, efficiency, and standardization. Although intervention dosage is a useful and serviceable measure of adherence, efforts to measure it are limited by their retrospective nature. It is difficult to calculate intervention dosage prior to the conclusion of therapy, given that sessions are often scheduled as treatment progresses and are contingent upon client and therapist schedules. Consequently, clinicians are not able to make proactive changes to increase adherence. Another complication is that, while common patterns of nonadherence may include sporadic attendance rather than complete termination, those patterns, when calculated retrospectively, may show no mathematical difference between clients who attend treatment sporadically and those who attend regularly but terminate prematurely. That is, clients can attend similar numbers of sessions, but their patterns of adherence can be distinctly different —depending on length of treatment and consistency of attendance, and leading to different outcomes. Given the above, intervention dosage, as a proportional measure, is most meaningful in treatments with a designated number of sessions, such as a manualized evidence-based treatment, rather than with open-ended treatments. Another common definition of adherence is as completion of treatment, though how completion is defined is itself a matter of considerable variation. Treatment completion can be connected to an outcome, such as a subjective (as determined by either the client or the clinician) or objective (standardized measurement) improvement in symptoms, the time in treatment (e.g., the completion of a three-month intervention), or a prescribed number of sessions (e.g., the completion of a 12-session intervention). At one extreme, treatment completion can be defined by attendance at the initial session only (following previous intake/referral). At the other extreme, the definition can incorporate attendance at follow-up or booster sessions after regular treatment has ended.44–47 Interpretations of level of adherence can also range widely. One study defined adherence as attending 4 or more sessions out of a maximum of 25,48 whereas other studies have defined adherence as attending every session.49,50 More recently, researchers have added therapist judgment as a determinant of treatment completion and have also, in some cases, added the client’s agreement regarding whether treatment should end.14,51–54 Intra-session Involvement Lack of within-session engagement, or intra-session involvement, represents a less easily measured form of nonadherence to psychosocial treatment. Within-session engagement can be construed as the degree of active participation that a client exhibits in session, the degree to which a client integrates or applies therapeutic insights or skills during sessions, or the consolidation of learning that occurs during clinical contact. Although intra-session client involvement Harvard Review of Psychiatry

has demonstrated utility in predicting clinical outcomes,55 client involvement in sessions is less commonly measured than objective session attendance—likely due to the inherent difficulty in developing behavioral measures of client internal processes, such as active listening and internal application of therapeutic learning. Various rating scales have been developed to operationalize clients’ within-session involvement. Early measures of within-session involvement required ratings by an external observer who was not actively involved in the session; examples include the Therapeutic Alliance Rating System56 and the Penn Helping Alliance Methods.57 The Psychosocial Treatment Compliance Scale is a 17-item, case manager–rated scale for use with people who have psychotic disorders.19 Incorporating an external observer, however, is rarely feasible in routine clinical practice. Adaptations of these external-observer methods have been developed that allow clinicians and clients to self-report their degree of involvement and collaboration in the therapeutic interaction.58 Client contributions to the therapeutic relationship are associated with their mental health outcomes; consequently, early detection of clients’ negative contributions to the therapeutic alliance are recommended.56 The Vanderbilt Psychotherapy and Process Scale59 is a widely used measure and has been adapted for self-report.60,61 This measure examines seven dimensions of clinician and client attitudes and behaviors, such as clinician warmth and friendliness, and client hostility. The majority of studies have used these various measures to examine the relationship between therapeutic alliance and client mental health outcome, but the measures can also be used to operationalize relatively intangible aspects of the client-clinician relationship for the purposes of predicting treatment attrition. Ultra-brief session-rating scales have been developed in paper and mobile phone app forms; these rating scales allow patients to rate their perceptions of the therapeutic relationship after each session (i.e., the Session Rating Scale)62 and also their perceived functional outcomes following each session (i.e., the Outcome Rating Scale).63 These scales comprise four items, can be completed quickly, and can be discussed at each visit. One potential difficulty, however, with use of clinician and client-rated measures to predict attrition is that little is known regarding how to interpret and integrate significant differences between clinician and client perceptions of the therapeutic alliance.58,64 Further research is needed to understand how differences in clinician and client perceptions of the therapeutic alliance affect psychosocial treatment adherence. Inter-session Involvement Session-by-session involvement, or homework completion, describes the degree to which a client completes therapeutic assignments or tasks that are designed to consolidate application of therapeutic constructs in real-life (in vivo) situations.8,65–67 Therapeutic homework is an integral part of www.harvardreviewofpsychiatry.org


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some treatments because it allows clients the opportunity to translate in-session learning to their life contexts. The intention behind homework is to solidify skills taught in session and to enable clients to call upon adaptive skills when the therapist is not present. Homework practice is considered a mechanism by which clients can become proficient at applying new therapeutic skills to their real-world circumstances and are intended, in part, to foster the client’s eventual independence from the therapist. For example, behavioral tasks such as keeping a diary, journaling, and skills worksheets can be assigned to generate awareness of behavior patterns or of emotional responses to triggers, or to support engagement in new tasks. Cognitive exercises, such as thought reframing, impulse-control strategies, and thinking of alternatives to self-destructive behaviors may also be used to enhance in-session learning and enable its translation to the client’s social environment. Homework completion allows for greater ease of measurement than within-session engagement. The ease of measurement will also depend, however, upon the complexity of homework assignments and whether clients are asked to keep documentation of these assignments in the form of homework sheets, diaries, or journal entries—from which the ratios or percentages of the completed assignments can be calculated. Stronger adherence to homework has been associated with improved treatment outcomes for clients.68,69 Research has found that approximately half (56%) of recommended therapeutic homework tasks are completed, with clients completing 67% of their homework through session 8 and only 41% after that point.70 More generally, empirical evidence indicates that homework completion rates tend to be higher early in treatment and diminish over the course of treatment.33,70–73 Clinicians can review clients’ progress in completing assigned therapeutic tasks. Indeed, such review is a foundational element in certain intervention modalities such as cognitive-behavioral therapy (CBT). Adherence can be represented as a binary measure (i.e., the client completed the assigned task or not). Clinicians may also record attempts to complete homework, including partial homework completion, using a Likert scale (e.g., the client completed a certain percentage of the assigned task).74 For clients who do not complete their homework, clinicians may want to consider identifying and measuring barriers to, and promoters of, the assigned tasks. After identifying such barriers and promoters, clinicians could ask clients to prioritize those factors or, using scaling questions, to indicate their effect on completing the assigned tasks. Behavioral assignments that incorporate documentation by patients allow for more transparency in measurement. Tasks such as journaling, diary keeping, skills worksheets, and technology (e.g., smartphone apps or SMS text messaging) can be reviewed for degree of completion. Other forms of therapeutic practice, however—such as thinking about therapeutic discussion between sessions, thought 34


reframing, exerting impulse control, and other relatively intangible activities—are difficult to measure directly. When clients do not complete assigned homework, clinicians can make changes proactively within the sessions. For example, a clinician may assess whether the client was fearful of the homework assignment, did not have time in his or her schedule to attempt the assignment, or did not think the assignment was appropriate or relevant.70 Clinicians may also record attempts to complete homework as well as partial homework completion.74 In these situations, clients have attempted the assigned task but did not complete the work. Discussion of partial completion offers clinicians the opportunity to revise assignments or provide additional supports for completing assignments. Troubleshooting the difficulties in completing homework assignments may also serve to solidify the clinician-client relationship by allowing both the clinician and the client to collaborate regarding barriers to the client’s progress. Table 1 summarizes core measures across the three types of psychosocial treatment adherence.

PREDICTORS OF PSYCHOSOCIAL TREATMENT NONADHERENCE Predictors of psychosocial treatment nonadherence have been conceptualized across a number of common domains, including the individual, family, clinician, agency, and environmental levels.6 Research has identified a number of predictors of nonadherence (see Figure 1). Though not conclusive, the presence of these predictors is a good starting point for recognizing clients who may be at heightened risk of nonadherence and for highlighting areas in which clinicians may be able to intervene to improve adherence. Individual Level Client demographic characteristics are among the significant predictors of psychosocial treatment nonadherence. In a review of the literature on attrition from mental health treatment, Barrett and colleagues75 concluded that minority individuals who are young and economically disadvantaged, and who have less than a high school education, are at higher risk for treatment dropout. Minority race/ethnicity is associated with nonadherence for both youth2,7,76,77 and adults.78 In a study examining predictors of nonadherence and treatment dropout in 196 clients receiving outpatient therapy, Krowinski76 found that ethnic minorities were 2.3 times more likely to be nonadherent in therapy. These findings are troubling, especially given the wellestablished disparities in access to mental health care in the United States for minorities.79 Other demographic factors associated with nonadherence include younger age78,80 and IQ and academic functioning.2 Other factors that may be associated with nonadherence include trauma history,81 criminal justice involvement,2,77,81,82 and prior negative experiences with mental health treatment, particularly for minority populations.83–85 Although demographic characteristics Volume 22 • Number 1 • January/February 2014



A basic count or ratio of the number of sessions attended by the number recommended

Attendance of sessions over the course of a specific period of time (e.g., weeks, months, years)

Completion of subjective or objective outcome, time in treatment, or prescribed number of sessions

Attendance at a session following successful treatment completion

Session attendance

Fixed time-period attendance

Treatment completion

Follow-up session attendance

Measures perception of core elements of the therapeutic relationship between the provider and client (e.g., participation, warmth, negative contribution, goal or task agreement)

Measures client satisfaction with their providers (e.g., counselor qualities) or treatment (e.g., meeting expectations or needs)

Therapeutic alliance

Satisfaction with provider or treatment

Intra-session involvement

Attendance at first session or intake session after referral

Description

Initial session attendance

Session attendance

Measured construct

Methods of Measuring Different Adherence Types

Table 1

Simple count; ratio

Simple count; ratio

Simple count; ratio

Simple count

No prior agreement on the number of sessions Accounting for missed or postponed sessions Retrospective No a priori agreement on treatment length

No a priori agreement or a posteriori agreement on treatment completion between provider and client Retrospective Lack of follow-up session structure (e.g., requirement, length of follow-up, number of sessions)

Objective Simple Inexpensive

Objective Simple Inexpensive Objective Simple Inexpensive



Parent Satisfaction Scale (PSS) Multidimensional Adolescent Satisfaction Scale (MASS)

Satisfaction may not be associated with involvement Objective Established, standardized measures

Continued on next page

Working Alliance Inventory (WAI) Penn Helping Alliance Methods Revised Helping Alliance Questionnaire (HAq-II) California Psychotherapy Alliance Scales (CALPAS) Session Rating Scale (SRS) Outcome Rating Scale (ORS) Psychosocial Treatment Compliance Scale (PTCS) Definition, constructs, and subscales vary across scales Training may be required Some scales are population specific

Objective Common Established, standardized measures Rated from various perspectives (e.g., provider, client, observer)


Simple binary outcome (yes/no)

Example instruments

Accounting for missed or postponed sessions

Disadvantages


Advantages


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Completion of skills practice (e.g., diaries, journal entries, therapeutic worksheets)

Thinking about clinical concepts between sessions (e.g., practicing cognitive reframing, other forms of intangible learning)

At-home behavioral task completion

At-home cognitive task completion

Difficult to quantify or establish agreement on quality or quantity of homework completion Difficult to verify

Simple Inexpensive

Simple count; percentage of completed tasks

Simple count; percentage of completed tasks

Reasons for Ending Youth Outpatient Treatment (RETQ)

Limited research Focus on youth

Objective Established, standardized measures

Measures therapeutic reasons (e.g., relations problems) and concrete reasons (e.g., staff, scheduling, financial) for treatment termination

Reasons for ending treatment

Difficult to quantify or establish agreement on quality or quantity of homework completion

Barriers to Treatment Participation Scale

Limited research Focus on children/youth

Objective Established, standardized measures Multiple raters (e.g., provider, client)

Measures barriers to treatment participation (e.g., perceived relevance, treatment demands, provider-client relationship)

Barriers to treatment participation

Simple Inexpensive

Psychotherapy Process Q-Sort (PQS) Vanderbilt Psychotherapy and Process Scale (VPPS)

Rated by provider or observer


Measures process involvement across the treatment/therapeutic interaction (e.g., participation, exploration, session atmosphere, behaviors, attitudes, affect)

Involvement in the treatment process

Inter-session involvement

Session Rating Scale Version 3 (SRS)

Example instruments

Rated by provider or observer

Disadvantages


Advantages

Measures content of individual sessions (e.g., method, approach, relationship, topics, goals)

Description

Session rating

Intra-session involvement

Measured construct

Continued

Table 1


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Figure 1. Predictors of psychosocial treatment nonadherence.

and prior experiences are not modifiable, clinicians can use knowledge about these factors to tailor psychosocial treatments to be more acceptable to individuals from specific populations at risk for nonadherence. Consistently replicated influences on nonadherence include the following: concrete and structural barriers such as conflicting priorities and situational demands,86,87 scheduling and time-management issues,6,88,89 and lack of transportation.7 Intrapsychic barriers include forgetfulness, anger, self-destructive behaviors, and degree of psychopathology.86,87 For example, using data from the National Comorbidity Survey Replication, Olfson and colleagues28 found that psychiatric comorbidity was associated with higher dropout rates. Behavioral problems are associated with nonadherence in youth,2,7,77,90 and oppositional, aggressive, and antisocial behavior is associated with nonadherence in adults.43,81 For adults with schizophrenia, factors associated with nonadherence include younger age, male gender, minority race/ ethnicity, and low social functioning.91 Findings for personality disorders are equivocal. Whereas some studies have found that cluster B personality disorders predict poor


adherence, a recent meta-analysis found that individuals with personality disorders did not have higher dropout rates in comparison to those with other psychiatric disorders.80 Additional intrapsychic factors, such as client perceptions, attitudes, and assumptions about mental health problems and treatment, are also associated with nonadherence.6,88,92 For example, fear of medication and fear of psychiatric hospitalization were associated with decisions not to seek psychosocial treatment for mental health concerns.93 Low motivation for change6,37,92,94 and lengthy expected treatment duration95,96 are also associated with nonadherence. Similarly, clients who perceive or believe that their symptoms are not improving are more likely to drop out from CBT.37 These concrete, structural, and intrapsychic predictors of nonadherence may be complex and challenging for clinicians to modify. Nevertheless, clinicians can use this knowledge to tailor intervention strategies to address the specific concerns and needs driving these individual-level barriers to psychosocial treatment adherence. Clinicians may be able to measure and influence clients’ attitudes toward psychosocial treatment through ongoing evaluations of



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treatment expectations compared to progress and by course corrections when indicated. Family Level Predictors of nonadherence at the family level center primarily on parental/family demographic and constellation characteristics, family conflict and stress, and other familylevel factors. For children in psychosocial treatment, familylevel demographic factors associated with nonadherence include single parenthood,2,7 low parental education attainment,77,82,97,98 low household income,7,90 and younger parental age.7,82,90 In terms of concrete and structural barriers, parents with external demands that compete with their children’s psychosocial treatment are at higher risk for nonadherence. For example, parents are more likely to terminate services prematurely if they have child care issues99 or multiple children receiving psychosocial treatment.77 Other factors associated with psychosocial treatment nonadherence for children include parental stress,2,7,77,100–102 parenting difficulties,88 parental depression,77,103 parental expectations about treatment and outcomes,104 and parental stigma of psychosocial treatment.6,88,102 Finally, social support and social networks are well-established predictors of service utilization and outcomes for adults seeking psychosocial treatment for their children105–107 and for themselves.108,109 It is important for clinicians to be aware of the role that social support and social networks may exert directly and indirectly in predicting treatment adherence. Clinician Level Demographic and background characteristics of clinicians (i.e., gender, age, experience, and skill) play a key role in clients’ psychosocial treatment adherence. Racial/ethnic similarity between client and clinician is associated with longer treatment continuation.110 Clinician education and experience have also been shown to be associated with treatment completion, though not always in the expected direction.111,112 For example, in a recent study of children receiving community-based psychosocial treatment for disruptive behavior problems, clinician experience was inversely correlated with treatment completion.97 Established clinician-level influences that may contribute to nonadherence include the following: failing to explain benefits or side effects, recommending complex regimens, not giving consideration to patients’ lifestyles, lack of availability, lack of willingness to explore topics of interest to clients, not reflecting clients’ meaning, lack of emphasis on past therapeutic successes, making inaccurate interpretations, not helping clients express affect, and failure to acknowledge clients’ experiences.113 The therapeutic alliance between clinician and client is also an important predictor of psychosocial treatment dropout. In a study examining treatment alliance, Baldwin and colleagues114 found that clinician, not client, characteristics predicted client outcomes. Therapeutic alliance focuses on 38


the quality of the bidirectional and interactional influence of client and clinician characteristics. For example, the clinician’s flexibility, honesty, respectfulness, trustworthiness, confidence, warmth, and interest interact bidirectionally with the client’s emotional attunement, likeability, receptivity, psychological accessibility, and willingness to introspect— contributing strongly to the therapeutic alliance.97,113,115–117 No clear relationships have been found between clinician characteristics and dropout, and the relationship between intervention characteristics and dropout remains unclear. For example, Masi and colleagues118 found no differences in no-show and dropout rates associated with particular treatment modalities (i.e., individual, family, or couples therapy). More recent research has focused on the role of nontraditional modalities (e.g., the use of telehealth [i.e., the use of live visual media via telecommunications technology], social media, and other Web-based technologies) in addressing treatment adherence and dropout. Two recent studies found that individuals receiving cognitivebehavioral interventions delivered via telehealth119 and telephone120 were more likely to complete treatment than individuals receiving in-person, face-to-face interventions. Specifically, Gros and colleagues119 examined the effectiveness of exposure therapy delivered via teleheath in a sample of veterans with posttraumatic stress disorder, and looked at predictors of treatment completion. Finally, in one of the first large randomized, controlled trials to compare CBT delivered via telephone versus face-to-face treatment in primary care patients with depression (n = 325), Mohr and colleagues120 found the former was as effective as the latter and was associated with lower attrition rates. Individuals receiving CBT via telehealth attended significantly more sessions and were less likely to drop out in the early phase of treatment (i.e., prior to week 5). Further research is needed to improve our understanding of clinician and client characteristics related to nonadherence. Agency Level Agency-level predictors of nonadherence can be categorized as constraints that involve funding (i.e., affordability), procedures (i.e., scheduling difficulties), and technology (i.e., lack of email).6 These predictors also include factors such as limited accessibility, goodness of fit, agency location, linguistic barriers, availability, and costs, as well as organizational factors such as health care network restrictions, copayments, and patients’ lack of insurance to cover treatment.121 Examining patterns and predictors of treatment dropout in the National Comorbidity Survey Replication, Olfson and colleagues28 and Wang78 found that the service sector in which care was provided (e.g., general medical provider, psychiatrist, other mental health provider, human services provider) was associated with dropout. Use of general medical providers predicted the highest probability of dropout. The use of alternative medicine, which included self-help groups and treatment from traditional healers, was associated with Volume 22 • Number 1 • January/February 2014



lower likelihood of dropout from traditional mental health services.28 Environmental Level Though considerably less research has focused on the environmental level, established predictors include sociocultural characteristics such as changing norms, cultural barriers, stigma, and opinions of social-network members. Mental health and psychosocial treatment are associated with considerable stigma and fear,88,122,123 particularly for racial and ethnic minorities. Social and cultural explanations for racial and ethnic variation in premature termination, however, have yet to be adequately examined.79

STRATEGIES TO PROMOTE AND ENHANCE ADHERENCE Adherence promotion strategies are practitioner behaviors that can be implemented throughout treatment to encourage adherence (e.g., reminder calls to promote appointment attendance, SMS text messaging, and transportation assistance). Adherence enhancement interventions include (1) more complex, manualized protocols used with clients at risk for nonadherence, and (2) a general set of agency/provider behaviors to promote adherence. Cochrane reviews of medication adherence promoters suggest that a multipronged approach emphasizing frequent, sustained contact increases adherence to medication.124,125 Studies of multipronged approaches have yet to be conducted for adherence to psychosocial treatment.4,11 Most protocols for improving adherence involve combinations of behavioral interventions and efforts both to increase the convenience of care and to educate clients regarding their conditions and treatments.11 A wide spectrum of activities is available to enhance the likelihood that clients will attend scheduled appointments. These interventions range from simple, cost-effective strategies such as scheduling to optimize client attendance, telephone reminder calls, and pre-therapy information groups,126,127 to more complex and intensive interventions, such as combinations of psychoeducation, motivational interviewing, and CBT to address barriers to ongoing adherence.128 Session Attendance Strategies Empirical work suggests that any form of pretreatment contact is associated with increased appointment attendance compared to no pretreatment contact.129 Longer wait times for appointments are also associated with failure to attend.129 Basic pretreatment orientation meetings help to familiarize clients with the treatment process130 and may serve as a tool to prioritize clients who are highly motivated for treatment, thereby reducing overall wait times for those who are seeking services.127 More complex pretreatment orientations combine the provision of treatment information with strategies to increase clients’ self-efficacy. In a 1998 study, McKay and colleagues131 investigated the use of a telephone intervention alone and in combination with Harvard Review of Psychiatry

in-person “engagement” interviews. The telephone intervention sought to increase parents’ self-efficacy in addressing their children’s problems, to initiate implementation of at least some early problem-solving strategies, and to begin a dialogue with families about the psychotherapeutic process. The four critical elements of engagement highlighted in the in-person interviews were the following: “(1) the need to clarify the helping process for the client; (2) the importance of establishing a collaborative working relationship with the client; (3) a focus on immediate, practical concerns; and (4) an emphasis on identifying and ameliorating barriers to help seeking.”131 Findings indicated that both telephone contact and engagement interviews were associated with increased rates of initial appointment attendance; however, the combination of both strategies was associated with a greater number of ongoing kept appointments than telephone contact alone.131 Relatedly, interventions with collateral staff (e.g., receptionists and security guards) may help to create an atmosphere of acceptance and respect that encourages clients to return for continued services following emergency room care.132 Similarly, brief emergency room interventions that help to create realistic expectations regarding follow-up care can help clients to understand the process of receiving mental health care.132 These interventions are associated with higher rates of return for follow-up care than standard emergency room treatment.132,133 More recently, in 2011, Gaudiano and colleagues134 described the initial development of an adjunctive intervention designed to improve both medication and psychosocial treatment adherence in individuals with comorbid bipolar and substance use disorders. This intervention employed three individual meetings, one family meeting with a significant other, and 13 telephone contacts with the client and his or her significant other over a period of six months. Though preliminary, and presented as a case series, data suggest that this intervention may be helpful and effective. Intra-session Strategies for Clinicians Collaborative learning models and collaborative care interventions have been used to promote and enhance psychosocial treatment adherence within session engagement.135 Collaborative care interventions provide clients with a supportive network of professionals and peers, and have been identified to positively enhance treatment adherence.136 As an exemplar, Bauer’s Life Skills Program for individuals with bipolar disorder focuses on forming a collaborative relationship between patients and providers, encouraging patients to take an active role in managing their mood disorders, and aims to create an ongoing and productive clinical relationship that enhances patients’ short- and long-term functioning and productivity.137 Qualitative research with patients who have participated in the program suggest that they welcome a collaborative approach and that collaboration increases the likelihood that they will remain engaged with treatment.138 www.harvardreviewofpsychiatry.org


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“Significant learning models” have been adapted from adult education and applied in the medical arena to help patients learn to live successfully with chronic physical illnesses, such as diabetes.139 These models of collaborative learning and clinical collaboration emphasize constructing a shared understanding of the consequences and management of chronic illness, enabling patients to develop concrete skills for handling symptoms and treatment regimens, and to understand how their social environments affect their ability to manage their illnesses. Although little work has been done to examine the efficacy of significant learning models in the treatment of psychological disorders, these models may hold promise for helping mental health clients manage chronic symptoms of emotional distress. A key aspect of significant learning models in clinical care is that collaborative construction of a treatment regimen capitalizes upon the expertise and knowledge of the clinician as well as the situated knowledge of the client. Barriers to treatment are objectively acknowledged, and plans for ameliorating those barriers are developed in the context of care. Studies that have examined congruency of treatment with patients’ preferences for depression care indicate significant associations between receiving preferred treatment and treatment initiation and adherence.140 Further research is needed regarding the potential utility of these models in the field of mental health. Inter-session Strategies for Clinicians The use of between-session contacts to sustain psychosocial treatment adherence represents an underutilized but promising area of intervention. Surveys of practitioners show that most rely heavily on therapeutic efforts to leverage the therapeutic alliance, but do not employ betweensession contacts such as phone, mail, SMS text messaging, or email.141 Most efforts to maintain a client after he or she begins treatment rely on unplanned, reactive telephone calls and letters following one or more missed appointments.11 Primarily, these contacts serve as a reminder of session schedule or to convey consequences for continued missed appointments such as program discontinuation or return to a wait list. In contrast, research on adherence promotion in the larger general medical field has found that adherence contracts between health care providers and patients increased early session attendance and that multipronged approaches improved adherence to treatment.124,125

Motivational Interviewing In the motivational interviewing (MI) paradigm, clinicians work collaboratively with clients to enhance their motivation to change by exploring and resolving ambivalence associated with the desired behavior.94 MI is a goal-oriented method that has been increasingly used as an adjunct psychosocial treatment to improve clients’ treatment adherence. 40


According to Miller and Rollnick,142 MI helps clients to become increasingly aware of nonadherence issues. Specifically, MI reaffirms clients’ recognition of the problem, explores reasons for nonadherence, explores clients’ roles in improving themselves, discusses treatment options, and evaluates the pros and cons of treatment nonadherence.94 Contingency management, an MI technique used in treating substance abuse, offers clients incentives, such as financial vouchers, contingent on session attendance or submission of marijuana-free urine specimens, and has been found to be effective in reinforcing such goals.143–145 Adding one or more sessions of MI to other psychosocial treatment as an adjunct has been found to improve treatment adherence and to reduce premature termination or dropout.146–150 Although MI has been effective in improving adherence within some mental health diagnoses and populations, null findings have also been reported.151 These findings, however, may reflect issues of dosage or MI’s having greater impact on adherence when the clients are more ambivalent about the change that treatment promotes.151 Social Media, Technology, and the Internet Despite the growing use of Web-based technology to deliver psychosocial interventions—whose efficacy is being documented in research152–154—the use of such technology in the between-session communication of clinicians and clients is in its infancy. Existing mental health interventions primarily rely on traditional (e.g., telephone, mail) and not technological (e.g., SMS texting, email) means of communication15,41 even though electronic communication reduces costs, requires less labor, and improves adherence to outpatient appointments across a number of medical and health issues.155–170 Electronic communication is also both well tolerated and a preferred form of communication with adults and adolescents,153,171–174 as it can be brief and personalized.175 The growing literature on electronic communications in psychotherapy strongly suggests that the use of this medium for between-session contacts can help to sustain client adherence to psychotherapeutic interventions.153,171–174,176

CONCLUSIONS AND RECOMMENDATIONS Adherence Promotion and Enhancement Strategies Given the large number of clients dropping out of psychosocial treatment and the multifactorial reasons for nonadherence, researchers and clinicians should implement a balanced approach that comprehensively focuses on barriers to adherence across various levels (e.g., individual, family, clinician, agency, environment) and also on how those barriers potentially influence the adherence of particular clients.6,135 Full, successful, and active engagement in treatment necessitates a collaborative and multipronged approach to achieving adherence. Increasingly, innovative methods, such as motivational interviewing and new Volume 22 • Number 1 • January/February 2014



technological interventions, represent the most promising methods to address fundamental impediments to psychosocial treatment adherence. Defining, Predicting, and Measuring Psychosocial Treatment Adherence Despite the importance of adherence to effective psychosocial treatment, nonadherence continues to undermine the treatment of mental health problems and contributes to worsening symptoms and increased health care costs. And as the demand for health care resources increases, intervention length is decreasing. Consequently, it is crucial that clinicians and researchers systematically consider the role of adherence in their intervention protocols. In particular, clinicians and researchers need to (1) identify and assess barriers that may place clients at higher risk for nonadherence, (2) define, measure, and report multiple forms of adherence in their work, (3) address identified barriers with their clients, (4) consider factors within their practice or approach that can be modified to reduce barriers to adherence, and (5) add adjunctive adherence strategies or interventions to prospectively promote psychosocial treatment adherence. Given the lack of consensus on definitions of psychosocial treatment adherence and nonadherence, no gold standard for measuring adherence is available, which hampers efforts to understand and consolidate research results. This long-standing problem needs to be addressed. In addition, future research needs to examine dose requirements (e.g., how many sessions are enough, and what is the threshold for treatment efficacy) and adherence patterns for psychosocial treatment. Further research is also required to determine how adherence factors (e.g., barriers, promoters) and the effectiveness of different interventions (e.g., treatment modalities) are influenced by client factors (e.g., race or gender). Finally, since medication adherence and psychosocial treatment adherence are typically examined separately, few studies have examined the interactions and complexities of adherence when both psychosocial and pharmacological treatments are prescribed. Thorough understanding of these factors and their interplay will be critical for tailoring psychosocial treatments that improve adherence and outcomes for the diverse population of individuals who seek psychosocial treatment for mental health problems. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. REFERENCES 1. Busby KK, Sajatovic M. Patient, treatment, and systemslevel factors in bipolar disorder nonadherence: a summary of the literature. CNS Neurosci Ther 2010;16:308–15. 2. Kazdin A, Mazurick JL. Dropping out of child psychotherapy: distinguishing early and late dropouts over the course of treatment. J Consult Clinica Psychology 1994;62:1069–74.


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