Date of Award

2025

Document Type

Open Access Dissertation

Department

Psychology

First Advisor

Kimberly D. Becker

Abstract

Clinical decision-making is a systematic process of collecting and using information to guide action regarding client care. Across frameworks of clinical decision-making, there is an emphasis on the assessment of a problem – which involves considering, identifying, and selecting a problem – as it directly informs intervention. In youth mental health services, problems related to treatment engagement or the ability to meaningfully participate in services are important to assess given their association with premature termination and poor outcomes. However, research suggests that assessment of engagement problems may be challenging, and one potential reason pertains to providers’ ability to assess across multiple dimensions of treatment engagement. This dissertation examined mental health providers’ clinical decisions across different treatment engagement dimensions for their clients who reported an engagement problem. This study anchored to the REACH framework of engagement, which stands for Relationship, Expectancy, Attendance, Clarity, and Homework, and the clinical decisions of considering, identifying, and selecting a problem. The first aim utilized descriptive statistics to describe the nature and frequency of these clinical decisions in the context of assessing treatment engagement problems. The second aim utilized descriptive and inferential statistics to examine providers’ differential sensitivity to assessing different treatment engagement problems that a client reports a problem in. Youth and caregiver clients completed the My Thoughts about Therapy survey, which assessed engagement problems according to the REACH framework. Providers were notified if the survey indicated at least one engagement dimension in the at-risk or high-risk range and were not told who or which engagement dimensions were flagged. Providers were instructed to discuss the client’s case in clinical supervision. Supervision transcripts were then coded using a behavioral observation coding system to identify decisions of when providers considered, identified, and selected a problem, and what engagement or non-engagement problems were associated with these decisions. Results revealed that while providers considered and identified a problem in nearly every case with a reported engagement problem, providers selected a problem in less than a quarter of cases. Providers assessed non-engagement problems more frequently than engagement problems. There was also a greater proportion of cases in which the provider did not identify or select any of the client’s reported engagement problems compared to when the provider identified or selected a problem that matched the client’s problems. Generally, providers’ sensitivity to assessing a problem was low and specificity was high. For youth and caregivers, engagement problem dimension and problem severity were not significant predictors of providers having assessed the engagement problem. Additional analyses suggested that providers may be more sensitive to Relationship, Attendance, and Homework problems, and less sensitive to Expectancy and Clarity problems. Together, these findings indicate the need for further investigation into what makes certain engagement dimensions less or more detectable to providers, as well as the need for decision making supports to facilitate providers in meeting the engagement needs of youth and families in mental health services.

Rights

© 2025, Wendy Chu

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