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Technological Adjuncts to Increase Adherence to Therapy:
A Review
Bonnie A. Clougha*
Leanne M. Caseya
aGriffith Health Institute, Griffith University, Brisbane,
Queensland, Australia
*Correspondence should be addressed to Bonnie A. Clough, School of Psychology,
Griffith University, Mt Gravatt Campus, Brisbane, QLD 4111, Australia (email:
b.clough@griffith.edu.au). Telephone: +61 7 37353348. Fax: +61 7 37353388
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Abstract
This paper identified and reviewed technological adjuncts to increase client adherence to
therapy. Three areas of adherence were identified, namely treatment dropout and non-
attendance, engagement during and between therapy sessions, and aftercare. Database
searches were conducted in each of these areas to identify relevant studies published between
the years of 1990-2010. Adjuncts designed to replace or reduce direct therapist contact,
change the medium of communication between the client and therapist, or alter the content or
style of the therapy were not included in this review. Adjuncts were reviewed in light of
theories of adherence, including Self Determination Theory, the Transtheoretical Model, and
the Theory of Planned Behaviour. Adjuncts reviewed included appointment reminders,
exercises and monitoring delivered by mobile phone, and exercises and data collection
delivered by computer. Limitations and directions for future research were addressed and
discussed.
Keywords: technology, adherence, compliance, dropout, reminders, engagement, homework,
aftercare.
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Technological Adjuncts to Increase Adherence to Therapy: A Review
1. Adherence to the Therapeutic Process
Adherence in psychological practice may be thought of as the extent to which a person’s
behaviours follow the advice given by healthcare professionals . These behaviours may
include entering a treatment programme, maintaining and completing a treatment programme,
keeping aftercare appointments, and taking prescribed medication . Adherence can also
include engaging in therapy sessions, openness and personal disclosure, and cooperation .
Problems with adherence can often lead to poorer treatment outcomes at many stages in
the therapeutic process . Although compliance with clinical medications has been estimated
at approximately 50%, adherence with behavioural regimes is often even lower . Patient
dropout, poor engagement, and homework compliance are all adherence issues that often
reduce the success and effectiveness of treatment . Poor client adherence can hinder even the
most efficacious of psychological programmes, often resulting in poor use of resources, staff
and client time, and increased costs associated with treatments (Chen, A., 1991). As such,
client adherence is an important issue for researchers and clinicians.
1.1. Psychology and Technology
The use of technology is becoming increasing prevalent throughout psychological
research and practice. Psychological interventions can now commonly be accessed by
internet websites, phone or video conferencing, email, and even chat rooms . The advantages
of these mediums of communication include greater flexibility in treatment timing; objective
assessment of treatment compliance; and increased self disclosure and social support .
Furthermore, treatments delivered by these means are more easily disseminated and are more
cost effective than traditional psychological interventions .
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There have been numerous reviews conducted of technologically based interventions .
However, a major goal of these technological interventions has often been to replace or
duplicate face to face therapy . The present review focused only on technological adjuncts
designed to increase client adherence during traditional face to face psychotherapy. The
present review is the first to focus on how technological adjuncts may be able to enhance
traditional therapist administered treatments, specifically by increasing client adherence to
the therapeutic process.
1.2. Adherence during Therapy
An initial comprehensive literature search identified four key areas in which
technology has been incorporated to increase adherence to the therapeutic process: dropout
and non-attendance, client engagement during and between therapy sessions, aftercare, and
adherence with medication regimes. Although technological adjuncts have been widely
researched in pharmacotherapy and adherence to prescribed medications , this area was
deemed to be beyond the scope of the present review.
1.2.1. Dropout and Non-Attendance. Client dropout and non-attendance are two
forms of non-adherence that are common throughout psychological practice. Although they
are similar concepts, the two should be distinguished in research.
Dropout is defined as client termination of treatment before the completion of the
therapy programme . It is however unclear as to what defines a complete treatment
programme. While some studies have defined dropout as client termination of treatment
before the therapist believes they are ready to do so , others have defined dropout as client
termination of therapy prior to attending a set number of sessions . Although the latter
definition provides a more objective method of assessing dropout, there are discrepancies as
to how many sessions constitute a complete programme. Depending on the definition of
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dropout, it has been estimated that approximately 40-60% of individuals attending mental
health clinics dropout before completion of treatment .
Non-attendance, or no-show, is client failure to attend booked appointments. Non-
attendance is often the first step towards dropout, and as such some studies fail to make the
distinction between the two. The percentage of non-attended scheduled appointments in
mental health settings has been estimated to be as high as 60%, with an average of about a
third of appointments not kept . Non-attendance increases the length of waiting lists, leads to
poor use of staff time and resources, loss of income for therapists and clinics, and
compromises the effectiveness of treatment programmes . Indeed, failure to attend regular
appointments has been associated with increased relapse rates during aftercare, higher patient
rates of psychological distress, and can precipitate other no-shows and dropouts in group
therapy .
1.2.2. Engagement during therapy sessions. Engagement during sessions can relate
to emotional disclosure , participation in exposure tasks or other in therapy activities and
processes. Engagement and adherence to tasks in session has been associated with better
treatment outcomes , and enhanced therapeutic alliance . Whilst adherence during therapy
sessions has been linked with personality traits such as avoidance and dependence, it has not
been associated with symptom severity .
1.2.3. Engagement between therapy sessions. Engagement between sessions is
most commonly conceptualized as homework compliance or homework adherence.
Homework is an important part of many therapy styles, providing continuity between
sessions and allowing clients to apply therapeutic techniques in real world settings . Although
commonly associated with cognitive behavioural approaches to therapy , homework is now
found in client centred psychotherapy, experiential therapy, interpersonal therapy, and couple
and family therapies .
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Homework adherence has been related to treatment outcome in a linear fashion, with
greater adherence being associated with greater outcomes . Furthermore, structural equation
modelling has found this relationship to be causal . Homework adherence may also help
reduce client dropout, with greater adherence early in therapy being associated with better
retention during treatment . Indeed, homework compliance may have the strongest
relationship to outcome during the first few sessions of treatment . Adherence has also been
associated with better outcomes after treatment has finished, indicating that homework may
be particularly important for client success when the therapist is no longer present .
Homework adherence has been positively associated with patient motivation and
dependent personality traits , but not associated with symptom severity or locus of control .
Homework adherence is also not associated with client educational background, baseline
level of coping skills, source of referral, level of motivation, or self efficacy .
1.2.4. Aftercare. Aftercare refers to the ongoing psychological care of patients
following discharge from inpatient or intensive outpatient treatment programmes . The
purpose of aftercare is to maintain psychological gains made in primary treatment and to
prevent relapse . Golkaramnay et al. report that while considerable gains are made during
inpatient treatment, a substantial amount of these are often lost in the first 12 months
following discharge. The first month after discharge has been identified as a critical period
when problems may occur and risk of relapse is highest .
Participation in aftercare programmes, whether structured or unstructured, has been
associated with increased likelihood of maintaining, and possibly enhancing, treatment gains .
However, it has been reported that as many as 70% of patients fail to make even their first
post-discharge appointment . Patient adherence and engagement with aftercare plans have
proven problematic for clinicians (Chen, A., 1991).
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1.3. Theories of Adherence
Many theories of adherence have been proposed throughout the literature. The purpose of
the present section was to provide brief overviews of three of the dominant theories of
adherence. The purpose of these overviews was not to critically discuss these theories in
detail, but rather to provide a means of understanding the concept of adherence, as well as the
mechanisms involved in increasing adherence.
1.3.1. The Transtheoretical Model. The most popular theory within the field of
psychological adherence has been the Transtheoretical Model (TTM) developed by
Prochaska & DiClemente . The TTM was originally intended to draw theories of behaviour
change together in a single system, and consisted of 14 components . The most well known
components are the stages and processes of change. The model consists of six stages of
change and ten processes of change . According to the TTM, individuals progress through the
various stages of change toward lasting behaviour change. As such, clinical interventions
should be tailored to meet the client’s current stage of change.
Although the TTM, and in particular the stages of change, have been widely popular
within health and clinical psychology, the model has been the subject of some criticism.
Research has found limited evidence of stage based interventions being any more successful
than usual care or no intervention . Furthermore, there has also been limited evidence
explaining the transition and divides between stages . Data would suggest that it is possible
for patients to be in several stages at once; a concept which is inconsistent with the model .
Such criticisms of the TTM have led to a divide in opinion among researchers and clinicians,
with some arguing that the TTM should no longer be used in research or practice .
1.3.2. Self Determination Theory. Self Determination Theory (SDT) is a broad macro
theory of psychological and health care motivation . The SDT asserts that people may
experience three different types of motivation; intrinsic, extrinsic, and amotivation .
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Intrinsic motivation refers to a person’s innate tendency to seek out and explore novel
and new experiences . Intrinsic motivation aims to fulfil the three innate psychological needs
of competence, autonomy, and relatedness. Conversely, extrinsic motivation results from
separable outcomes which are associated with performance of the activity . It differs from
intrinsic motivation in which the activity is performed because of the inherent satisfaction it
provides. Extrinsic motivation is based upon four different regulatory styles, ranging from
external regulation to integrated regulation . These regulatory styles represent the varying
extent to which behaviour is perceived as being autonomous. The third type of motivation,
amotivation, is the state of lacking intent to act .
Ryan and Deci have proposed that clinical outcomes may be optimal when individuals
are internally motivated in the therapeutic process, with internal motivation leading to
integrated learning and behaviour change. Furthermore, the SDT may provide a rationale as
to the effectiveness of motivational interviewing .
Support for SDT has come from studies in fields such as online learning (Chen, K. C., &
Jang, 2010), glycemic control behaviours , tobacco cessation , maladaptive weight control
behaviours , video game engagement , work practices , and dental treatment and hygiene .
However, the theory has also been criticised for not taking into account the social motivations
and social processes of human behaviour . It has also been argued that the evidence base
behind the selection of the three innate psychological needs is not strong, and may not take
into account cultural and individual differences relating to these needs .
1.3.3. The Theory of Planned Behaviour. The Theory of Planned Behaviour (TPB)
was developed from the earlier Theory of Reasoned Action . The two theories share the
assumption that intentions are the immediate antecedents to behaviour. That is, the stronger
the intention to perform a behaviour, the greater the likelihood of the behaviour actually
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occurring . The TPB is designed to predict and explain human behaviours in specific
situations .
According to the TPB, behavioural intentions are influenced by attitude toward the
behaviour, subjective norm, and perceived behavioural control . Attitude toward the
behaviour refers to how positively or negatively a person evaluates the target behaviour,
whilst subjective norm refers to perceived social pressure to perform or not perform the
behaviour . Perceived behavioural control refers to the ease or difficulty with which the
individual believes they can perform the behaviour. These three antecedents to intentions are
argued to develop from beliefs, such as behavioural beliefs, normative beliefs and control
beliefs .
According to the TPB, client intentions will be predictive of treatment adherence
provided that clients have volitional control over treatment behaviours. Client intentions
toward engaging in treatment behaviours may be improved by assessing client beliefs about
subjective norms and perceived behavioural control, as well as implementing interventions to
increase positive attitudes toward the treatment behaviours.
The TPB has been used for research in the prediction of health behaviours, such as diet ,
child immunisation rates , exercise , condom use , and smoking behaviours . The efficacy of
the TPB has been supported by empirical studies , and a meta analysis . Doll and Ajzen have
also found that direct experience with a behaviour increases the predictive ability of
behavioural intentions as well as the temporal stability of attitudes. Over the past 20 years the
TPB has been a popular and influential behavioural theory within psychology and healthcare,
and has shown strong predicative abilities for healthcare behaviours.
1.3.4. Theories and the present review. The three theories of adherence discussed in
this paper have been useful in understanding and researching client adherence in clinical
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practice. The present review of technological adjuncts to increase adherence to therapeutic
processes is discussed with reference to these theories of adherence, with a focus on the TPB.
1.4. The Current Review
The studies included in this review were selected on the basis that they were aimed at
enhancing client adherence to therapy with the use of technological adjuncts. That is, the aim
was to improve adherence within therapist administered treatments, rather than maintaining
adherence whilst reducing therapist time with the client or changing the medium of therapist
communication (e.g., webcam or email). The focus in this review was on clinical
applications, and thus studies from areas such as experimental, neuropsychology, health, or
organisational psychology were excluded.
Database searches were conducted for articles published between the years of 1990-
2010, using the databases of PsycINFO, Web of Knowledge, and ProQuest Psychology
Journals. Search terms were (psychotherapy, psychology, counselling or counseling) paired
with key terms for each of the three areas; dropout and non-attendance (dropout, non-
attendance, reminder/s, or prompt/s), engagement during and between therapy sessions
(engagement, homework, extratherapy, extratreatment, home practice, or self help
assignments), and aftercare (aftercare or continuing care). Where sufficient data was
provided, Cohen’s d was calculated as a measure of effect size.
2. Dropout and Non-Attendance
To date, research has found no definitive cause of dropout or non-attendance.
However, certain client characteristics have been associated with increased risk. These
characteristics include having a current diagnosis of substance abuse disorder , borderline
personality disorder , being female, young, with a previous history of defaulting during
treatment , or having a longer duration of illness or current family distress . Other social
factors have also been linked with increased risk for dropout and non-attendance, such as
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minority status, economic disadvantage and limited education . However, research is in large
part still inconclusive, and sometimes even conflicting . Yet, one factor that has been linked
consistently with increased risk for dropout and non-attendance is time spent on waiting lists,
with longer waits associated with poorer outcomes .
2.1. Interventions
Current interventions to combat dropout and non-attendance have been categorized
into nine strategic categories; pretherapy preparation, patient selection, time-limited or short-
term contracts, treatment negotiation, case management, appointment reminders, motivation
enhancement, facilitation of the therapeutic alliance, and facilitation of affect expression .
Despite these strategies, dropout and non-attendance remain a problem for many psychology
clinics . Technological adjuncts may have the potential to improve current intervention
strategies.
2.2. Appointment Reminders and Prompts
Appointment reminders and prompts have been researched as one strategy for
decreasing no-shows and preventing dropout. This strategy has been in use for over 30 years
with early research focused on reminders sent by mail, although more recent research has
utilized telephone reminders. Fourteen studies were identified as utilizing some form of
technological device for delivering prompts, and are summarized in Table 1. Effect sizes
were calculated for eight studies. For those studies which utilized chi squared analyses
Cramer’s phi (Φc) was used as a measure of effect size.
2.2.1. Effectiveness of telephone reminders. Three studies found appointment
reminders to be ineffective in increasing attendance , whilst the remaining 11 found positive
effects associated with the reminders. Appointment reminders were only effective at
increasing attendance for initial appointments, not subsequent appointments . Reminders with
direct client and direct therapist contact were more effective than indirect reminders, such as
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letters, recorded messages, or reminder calls made by the clinic secretary , as were reminders
issued temporally close to the appointment date . Kluger and Karras found reminders with an
added orientation component, introducing the client to the clinic and outlining what to expect
from therapy, were more effective than reminders without the orientation component.
However, this finding was not supported by Kourany et al. . In most studies, reminders were
also cost effective, and initial outlays were returned by the increase in kept appointments.
Indeed, Turner and Vernon reported that the six monthly cost of their telephone reminder
intervention was recovered with only six extra kept appointments.
2.2.2. Relationships with demographic variables. Three studies examined the
association between attendance and demographic variables. Conduit et al. found appointment
non-attendance was not related to socioeconomic status (SES). However, authors used
appointment fee as a measure of SES, which may have been less than an optimal
representation. Kourany et al. also found demographic variables such as age, sex, race, time
of appointment and referral source to be unrelated to appointment attendance. Furthermore,
although Watt et al. found indigenous status and living situation to be related to attendance,
other demographic variables such as age, employment, education, and referral source were
again not found to be associated. As expected, studies that did examine time spent on waiting
lists, found longer waits to be associated with higher non-attendance .
2.2.3. Theoretical explanations. It has been suggested that appointment reminders
may be effective because they act as cues to counteract prospective memory failures . This
notion is supported by studies which have found the most common reason patients cite for
missing an appointment is because they simply forgot about it . However, this perspective
does not explain why the success of appointment reminders appears to be moderated by the
type of appointment; that is, why reminders are only successful at improving attendance for
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initial appointments. This effect is also not easily understood by the theoretical approaches of
TTM or SDT.
Martinez and Wong have suggested that the relationship between reminders and type
of appointment can be understood by social and operant learning theory. According to this
theory, behaviour is affected by the antecedent and consequent stimuli that immediately
precede and follow the target behaviour. That is, antecedent stimuli affect the behaviour by
reliably predicting the consequences of the behaviour .
In the context of therapy, the reminders (antecedent stimuli) will be effective in
increasing appointment attendance (target behaviour) provided the clients receive some
benefit from their attendance (consequent stimuli) such as useful information, alleviation of
symptoms or emotional support . If the antecedent prompts have no value in predicting the
consequent stimuli, that is, if patients no longer find the therapy sessions rewarding, then the
prompts will eventually be ignored by the client . Therefore, clients may fail to attend after
the initial appointment because the therapy is not meeting their expectations or needs, and
thus the antecedent stimulus is no longer a reliable predictor of the consequent stimuli.
Similarly, the TPB may also be useful in understanding the relationship between
appointment reminders and attendance. It may be that client intentions to attend treatment
sessions change following the first appointment session. Indeed, direct experience with a
behaviour is believed to increase the predictive ability of the behavioural intention (Doll &
Ajzen, 1992). Therefore previous experience with therapy may change perceived behavioural
control, social norms, or even attitudes toward the behaviour through social and operant
learning theory. It may be beneficial for therapists to discuss possible barriers concerning
social norms and perceived behavioural control during the first appointment. Taken together,
a measure of the three antecedents to behavioural intentions may be a useful predictor of
subsequent appointment attendance.
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Although many studies have examined the relationship between client attitudes,
satisfaction and dropout, most of these ratings are usually taken retrospectively after dropout ,
or immediately before weekly psychotherapy sessions . Both of these methods may fail to
capture actual client satisfaction with the current therapy session, and whether it relates to
attendance at the following session. Confidential client feedback taken immediately after
individual therapy sessions may provide valuable insight into this relationship.
2.2.4. Limitations and directions. Although these studies demonstrate that
appointment reminders may be an effective means of increasing appointment attendance,
there have been limitations with current research. Many of the studies fail to examine
demographic variables, and there is often a lack of detail in reporting methods, including
exactly when reminders were issued in relation to the appointments. Furthermore there is a
lack of randomised controlled trials conducted with appropriate statistical analyses. Some of
the studies also failed to examine the individual treatment effects of reminders, separate from
other non-attendance interventions .
Some researchers have also experienced difficulties in implementing the
interventions. Hochstadt and Trybula experienced initial enthusiasm from clinicians toward
the telephone reminder intervention. However as the intervention became successful,
clinician enthusiasm waned as many had become reliant on no-show time for completing
other tasks. Kluger and Karras found only 50-60% of clients could be reached by telephone
at the times calls were made. This difficulty in reaching clients is likely to be common as
reminder calls are most often made during business hours. A possible technological solution
to this problem may be to send reminders via mobile phone text messaging or even email.
The asynchronous nature of these two mediums of communication allows clients to read and
respond in their own time . Text message reminders are already being used routinely in
medical settings, and have been found to be effective at increasing appointment attendance .
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To date, the use of text message reminders has yet to be reported in the psychological
literature.
Indeed, technology could be utilized further by incorporating orientation components
into electronic reminders. Orientation components often contain information about the clinic,
staff, and what to expect during therapy and the first appointment. Some studies have found
orientation statements to further improve the effectiveness of mailed reminders . This
relationship could be tested by adding multimedia orientation components to text messages or
emails. Like written orientations, a multimedia orientation could introduce clients to the
clinic and staff, as well as outline what to expect from the therapeutic process; all before
therapy has begun. This orientation may however be much more realistic and accurate than
written orientations, and as such may be more effective.
2.3. Electronic Questionnaires
Standardised questionnaires are regularly used as a means of diagnosing, monitoring,
and assessing patient progress and psychological functioning. Recently, researchers have
begun to develop electronic versions of many established questionnaires. These versions
often save time in data coding and analysing, and allow for instantaneous review of data sets.
The Outcome Questionnaire – 45 (OQ-45), is one such measure that is now available in
electronic form.
The OQ-45 is designed to track patient progress during and following therapy, and to
identify those patients at risk for deterioration or dropout . Questionnaire items measure four
constructs; psychological disturbance, interpersonal problems, social role functioning, and
quality of life. Based on the formula for reliable change therapists can monitor whether
patients are improving, not responding or deteriorating from week to week . Therapists can
also compare an individual patient’s progress to expected patient progress, as represented by
recovery curves . This feedback has been found to improve patient outcomes for non
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responsive patients, by allowing therapists to change tactics before the client drops out of
treatment .
One recent technological advance in this system has been the development of the OQ-
Analyst software. This software allows electronic administration of the OQ-45. Prior to each
therapy session, patients complete the questionnaire on palm held computers and data is then
transmitted instantaneously to the therapist’s computer . This method of administering the
OQ-45 saves time in scoring and analysing data, and also improves dropout prevention
strategies by alerting therapists to treatment deterioration prior to the commencement of
sessions. The development of the OQ-Analyst software is an example of how technology can
be implemented in psychological practice to improve dropout prevention techniques, and
increase client adherence to therapy.
2.4. Future Research
Technological adjuncts have great potential for use in targeting client dropout and
non-attendance. Research in this area has thus far been limited. Of the nine strategic
approaches outlined by Ogrodniczuk et al. , to date, technology has only been used for
appointment reminders and patient selection. However there are many more ways that
technology can be utilized to decrease dropout and non-attendance.
Technological adjuncts could be used to enhance pretherapy strategic methods.
Current pretherapy strategies include vicarious pretraining, where the patient is provided with
examples of therapy, and experiential pretraining where the patient experiences a simulation
of therapy . Both strategies have shown positive results in reducing dropout and non-
attendance
Technological adjuncts could greatly enhance vicarious pretraining by providing
prospective clients with digital therapy examples rather than the traditional audiotape,
videotape or written materials sent to clients. Indeed, these digital examples could be mailed
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to clients in the form of DVDs or CDs, emailed to clients as digital attachments, or played
through dedicated websites. Examples could be designed to be interactive, and provide clients
with much more realistic demonstrations of appropriate therapist and client behaviours.
Digital simulations could also improve experiential pretraining by enhancing traditional role
playing methods. This could be further enhanced by the use of virtual reality technology,
which would allow client immersion in virtual therapy settings.
Appointment reminder strategies could also be enhanced by incorporating text
messaging and email reminder systems, as previously discussed. These reminders could
include multimedia components which may act as clinic orientations. These types of
reminders also have the advantage of being instantaneous, and allow for asynchronous
responses outside of normal business hours. Tailored reminder messages may also facilitate
early development of the therapeutic alliance, another strategy often employed to decrease
dropout.
3. Client Engagement During and Between Therapy Sessions
3.1. Review of the Literature
Six studies were identified as utilizing technological adjuncts to increase client
engagement during and between therapy sessions. These studies are summarized in Table 2.
Effect size could only be calculated for one study.
3.1.1. Client engagement and computer games. Adolescence has been noted as a
time of stress for many individuals, however the majority of disturbed adolescents do not
receive professional mental health care . Of those that do receive care, many are obliged into
therapy programmes by their parents , and may be resistant toward therapists . Computer and
video games have been identified as a method of increasing engagement with adolescent
clients.
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It has been noted that one of the best methods for ensuring the transfer of problem
solving skills from therapy situations into real world situations is by presenting adolescents
with situations that resemble real problems . Video games can provide these realistic real
world scenarios, which can be experienced within the safety of the game . Other advantages
include that the therapist is able to observe the child’s problem solving skills, ability to
foresee consequences, hand eye co-ordination, aggression, impulse control, and ability to deal
with success and defeat .
“Treasure Hunt” is a psychotherapeutic computer programme developed by
researchers in Switzerland . Although originally developed for the delivery of electronic
homework assignments, the game was also utilized to encourage client engagement during
therapy sessions. “Treasure Hunt” is an interactive adventure game with multiple levels, and
is based on the principles of cognitive behavioural treatment for children. The game was not
designed to be a self help tool, but rather to be used as an adjunct during the normal therapy
process for use among children and adolescents with internalizing or externalizing disorders.
Concepts taught in therapy, such as automatic thoughts and the influence of thoughts on
feelings, can be reinforced between sessions in a manner that is fun and attractive to children.
An early pilot study revealed that therapists and clients responded well to the
programme. Therapists reported that the game was useful in structuring therapy sessions,
designing new homework assignments based on the characters and concepts in the game, and
also acted as a reward for children at the end of therapy sessions. Children reported that they
liked to work with the game and found it enjoyable. Unfortunately no data was collected or
analysed during the pilot study. As such it is unclear whether this technological adjunct
increased client engagement, or the types of disorders in which it may be beneficial. However
the initial report is promising and further investigation is warranted.
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Coyle and colleagues have also developed a computer game for use in psychotherapy
with children and adolescents. This game, “Personal Investigator”, links the goal oriented
style of computer gaming with that of Solution Focused Therapy. Clients take on the role of
investigator, with the aim of finding solutions to personal problems. Adolescents move
through various levels of the game which are set in a detective academy. In collaboration
with the therapist, the adolescent sets their own therapeutic goals, and is taught such skills as
recognising strengths, identifying people in their lives who can support them, and learning
new coping strategies. The game was designed to be used during therapy sessions with the
therapist acting as a partner for the adolescent Personal Investigator.
Coyle et al. report four case studies involving the use of Personal Investigator.
Adolescents had mental health problems ranging from anxiety and behaviour problems to
attempted suicide and difficulties with social skills. All therapists rated the game as being
easy to integrate into therapeutic work and helpful in engaging adolescents in therapy.
Therapists thought the game was particularly helpful for keeping clients focused on
therapeutic tasks for the duration of the therapy session, whilst also keeping the sessions fun
and enjoyable for the clients. All four adolescents found the game easy and fun to use, and
would recommend the game to other adolescents. Unfortunately no statistical analyses were
conducted and the study also lacked a control group. Therapists also experienced technical
difficulties with each therapist experiencing a software crash at least once.
One other study utilized a video game based on cognitive therapy principles for the
treatment of adolescents with low impulse control . Participants explored an underground
cave and were required to make choices relating to specific scenarios. When a correct choice
was made points were added to the participants score, and conversely points were deducted
when an incorrect decision was made. Clarke and Schoech found adolescents became more
cooperative and enthusiastic about treatment, and attendance in therapy increased following
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introduction of the video game adjunct. These studies are examples of how video game
software may be used to enhance client engagement during treatment.
Unlike the previously discussed studies requiring specialised software, Gardner made
use of Nintendo games such as Mario Bros and Zelda to place the therapist on common
ground with child clients. Gardner found participants gained better social skills, increased in
self efficacy and decreased anxiety. Participants also gained better impulse control and
became more engaged during therapy sessions. However, no statistical analyses were
conducted, nor was there a control group or multiple baselines design.
Computer and video games may be promising technological adjuncts to increase
client engagement during therapy. In accordance with the TPB, it may be that these games
positively influence clients’ attitudes towards therapy and thus create more favourable
behavioural intentions toward participating and engaging in therapeutic tasks. However there
is a current lack of randomised controlled trials and standardised programmes available in
this field.
3.1.2. Client engagement and email. To date email has been used predominately in
psychotherapy as a replacement for traditional face to face therapy . However, it has yet to be
thoroughly investigated as an adjunct in the therapy process, particularly for increasing client
engagement. Murdoch and Connor-Greene report that email may be useful in prompting
patients for homework reports, providing more frequent feedback on homework, and to
encourage reflection. Patients are able to save therapist’s emails and reread them as needed.
Time can also be taken in formulating responses, which may encourage deeper thinking and
understanding. All of these strategies may encourage patients to engage in therapy related
thinking and activities between sessions, and may strengthen the therapeutic alliance and
increase engagement within sessions.
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Murdoch and Connor-Greene report two case studies involving the use of an email
component additional to normal therapy. The first case presented was that of a young female
suffering depression. The patient initially had difficulty self disclosing during therapy
sessions and only completed a quarter of homework tasks. No significant changes were
observed during the first 14 weeks of therapy, following which the patient was asked to email
homework assignments to the therapist each working day. If assignments were not received
by midday the therapist was able to email the client prompting for completion of the
homework.
The patient reported feeling more comfortable disclosing to the therapist in emails
than in person, and this increased self disclosure was eventually continued into therapy
sessions. The therapist was also able to provide more timely feedback on homework tasks,
encouraging the patient to continue progressing. The researchers report that symptom severity
decreased dramatically following the addition of the email component to therapy, and
contend that this was a result of increased client engagement during and between therapy
sessions.
The second case study reported by Murdoch and Connor Greene involved the
treatment of a young female presenting with an eating disorder. This patient displayed a
consistent pattern of responding well to therapy in the days immediately following each
session, but then deteriorating up until the next therapy session. After nine weeks of therapy
an additional email component was introduced whereby the patient was asked to email the
therapist each day reporting on behavioural progress and thinking patterns. The client
reported finding this extremely helpful and began to discuss family conflicts in greater depth
during the emails, which then also led to increased self disclosure during the weekly therapy
sessions. Following the implementation of the email component the patient was able to
maintain therapeutic gains throughout the week between regular therapy sessions.
21
The two case studies presented in by Murdoch and Connor-Greene demonstrate how
email may be valuable for increasing client engagement between therapy sessions, which
may also lead to increased engagement during therapy sessions. These cases are however
lacking in that they contained no control group or multiple baselines design, and no formal
statistical analyses were conducted. Further research is required. In accordance with the TPB,
it may be that participants have a more favourable behavioural intention toward electronic
homework tasks, due to positive social norms surrounding the use of email in everyday life.
3.1.3. Client engagement and computer based training. One study describes the
development of a computer delivered homework component for the treatment of substance
addiction . “CBT4CBT” was developed as an additional adjunct to cognitive behavioural
treatment of drug dependency.
The programme covered such concepts as coping with craving, refusing offers of
drugs and alcohol, and improving decision making skills . Material was presented in a variety
of formats including verbal instructions, voiceovers, interactive assessments, video examples,
graphic illustrations, and practice exercises. Participants were randomly assigned to treatment
as usual and CBT4CBT conditions. All participants were offered weekly individual and
group sessions of general drug counselling, and were also tested twice weekly for traces of
drugs and alcohol. Those in the experimental condition were also offered the use of the
CBT4CBT programme between therapy sessions, run on private computers within the clinic.
Participants in the experimental group tested positive for drugs significantly fewer
times than those in the treatment as usual condition . Those in the experimental group also
reported longer periods of abstinence from drugs. Treatment involvement and homework
completion were strongly related to treatment outcome, but only in the CBT4CBT condition.
The best indicator of treatment outcome for the control condition was severity of baseline
22
symptoms. These results provide a link between the programme and outcome, and support for
the use of such technological adjuncts to increase client engagement.
3.2. Limitations
Current research is limited by a lack of appropriately conducted randomised
controlled trials. Indeed, of the six studies reviewed in this section, only one contained a
control group or conducted any formal analyses.
Research in the use of video games to increase engagement has been promising;
however these results are limited due to a lack of psychotherapeutic games that are readily
available to practising clinicians. Indeed, much of this research remains in experimental
settings. Although one study made use of commercially produced video games , as yet there
is no guide for clinicians as to which games may be appropriate during therapy. It is highly
unlikely that many practising clinicians will purchase and work through a variety of computer
games to find the right ones for specific clients. Future research should focus on the
development of psychotherapeutic computer games that may be made widely available to
clinicians, and in the development of guides for the use of commercially produced games.
There are also limitations associated with the use of email technology. Although the
researchers in the Murdoch and Connor-Greene study reported that reading and responding
to individual client emails took approximately 10 minutes per day, this time may easily add
up for clinicians seeing several clients per day. Indeed, this additional 10 minutes per client
per day could easily add hours per week to the average clinicians work load. Therefore, while
this technological adjunct may be useful for increasing self disclosure and engagement, it
may be that it is best reserved for those particular clients struggling to make gains during
traditional therapy programmes. Emails also present issues surrounding confidentiality and
psychiatric emergencies. Appropriate guidelines must be developed surrounding the use of
such adjuncts and must adhere to governing privacy rules concerning the electronic exchange
23
of healthcare information . Clinicians may also find it beneficial to discuss some of these
issues with clients before introducing an email component to therapy.
3.3. Future Research
Aside from those limitations present in the current body of research, there are also a
variety of other ways research in this field should be expanded. Homework adherence has
been identified as a critical factor affecting the success of many forms of therapy. Yet despite
the increase in technological adjuncts within psychology, many homework assignments are
still delivered by pen and paper. Clients are often required to complete thought and mood
charts in paper diaries, and records of relaxation exercises are also still recorded manually.
Many of these homework tasks could be converted to an electronic format that the client
could complete via computer, personal digital assistant (PDA) or even “Smartphone”.
Completing tasks electronically using a device such as the Smartphone holds many
advantages . Clients would be able to complete homework tasks when and wherever they
choose, making responses more ecologically valid. Furthermore, completing assignments this
way is more discreet than by traditional methods, and may also be more enjoyable for the
client. Responses may be sent to the therapist automatically, and the therapist can prompt
clients for missing responses. All of these factors may lead to increased homework
adherence.
Psychologically based video games may also be delivered by portable devices such as
the Smartphone or PDA. As these games have shown promise in increasing engagement
during therapy sessions, it may also be possible that they may increase engagement and
homework adherence between sessions. Clinicians may find that adolescents may be much
more likely to complete a certain level of a game as homework, rather than a paper based
assignment which may be associated with school homework tasks.
24
Another issue that may warrant further attention is whether the implementation of
such adjuncts are susceptible to reactivity, such as the Hawthorne effect . It may be that the
addition of a new and novel experience to the therapeutic process, or perhaps an overall sense
of the therapist “watching”, is enough to increase client engagement regardless of the
therapeutic content. An interesting design may be to examine client adherence when a video
game is implemented under psychotherapeutic or non-psychotherapeutic conditions.
However, even if reactivity effects partly account for improved outcomes observed in
technologically enhanced therapies, this reactivity does not represent a limitation. It may
ultimately be useful to conceptualize use of technology adjuncts as involving both common
and specific factors in a way that is analogous to perspectives on change factors involved in
therapy . It may however be of theoretical interest to identify the specific treatment effects of
the adjuncts compared with any reactivity effects.
4. Aftercare
As discussed previously, client adherence with aftercare programmes can be a
significant challenge for therapists. Feedback, prompts, and adherence contracts have all been
associated with increased utilization of psychological aftercare . Patient variables such as self
efficacy , employment status and nature of psychological complaint , as well as history of
prior hospitalizations, less denial of illness, high scores on scales measuring helplessness and
hopelessness, and longer length of hospital stay have also been associated with increased
utilization of services (Chen, A., 1991). Lastly, therapist continuity and fewer days between
discharge and first appointment have also been associated with increased engagement in
aftercare (Chen, A., 1991). To date, little research has been conducted assessing how
technology may be able to increase adherence to psychological aftercare programmes.
25
4.1. Review of the Literature
Five studies were identified as incorporating technology to increase patient adherence
to psychological aftercare programmes, and are summarised in Table 3. Effect sizes were
able to be calculated for two studies.
4.1.1. Aftercare and online chat. Online chat has recently been used in the delivery
of aftercare services . The most common form of aftercare usually involves a shift from
inpatient psychological care to outpatient appointments. However, as Golkaramnay et al.
report, this treatment is not always readily available due to long waiting lists for outpatient
services.
Golkaramnay and colleagues compared the efficacy of an aftercare online chat
intervention to treatment as usual. Participants were patients transitioning from inpatient to
outpatient care at a German psychiatric hospital, and had a variety of presenting complaints
including mood and affective disorders, personality disorders, and neurotic and somatoform
disorders. Participants were non-randomly assigned to conditions based on whether their
health insurance would cover the online aftercare intervention. Those in the online
intervention participated in weekly chat sessions with 8-10 other participants also recently
discharged from the same psychiatric unit. Groups met in virtual rooms and communicated
through written messages. The clinical focus was closely linked to that of face to face group
therapy. Both control and experimental groups were able to seek other outpatient
psychological services as desired.
The online intervention was found to be user friendly and was rated positively by 90%
of participants. The researchers also used a global measure of general improvement,
identifying any participants that had not shown substantial benefit across a number of the
different outcome measures. These cases were labelled as “signal cases”. At twelve month
follow up the intervention group contained less “signal” cases than the control group, despite
26
the two groups being equal at discharge. The online chat participants were able to better
maintain treatment gains and also displayed less psychological stress than control
participants. The intervention was well accepted, with session attendance high (85%) and
attrition low (9.4%). Results were however limited by the non-random assignment of
participants to groups. It may also be valuable to assess the exact nature of any aftercare
accessed by control participants in the twelve months.
Online chat groups may be a feasible and effective method for promoting
maintenance of treatment gains and bridging between inpatient and outpatient settings . These
programmes may be effective in providing psychological support for participants in the
critical first month after discharge, particularly while waiting for outpatient treatment. It
should be noted that this treatment option is not likely a replacement for face to face
outpatient psychotherapy and may not be appropriate for use in the aftercare treatment of all
psychological complaints, such as those where significant suicidal ideation may be a clinical
focus. However, the Golkaramnay et al. study demonstrates that this approach may be able to
enhance current aftercare practices under certain conditions.
4.1.2. Telephones and aftercare. Lynch et al. compared telephone monitoring
(TM), telephone monitoring with counselling (TMC), and treatment as usual conditions in an
outpatient continuing care programme for alcohol dependence. Treatment as usual consisted
of ongoing outpatient psychotherapy of up to four months duration. The telephone
interventions were added to the programme upon participants completing the first three
weeks of outpatient care. The telephone interventions consisted of brief telephone calls with
counsellors. Calls were delivered weekly for the first eight weeks, and fortnightly for the
remaining 44 weeks of the 18 month trial. In the TM condition calls were a brief structured
assessment of current substance use status as well as risk and protective factors. Calls in the
27
TMC condition contained added counselling including monitoring of progress, identification
of high risk situations and rehearsal of coping behaviours.
The TMC condition produced significantly improved alcohol outcomes than the TM
condition or the outpatient treatment as usual conditions . No significant differences were
found in alcohol measures between the TM and treatment as usual conditions. These results
indicate that the additional counselling delivered by telephone in the TMC condition was able
to enhance gains in the outpatient programme, and to help participants maintain these gains
over an 18 month period. The Lynch et al. study demonstrates that brief telephone adjuncts
may be able to enhance current aftercare practices in the treatment of alcohol dependence.
Results of the Lynch et al. study were not however supported by results from
Hubbard et al. . Hubbard et al. also compared the efficacy of standard outpatient aftercare for
substance use disorders to combined aftercare and telephone counselling.
Telephone counselling provided positive feedback and encouragement with aftercare
compliance, including attendance and participation in outpatient therapies . Calls were made
in seven of the 12 weeks following discharge from inpatient or residential treatment. No
significant differences were found between groups in measures of self reported aftercare
attendance. Attendance data collected in sessions indicated that participants in the telephone
counselling group attended more aftercare sessions than participants in the treatment as usual
group, however this difference was also not significant.
Differences between the two studies include that Lynch et al. applied more cognitive
and psychotherapeutic strategies during the phone calls, rather than the purely compliance
encouragement provided by Hubbard et al. . Future research should aim to clarify these
effects.
4.1.3. Mobile phones in psychological aftercare. Two recent studies have focused
on the use of Short Message Service (SMS) text messaging in the aftercare of bulimic
28
patients . The SMS-based aftercare intervention was first offered to 30 patients suffering from
bulimia nervosa (BN) in a German hospital . The programme lasted six months following
inpatient treatment, and aimed to reduce the risk of relapse.
Participants were sent messages once weekly in a standard format relating to their
bulimic symptoms. Participants were required to reply to these messages, and were also able
to send additional free messages to the researchers throughout the week. The researchers
replied with one message per week offering support and advice. These SMS responses were a
mixture of pre-programmed and individually tailored components.
Although aggregate data was not available for the initial pilot study, case information
was reported from two patients. Results indicated that the SMS aftercare intervention was an
appropriate bridge between inpatient treatment and outpatient daily life. The SMS
programme helped support patients following psychological treatment, and to help them
maintain and consolidate the gains achieved in treatment.
Following the success of the programme in Germany , an English version of the
intervention was piloted on 21 BN patients in the United Kingdom . The programme
however, was designed to begin on completion of outpatient BN therapy rather than inpatient.
The same software and largely the same methodology were used in the UK pilot as in the
German pilot . However, with low usage and high attrition, the UK pilot was only moderately
accepted by participants . Less than half of the participants completed the study. The majority
viewed the lack of personal contact negatively, and would not recommend the program to
others.
Key differences between the two studies are that the German participants were given
an introduction to the programme during treatment, whilst the UK participants were not.
Furthermore, unlike the German study, participants in the UK pilot were not selected based
on symptom severity which may have led to a sample with more severe symptoms. The
29
authors noted that as the SMS programme was a minimal aftercare intervention, it may not
have been appropriate for the more severe cases. Such an aftercare programme may also not
be appropriate for use in the treatment of all psychological disorders, and as such must be
further researched before implementation.
The two studies demonstrate that the use of technology in psychotherapy must be
well planned and implemented in order to be effective. It is important that clinicians do not
“add on” technological adjuncts simply because they are available. Rather, these adjuncts
must adhere to the goals and aims of the therapy process, and match the specific
characteristics of the client and environment for which they are to be implemented.
4.2. Limitations
Current research in this field is limited by a lack of studies with appropriate control
comparison groups and random allocation of participants. Indeed, of the three aftercare
studies reviewed in this section, only one contained a comparison group . This study did not
however contain random assignment to conditions.
The Bauer et al. and Robinson et al. studies demonstrate the need for technological
adjuncts to be well planned and implemented, rather than on an ad hoc basis. These studies
also demonstrate the need for interventions to be matched with patient characteristics such as
symptom severity. As these two studies demonstrate, although minimal aftercare
interventions may be appropriate for some patients, those with more severe symptoms may
require more intensive aftercare programmes.
Indeed, while technologically based aftercare interventions may provide a useful
bridge between inpatient and outpatient care, particularly if waiting lists are long, it is
unlikely that these chat or text based methods will replace traditional face to face therapy.
This may be the case particularly for patients with more severe symptoms or with greater risk
factors . Indeed the web and text based interventions discussed in this section do not contain
30
protocols for care in psychological emergencies, or for ethical issues such as privacy. The use
of such adjuncts must therefore be implemented with respect to the various ethical codes and
privacy rules governing healthcare practices. Despite this, these interventions may be useful
as additional adjuncts to enhance traditional psychological aftercare programmes, and for
patients waiting or unable to access such programmes.
4.3. Future Research
There are many directions for future research in this field, such as in the delivery of
feedback, prompts, and orientations. These devices have been found to increase participant
adherence to aftercare , although to date they have been delivered only by paper or telephone.
Future research could assess whether digital versions of these orientations and prompts could
also enhance utilization of psychological aftercare. That is, these orientations and reminders
could be sent by email, text message, or multimedia message. As discussed with appointment
reminders, this may allow for more personalised and expanded delivery of content.
Future studies should also aim to expand upon the work of Bauer et al. and Robinson
et al. by incorporating mobile phones and Smartphones into aftercare therapy. These studies
have demonstrated that bulimic symptoms can be tracked for up to six months after
completion of therapy, by means of text messaging. However, it may be possible to track
other psychological symptoms via mobile phone as well. For example, standardised
questionnaires may be delivered via Smartphone, with responses returned to the therapist by
means of wireless internet. This may allow therapists to monitor patients’ symptoms on
completion of therapy, and throughout aftercare. Therapists may be alerted if the patient is
regressing considerably or at risk of relapse. Patients may also be able to access intermittent
feedback from therapists by text message, email, or phone call. These services may enhance
current aftercare practices and create better continuity for patients during the transition period
from inpatient to outpatient.
31
The work of Golkaramnay et al. may also be expanded upon by the use of video
conferencing. Use of video media would allow for greater expression of emotion and
language than in text based chat rooms, and would more closely resemble traditional group
therapy. This style of intervention would however require additional resources such as web
cams, microphones, and high speed internet. These pieces of equipment could be provided for
the duration of aftercare, or to cover the break between discharge and aftercare. However, the
provision of such equipment may prove prohibitively expensive for some clinicians, and may
also be logistically impractical if the patient is not receiving aftercare from the same source
as primary care. Yet for those participants with access to such resources, video conferencing
may be a valuable technological adjunct to increase adherence to, and enhance current
aftercare programmes.
5. General Conclusions
The purpose of the present paper was to identify and review technologies to enhance
current psychotherapy practices with a specific focus on increasing client adherence to
therapy. Three theories of psychological adherence were presented and discussed; the TTM,
TPB and SDT. Limitations were placed on the content that was reviewed in this paper.
Adjuncts designed to replace or reduce direct therapist contact, change the medium of
communication between the client and therapist, or alter the content or style of the therapy,
were not included in this review. Three areas of adherence were identified, namely treatment
dropout and non-attendance, engagement during and between therapy sessions, and aftercare.
Dropout and non-attendance studies were found from the strategic areas of patient
selection and appointment reminders. Telephone reminders were effective for increasing
attendance at initial but not subsequent therapy appointments. Social and operant learning
theory, as well as the TPB may be useful in understanding this reminder effect. It may also be
beneficial to assess client attitudes immediately following therapy sessions. Although
32
appointment reminders have been researched for over 30 years, to date no research has
examined the efficacy of electronic reminders. Future research should assess the effectiveness
of electronic forms of reminders such text and email reminders. Prompts may also benefit
from interactive and multimedia components. Multimedia and electronic orientations may
increase client attendance at therapy sessions, particularly when using vicarious and
experiential pretraining.
Engagement during and between therapy sessions may be improved by the use of
emails, video games and computer based training. The field would benefit from the
development of a greater number of standardised and widely available psychotherapeutic
video games. Electronic homework tasks may increase adherence and client satisfaction, as
well as provide greater options for behavioural monitoring, interactive tasks, and relaxation
exercises. Portable technological adjuncts such as Smartphones and PDAs may be
particularly effective in the delivery of such activities. Future research may benefit from
examining whether such technological adjuncts may be susceptible to reactivity effects.
Aftercare practices may also be improved by the use of technological adjuncts such as
online chat, telephone counselling and SMS interventions. Online video conferencing could
extend current research and enhance chat room aftercare for patients awaiting outpatient
treatment. Incorporating mobile phones into aftercare may also aid client monitoring, as well
as provide an ongoing link for the client once therapy has ceased. These interventions may
help bridge the gap between inpatient and outpatient treatment, or outpatient and daily life.
Such interventions may improve the effectiveness of aftercare programmes, and assist
patients in maintaining treatment gains.
Overall, current research in this field is limited by a lack of randomised controlled
trials, standardised interventions, and appropriate data analysis. It is also unclear whether
certain technologies may be more amenable to the treatment of specific disorders, or how
33
generalizable current research is among differing treatment modalities, diagnoses, and
severities. This field is still a relatively new field in psychology, and there is considerable of
scope for further research. Indeed, although some of the techniques discussed in this paper
were available 20 to 30 years ago, many are only now becoming increasingly adopted and
researched within clinical psychology. With the expansion of this field also comes new
challenges in ensuring appropriate levels of privacy and security of patient information. It is
important for such adjuncts to be implemented with respect to current ethical and privacy
rules concerning healthcare communications and treatment guidelines. Above all, such
adjuncts should only be implemented with the informed consent of the patient.
Current research has indicated a great potential for technological adjuncts to enhance
current psychotherapy practices by increasing client adherence to the therapeutic process.
Developments in this field will not only provide greater options for clinicians, but increased
care for clients.
34
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48
Table 1
Appointment Reminders Using Technological Devices
Study Sample Method Results
N = 512 appointments at an
Australian university
psychology clinic.
Reminder calls made in alternating weeks over a
20 week period. Calls were made one week prior
to scheduled appointments.
Reminders significantly reduced non attendance
compared to baseline, but only for first
appointments. Females more sensitive to reminders
than males.
N = 88 individuals seeking
help at an outpatient mental
health clinic.
Participants assigned sequentially to treatment
conditions; control, telephone prompt one day
prior, telephone prompt three days prior, or letter
prompt three days prior to appointment.
Temporal proximity of reminder to appointment
was the most important factor. The one day prior
group displayed significantly reduced initial
appointment no-shows (9%) than the control group
(55%), (Φc = .488).
N = 172 clients attending a
specialist alcohol treatment
clinic as outpatients.
A multiple baselines approach used six alternating
four week testing phases. Telephone calls were
made to clients as reminders.
Reminders improved initial (Φc = .250) and
subsequent (Φc = .172) appointment attendance.
N = 259 clients attending a
university psychology clinic.
Participants randomly assigned to control,
telephone, or letter reminder groups.
No significant differences in first session
attendance, or in client anxiety or satisfaction.
N = 141 individuals seeking
help at an outpatient mental
health clinic.
Participants randomly assigned to conditions;
control, orientation letter only, orientation letter
and reminder phone call, or reminder phone call
only. Calls made within 24 hours of appointment.
First appointment attendance significantly higher in
the combined orientation and phone prompt group
than in the control group (Φc = .371). No other
differences between groups.
N = 111 outpatients at a
university child psychiatry
clinic.
Participants randomly assigned to control,
telephone reminder, orientation letter, or
telephone reminder and orientation letter groups.
No differences found in initial appointment
attendance rates between intervention groups,
although all three significantly improved attendance
compared to the control (Φc = .178).
N = 41 substance dependent
individuals completing
inpatient or extensive
outpatient treatment.
Participants randomly assigned to control or
experimental groups. Experimental group
received attendance feedback and prompts related
to aftercare group therapy.
Participants in the prompt and feedback condition
more likely to begin (Φc = .425) and maintain an
aftercare programme than those in the control
condition. Also less likely to be readmitted to
hospital.
N = 15 female victims of
domestic violence
participating in group therapy
as part of a residential
programme.
Multiple baseline design was utilized. During
experimental phases written and telephone
prompts were delivered to participants.
Prompts more than doubled attendance during
intervention phases. No statistical analyses
conducted. Individual treatment effects of the letter
and phone prompts were also not analysed.
49
N = 660 individuals referred
to a community mental health
centre.
Design included two baseline and one
intervention phases. Telephone reminders made to
patients one day prior to scheduled appointments.
No control group.
Prompts increased first appointment attendance,
particularly when direct rather than indirect contact
was made with the patient (Φc = .201). No
statistical analyses.
N = 451 appointments
scheduled over a nine week
period at a rural mental health
centre. Two pilot studies.
Experimental conditions were randomly assigned
to each week of the nine week testing period.
Conditions were no reminder calls, therapist made
calls, and staff made calls.
Reminders with direct therapist contact
significantly increased client attendance,
particularly for intake sessions. No effect for other
reminder conditions.
N = 128 individuals seeking
outpatient treatment at a
substance abuse clinic.
Participants randomly assigned to one of four
groups. First group had appointments scheduled
within 48 hours of contact, no reminders given.
Remaining three groups had appointments
scheduled more than 48 hours after initial contact.
Given either a telephone, mail or no reminder.
Intake attendance significantly higher for
appointments scheduled within 48 hours of initial
contact. Neither reminder condition significantly
increased attendance when compared to the no
reminder condition (d = .025). No groups differed
in attendance for subsequent therapy sessions.
N = 1355 individuals seeking
treatment at a community
mental health clinic
Multiple baseline design utilized. During
intervention phases telephone prompts delivered
to clients one to three days before appointments.
Phone prompts reduced no-shows from 32% to
11%. No statistical analyses.
N = 262 consecutive referrals
to two child and youth mental
health clinics.
Participants randomly assigned. Intervention
group received telephone reminder calls prior to
scheduled appointment. Control group received no
appointment reminders.
Reminders effective at increasing attendance, but
only for adolescents with conduct disorder. This
group had a lower initial attendance rate.
Intervention increased attendance rates to those of
adolescents without conduct disorder.
N = 113 psychiatric
outpatients
Randomly assigned to usual care (appointment,
mailed reminder and telephone reminder) or
intervention (usual care plus two motivational
telephone sessions).
Greater number of participants in the intervention
group attended at least one appointment, also
attended a greater number overall than the control
group (d = .33).
50
Table 2
Technology to Increase Client Engagement
Study Sample Method Results
Children and adolescents
presenting for outpatient
psychological treatment
Computer game incorporated cognitive behaviour
modification training with electronic homework
assignments.
Children and therapists responded positively to the
programme. Children enjoyed playing the game,
and therapists found it useful as positive
reinforcement. No compliance data was collected.
N = 77 individuals seeking
treatment for substance
dependence
Participants randomly assigned to CBT treatment
or CBT combined with additional biweekly CBT
skills training delivered by computer.
Participants in CBT computer group submitted
fewer urine samples positive for drugs (d = 0.59),
and had longer continuous periods of abstinence (d
= 0.44). Increased engagement and homework
adherence was associated with better outcomes.
4 X N = 1 adolescents with
low impulse control, (4
adolescent case studies)
Computer game based on cognitive treatment for
low impulse control. Game was used during
therapy sessions to increase engagement.
Attendance in therapy increased. Clients became
more cooperative and enthusiastic. Impulse control
behaviours improved. No statistical analyses.
4 X N = 1 adolescent
outpatients, (4 case studies)
Computer game was developed with elements of
Solution Focused Therapy. The game was used in
therapy sessions to increase engagement.
Therapists rated the game as being easy to integrate
into therapy. Also reported that the use of the game
increased client engagement during sessions.
Clients reported the game was fun and enjoyable.
No analyses were conducted.
4 X N = 1 adolescent
outpatients, (4 case studies)
Nintendo games used during therapy to increase
engagement and observe child behaviours.
Social anxiety decreased and self efficacy
increased. Improvements in impulse control. No
statistical analyses.
2 X N = 1, (2 case studies) Homework assignments completed by email. Emails facilitated increased self disclosure and
engagement during therapy sessions. Homework
adherence increased by therapists sending reminder
emails when homework had not been received. No
statistical analyses performed.
51
Table 3
Technology to Increase Adherence to Aftercare
Study Sample Method Results
N = 30 bulimic patients Used SMS communication to monitor and provide
support to patients in an aftercare programme.
Low attrition and high engagement with programme.
Most participants valued the extra support and would
recommend the programme.
N = 228 recently discharged
from inpatient treatment for a
variety of psychological
complaints
Participants non-randomly assigned to control or
experimental conditions. Experimental conditions
consisted of weekly 90 minute online group chat
sessions over 12-15 weeks.
At one year follow up participants in the treatment
group were at lower risk for negative outcomes than
the controls, and displayed significantly reduced
psychological stress as measured by the OQ-45 (d = .
32). Also low dropout rate and attendance.
N = 339 patients completing
inpatient and residential
substance abuse programmes
Participants randomized to treatment as usual or
aftercare with added phone reminders and
counselling.
Participants receiving calls attended more aftercare
sessions (48%) than those not receiving calls (37%).
Difference not statistically significant.
N = 252 receiving intensive
outpatient treatment for
alcohol dependence
Participants randomly assigned to telephone
monitoring, telephone monitoring with
counselling, or treatment as usual conditions.
Combined outpatient programme with telephone
monitoring and counselling produced significantly
better alcohol use outcomes than did the outpatient
programme alone. Monitoring without counselling
did not enhance the programme.
N = 21 BN patients Used SMS communication to monitor and provide
support to patients as an aftercare programme.
Low usage and high attrition. Only moderately
accepted by participants. No significant changes pre
to post treatment in fear of becoming fat (d = 0),
perception of body shape (d = -.111), or perception of
attractiveness (d = -.0285). Greater binge episodes
were reported post intervention than pre intervention
(d = -.200)
52
