Explaining Engagement in Outpatient Therapy of Adults with Serious Mental Health Conditions By Degree of Therapeutic Alliance, Therapist Empathy and Perceived Coercion

Background and Purpose: In the context of the recovery movement, individuals with serious mental health conditions (SMHC) are seeking less restrictive treatment options to manage their mental health symptoms. Individuals with SMHC disengage from treatment at a higher rate than other populations, with deleterious effects on mental health outcomes. Factors associated with treatment engagement for this population in other contexts, or in outpatient therapy for other populations, include therapeutic alliance, therapist 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?

Methods: Data were collected employing a cross-sectional survey design. The anonymous web-based survey was completed by 131 participants recruited through convenience and nomination sampling. Participants represented a variety of sociodemographic and clinical characteristics. Diagnoses spanned mood, trauma, personality, and psychotic disorders with reported impairments to relationships, employment, completing daily living activities and meeting basic needs. Symptom experience varied with nearly one-third reporting thoughts of self-harm and perceptual disturbances. Therapeutic alliance, therapist empathy, and perceived coercion were measured using psychometrically sound scales. The relationships between variables were tested using multivariate regression analysis with hierarchical blocks, controlling for known correlates of engagement, including symptom severity, substance use, education level, age, and duration of treatment.

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.

Conclusion and Implications: 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. Therapeutic alliance explained the greatest variation in the degree of engagement, and these findings suggest two key strategies to enhance engagement: improve therapist expressions of empathy and strengthen alliance. Both strategies are consistent with a recovery-orientation and social work values, and they are compatible with a client-driven approach for individuals with SMHC, a population that experiences high rates of marginalization and oppression in society and across treatment contexts. Social workers are frequently the primary providers for this population and study implications have the potential to enhance the provision of care to highly vulnerable clients. Additional research is needed to better understand engagement in therapy for this population and to develop more sensitive measures for evaluating these constructs.