Research That Matters (January 17 - 20, 2008)

BACKGROUND: Obesity among adolescents has nearly tripled over the last twenty years, within which African American adolescents are disproportionately represented. Despite this impressive trend, few interventions have targeted adolescents and fewer have specifically targeted minority youth. Of the adolescent weight loss interventions that have been conducted, attrition is a noted concern. Research on treatment engagement has relied primarily on quantitative indicators such as attendance, duration, intensity of participation, or homework completion. Others have assessed individual characteristics that may impact treatment engagement, like readiness for treatment, preparation for treatment, and client perceptions of treatment and the treatment process. Although the client's experience in treatment has been demonstrated as an important factor in engagement, only one study developed an observational coding scheme to describe treatment engagement. This qualitative study explores treatment engagement from the perspective of the therapeutic process. The primary research question was how the experience of treatment dropouts in family therapy sessions differs from the experience of treatment successes and how these differences might inform future practice.

METHOD: This study is part of a randomized clinical pilot study investigating the efficacy of Multisystemic Therapy, a home and community-based family therapy, for weight loss in obese African American adolescents. This pilot study included 48 African American adolescents (12-17) and their primary caregivers of which the top five treatment successes (i.e., weight loss) and five treatment drop outs were included in this analysis. The first two therapy session recordings after the initial session were transcribed and then analyzed using a hermeneutic phenomenological approach. Potential indicators of client engagement were extracted from the literature to form a conception of how treatment engagement has historically been measured. These indicators were clarified and refined into a thematic structure consisting of four primary themes: client-therapist agreement, collaboration with therapy and therapeutic tasks, client-therapist interaction, and verbal expression of client motivation. This framework was the basis of the analysis.

RESULTS: Hermeneutic phenomenological analysis suggested that successful families differed from families that dropped out of treatment. Specifically, evidence emerged implying families that later dropped out of treatment had poor follow through on homework assignments, were resistant to scheduling sessions, and had a lack of optimism for treatment. Transcripts of sessions involving families that were successful in treatment indicated higher levels of cooperation with the therapist in the identification of problems and goals as well as greater participation in therapy sessions and on therapeutic tasks.

CONCLUSION: Understanding therapeutic indicators of treatment engagement may improve treatment retention, thereby reducing attrition. Further, treatment engagement is linked to positive treatment outcomes while attrition is related to continued and worsening problematic behaviors. Therapist behaviors possibly contributing to attrition will be discussed. This understanding offers an opportunity for clinicians to identify families at risk of drop out early in treatment and develop strategies to improve treatment engagement and, consequently, treatment outcomes.