Engagement and retention of high-risk adolescents and their families is a serious challenge for providers in community social service agencies. Research on rates of engagement has shown that 40% to 60% of families who begin services terminate prematurely (Coatsworth, Santisteban, McBride, & Szapocznik, 2001), and only 22% of families seeking treatment for a youth behavior problem actually complete initial assessments (Szapocznik et al., 1988). Because clients who inconsistently participate in the therapeutic process and prematurely terminate treatment are less likely to successfully attain treatment goals (Dakof, Tejeda, & Liddle, 2001), providers need therapeutic tools to improve engagement and retention strategies.
Despite the need to understand the critical components of successful treatment outcomes, little is known about the mechanisms involved in the process of treatment engagement and retention (Kazdin & Nock, 2003). In an effort to address this gap, this study reports on a test of an innovative method to improve engagement and retention in family therapy sessions in comparison with family therapy treatment as usual. Experiential activities were incorporated in family therapy sessions delivered in a family's home environment. These activities were developed as creative techniques designed to increase youths' and families' participation in treatment sessions, improve their capacity for relationship building, and increase the likelihood of treatment completion.
ENGAGEMENT AND RETENTION
Engagement is a complex and crucial component of effective treatment that increases retention in services--a requirement for successful outcomes and behavior change (Simpson, Joe, Rowan-Szal, & Greener, 1995). Engagement is typically defined across general dimensions of therapeutic involvement and participation during treatment. Clients who are engaged in the treatment process are more likely to bond with therapists and endorse treatment goals, and they participate to a greater degree during treatment (Broome, Joe, & Simpson, 2001). Providers who actively work to increase client engagement are likely to build stronger alliances with their clients and elicit greater client investment in the treatment process (Dearing, Barrick, Dermen, & Walitzer, 2005).
Retention refers to the duration of treatment and represents a global indicator of the dose of treatment (Joe, Simpson, & Broome, 1998).With clients who initiate treatment, retention has been shown to be a challenging clinical task (Coatsworth et al., 2001), but it has also been shown to be the single best predictor of positive outcomes (Joe et al., 1998). Clients who leave services prematurely are less likely to show the clinical gains found among service completers (Stanton & Shadish, 1997), and 40% to 60% of adolescents who begin treatment terminate prematurely (Kazdin & Wassell, 1999). Thus, retention is an important area of clinical focus.
IN-HOME FAMILY THERAPY
Considerable empirical support confirms the effectiveness of including family members in therapy with adolescents (Liddle et al., 2001; Stanton & Shadish, 1997). In addition, delivery of family therapy in the homes of clients has also been shown to significantly increase attendance and participation of adolescents and their families in therapeutic sessions in comparison with office-based therapy (Slesnick & Prestopnick, 2004). Home-based family therapy has been found to be more effective than peer groups (Liddle et al., 2001), parent education (joanning, Quinn, & Mullen, 1992), multifamily interventions (Liddle, 1995), and individual counseling (Henggeler et al., 1991).
Researchers and practitioners have noted that barriers to families seeking and engaging in traditional office-based family therapy include the lack of reliable transportation, inconsistent or late work schedules, limited financial resources, and child care difficulties (Kazdin & Wassell, 1999). …