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ORIGINAL PAPER
Raymond J. Kotwicki
rkotwicki@skylandtrail.org
Alexandra M. Balzer
abalzer@skylandtrail.org
Philip D. Harvey
pharvey@med.miami.edu
1 Skyland Trail, 1961 North Druid Hills Rd, NE, Atlanta,
GA 30329, USA
2 Leonard M. Miller Professor of Psychiatry and Behavioral
Sciences, University of Miami Miller School of Medicine,
1120 NW 14th Street, Suite 1450, Miami, FL 33136, USA
Received: 7 October 2015 / Accepted: 20 September 2016
© Springer Science+Business Media New York 2016
Measuring and Facilitating Client Engagement with Financial
Incentives: Implications for Improving Clinical Outcomes in a
Mental Health Setting
Raymond J. Kotwicki1 · Alexandra M. Balzer1 · Philip D. Harvey2
5.4 % improved in their engagement to levels required for
the incentive. Longitudinal analysis demonstrated that indi-
viduals who maintained or increased their level of engage-
ment over time were more likely to complete treatment
in accordance with planned treatment goals. The initial
engagement and the course of engagement in treatment
predicted successful completion, but incentives did not
lead to increased engagement in initially poorly engaged
patients. These data are interpreted in terms of the likely
success of extrinsic rewards to increase engagement in
mental health services.
Keywords Engagement · Incentives ·
Mental health services · Motivation
Introduction
The clients most in need of services in community mental
health settings are often the most difcult individuals to
engage in treatment (e.g., Gillespie et al. 2004; Sainsbury
Centre for Mental Health [SCMH] 1998; Tait et al. 2002,
2003; Wagstaff 2011). This is particularly true in indi-
viduals with psychosis, though some evidence suggests
that individuals with all severe mental illness diagnoses
must be continually engaged in treatment to achieve posi-
tive outcomes (Meaden et al. 2012; O’Brien et al. 2009;
Kreyenbuhl et al. 2009), particularly in young adults (Kim
et al. 2012) and in veterans (Hearne 2013; Stecker et al
2011). Several models of care have been developed to
increase levels of engagement in those identied as dif-
cult to treat, under names like ‘assertive outreach’ (Gil-
lespie et al. 2004; Priebe et al. 2005; SCMH 1998; Wright
et al. 2011), ‘therapeutic alliance,’ or ‘integrative’ models
of care, which attempt to foster a recovery style focused
Abstract Signicant numbers of individuals with severe
mental illnesses are difcult to engage in treatment ser-
vices, presenting challenges for care. To be able to assess
the relationship between engagement and discharge out-
comes, we modied the “Milestones of Recovery Scale”.
This scale was modied for content to match the current
clinical setting, evaluated for inter-rater reliability after
modication in a sample of 233 cases receiving psychiat-
ric rehabilitation, and then was administered to 423 addi-
tional psychiatric rehabilitation clients over a 24-month
study period. In an effort to determine whether provision
of nancial incentives lead to sustained increases in cli-
ent engagement, a cut off for client eligibility for nancial
incentives was evaluated on the basis of the reliability study
and the course of engagement was related to receipt of this
incentive and successful completion of treatment in a new
sample of 423 patients. Of this sample, 78 % received an
initial nancial incentive during treatment (were initially
engaged), and 93.3 % of that subgroup sustained this level
of engagement it over their entire course of treatment. Of
the 22 % of cases not receiving an initial incentive, only
1 3
Community Ment Health J (2017) 53:501–509
DOI 10.1007/s10597-016-0053-z
/ Published online: 26 September 2016
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
