Psychological Services 2014, Vol. 11, No. 3, 324 –332

© 2014 American Psychological Association 1541-1559/14/$12.00 DOI: 10.1037/a0035686

Brief Acceptance-Based Intervention for Increasing Intake Attendance at a Community Mental Health Center Michael A. Williston

Jennifer Block-Lerner, Andrew Wolanin, and Frank Gardner

University of Pennsylvania

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Kean University Intake no-show rates for psychotherapy vary from 20% to 57% (Swenson & Pekarik, 1988), and experiential avoidance may be related to failure to attend intake sessions. This pilot study attempted to increase intake attendance at a community mental health center by employing a brief experiential acceptance-based intervention. Those who scheduled intakes were randomly assigned to 1 of 2 groups: orientation letter or acceptance-enhanced orientation letter; rates from these conditions were compared with a retrospective comparison control group. Participants were randomized by way of an online random number generator. Persons assigned to the orientation group did not have a higher show rate than persons within the control group (⬃48% compared with ⬃52%). Persons assigned to the acceptance group did have higher show rates than persons in the other two groups (⬃67% compared with ⬃48% and ⬃52%, respectively), however this difference was nonsignificant. Results suggest that brief acceptance-based interventions should be further studied for their potential value in maximizing client attendance. Keywords: acceptance, letter intervention, community mental health, experiential avoidance, psychotherapy attendance

Furthermore, clients who receive an intake appointment scheduled for within about 24 hours following their first contact with a clinic are more than four times as likely to present for their intakes as those persons scheduled days or weeks later (Festinger et al., 2002). Interestingly, Hochstadt and Trybula (1980) found that temporal proximity of an orientation/reminder letter to the intake appointment was the strongest predictor for increasing attendance rates. Dopke (2008) suggested that letter prompts serve a similar function to short wait times when they are received after first contact and before intake.

Approximately 70% of individuals in need of psychological services do not receive them (Kazdin, 2012). While a variety of contributing factors have been explored, such as a lack of awareness of potential services (Leong & Lau, 2001) and stigma (Corrigan, 2004), very little attention has been directed specifically toward studying the occurrence of first appointment no-shows. The first appointment, frequently referred to as a diagnostic intake interview, is usually the initial step in delivering behavioral health care services to clients. Intake no-show rates vary from 20% to 57% (Swenson & Pekarik, 1988). When a potential client wants services but does not arrive to receive them, her or his needs might never be met (Larsen, Nguyen, Green, & Attkisson, 1983), as missed intakes are frequently not rescheduled (Sparr, Moffitt, & Ward, 1993; Kruse, Rohland, & Wu, 2002). Several researchers have investigated variables connected to intake failure. A number of investigators have studied the association between length of waiting time between first contact with a clinic and the scheduled intake. Raynes and Warren (1971) and Wolkon (1972) reported a significant association between wait time and intake no-show. Similarly, Festinger, Lamb, Marlowe, and Kirby (2002) found that significantly more clients scheduled 1 day later attended their intake appointments (72%) compared to those persons scheduled 3 days later (41%) or 7 days later (38%).

Interventions Intended to Increase Intake Attendance Numerous methods such as introductory interviews, letters, phone contacts, videotapes, and written brochures have all been used to increase intake attendance (Swenson & Pekarik, 1988). Garrison (1978) reported that an orientation statement that took 10 to 15 minutes to read increased attendance rates. Kluger and Karras (1983) reported that spoken introductory orientations via phone are also effective at increasing intake attendance. Finally, Hagan, Beck, Kunce, and Heisler (1983) successfully employed the novel method of a video presentation to improve the first outpatient visits of previous psychiatric inpatients. Phone preparations and phone prompts have been the most common techniques used to increase intake attendance (Swenson & Pekarik, 1988). Studies have established that phone orientations (descriptions of the nature of therapy) and prompts (reminders of scheduled visit times) are effective at increasing intake attendance (Turner & Vernon, 1976). Indeed, it has been found that reminding people to go to outpatient mental health clinics for the first time encourages them to attend (Kitcheman et al., 2008). However, Burgoyne et al. (1983) and Kluger and Karras (1983) reported that

This article was published Online First March 17, 2014. Michael A. Williston, Department of Psychiatry, University of Pennsylvania; Jennifer Block-Lerner, Andrew Wolanin, and Frank Gardner, Department of Advanced Studies in Psychology, Kean University. Correspondence concerning this article should be addressed to Michael A. Williston, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Room 661, Philadelphia, PA 19104. E-mail: [email protected] 324

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

INCREASING INTAKE ATTENDANCE

they were able to get in touch with only about half of their clients by phone following multiple attempts. Another method for increasing intake attendance is to employ a mailed orientation statement. For example, in a controlled study, Huws (1992) researched the effects of an information sheet sent to clients referred to an outpatient mental health clinic and found that this intervention led to a significant increase in attendance at intake assessment interviews compared with a control group who received standard care. In a related study, Kitcheman et al. (2008) conducted a large-scale randomized controlled trial, the aim of which was to increase attendance for first-time consultations at seven urban outpatient mental health clinics. The intervention that these researchers employed was an orientation statement letter delivered to clients 24 to 48 hours before their intakes and the main outcome studied was attendance at the first appointment. The participants in this study were individuals with an appointment to attend an outpatient mental health clinic for the first time. Follow-up was for 763 out of the 764 participants (⬍99%) for the main results and for 755 out of the 764 participants (98.8%) for secondary outcome results. Kitcheman et al. found that their orientation statement letter significantly increased the number of people who attended their intakes (309 out of 388) compared to a control group who received standard care (275 out of 376). These researchers concluded that reminding people to go to outpatient mental health clinics for the first time (via orientation letters) encourages them to present at intake and, more generally, that practical trials within a busy outpatient clinical setting are possible and helpful. In sum, many interventions improve intake attendance including prompt appointment scheduling, reminder letters and phone calls, asking for client commitment, and resolving barriers to session attendance (Lefforge, Donohue, & Strada, 2007).

Experiential Avoidance as a Variable Related to First Appointment Failure Experiential avoidance has been defined as “the phenomenon that occurs when a person is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to alter the form or frequency of these events and the contexts that occasion them” (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, p. 1154). Experiential avoidance is related to many psychological disorders including posttraumatic stress disorder (PTSD; Boeschen, Koss, Figueredo, & Coan, 2001; Thompson & Waltz, 2010) and substance abuse (Forsyth, Parker, & Finlay, 2003; Stewart, Zvolensky, & Eifert, 2002). Clients who meet criteria for PTSD and/or substance abuse are more likely than those with other behavioral disorders to miss intake appointments (Sparr et al., 1993). The high levels of experiential avoidance measured in these populations may account for these high no-show rates. Those with PTSD may fail to attend their intake appointments because they want to avoid talking about feelings and thoughts associated with the trauma they have experienced. Likewise, those who abuse substances may fail to attend their first appointments because they want to avoid withdrawal symptoms (unpleasant physiological sensations) that accompany “sobering up,” often a prerequisite for engaging in outpatient therapy. Experiential avoidance is also correlated with other forms of psychopathology such as anxiety and mood disorders (Marx & Sloan, 2005; Roemer, Salters, Raffa,

325

& Orsillo, 2005; Tull, Gratz, Salters, & Roemer, 2004), which are some of the common referrals for outpatient psychological services.

Brief Acceptance-Based Interventions Empirical data supporting the efficacy and effectiveness of mindfulness- and acceptance-based behavioral interventions for diverse clinical populations are accumulating rapidly (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004; Hayes, Villatte, Levin, & Hildebrandt, 2011). Indeed, treatments that explicitly address experiential avoidance have been developed for such disorders as generalized anxiety disorder (Orsillo, Roemer, & Barlow, 2003; Newman & Llera, 2011), anorexia nervosa (Hayes & Pankey, 2002; Rawal, Park, & Williams, 2010), PTSD (Mulick, Landes, & Kanter, 2005), and comorbid substance abuse and PTSD (Batten & Hayes, 2005). Use of very brief mindfulness- and acceptance-based behavioral interventions (i.e., 15 minutes or less) has also been documented in the psychological literature. Indeed, rationales given from this viewpoint have been compared with those that promote controloriented emotion regulation strategies (e.g., thought suppression) and the empirical evidence has, by and large, supported the superiority of an acceptance-based approach in increasing willingness (approach behavior). Levitt, Brown, Orsillo, and Barlow (2004) conducted a study in which participants with panic disorder underwent a 15-min, 5.5% carbon dioxide “challenge” (i.e., inhalation). Prior to this challenge, participants were assigned to one of three conditions: a 10-min audiotape describing one of two emotion-regulation strategies (acceptance or suppression), or a neutral narrative (control group). The acceptance group was significantly less avoidant than the suppression or control groups in terms of willingness to participate in another challenge (Levitt et al., 2004). Similarly, Campbell-Sills, Barlow, Brown, and Hofmann (2006) found that participants diagnosed with anxiety and mood disorders displayed less negative affect and showed decreased heart rate after watching an emotion-provoking film when they had been instructed to accept (rather than suppress) their emotions. Finally, Hofmann, Heering, Sawyer, and Asnaani (2009) found that those participants who were instructed to suppress their anxiety showed a greater increase in anxious behaviors compared to those who were instructed to accept their anxiety.

The Present Study The objective of this pilot study was to investigate the capacity of a brief acceptance-based intervention to decrease the rate of missed intake appointments at a university-funded CMHC. Following consideration of results from previous studies, two interventions were designed: (a) a letter prompt containing a written orientation statement that was mailed to potential clients prior to their intake appointments, and (b) a letter containing the orientation statement plus psychoeducation about experiential avoidance (and experiential acceptance as an alternative) that was also mailed prior to scheduled intake appointments. In order to standardize (and thus control for) the length of each letter, some nonessential information was added to the orientation condition. Based upon the literature reviewed previously, the following predictions were test-

WILLISTON, BLOCK-LERNER, WOLANIN, AND GARDNER

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

326

ed: (a) clients receiving a letter containing a prompt (i.e., a simple reminder of the appointment day and time) plus an orientation statement would have a lower rate of missed intake appointments than clients receiving no intervention at all; and (b) clients receiving a prompt/orientation letter containing psychoeducation about experiential avoidance (and the acceptance alternative) would have a lower missed intake appointment rate than clients receiving an orientation-only letter. While the association between length of waiting time between first contact and intake was not investigated in the present study, the average waiting time between phone screen and intake for clients at the clinic at which this study was conducted was ⬃15 days (with a standard deviation of ⬃11 days). Front desk staff attempted to schedule appointments within 7 days, but client requests to reschedule as well as clinic closures sometimes pushed actual intake dates back. This study only focused on the first appointment; therefore, if a client rescheduled before the first set intake date, s/he was counted as a no-show (i.e., counted as not having attended her/his intake appointment). In such cases, these individuals did not receive a second letter.

Method

Table 1 Clinic Demographics Variable Age Gender Race

Education

Employment

Participants The present study included 99 participants from a universityfunded CMHC serving an urban population in the Mid-Atlantic region of the United States. Participant demographic data is not detailed as per the request of the university’s institutional review board. Any characteristics that could be considered identifying information are not reported due to the fact that participants could not provide informed consent to participate in the study prior to receiving their letters. However, basic demographic data about the population typically served by the clinic is available (see Table 1). Potential clients who were scheduled for a first intake appointment throughout the time period that this study was run were excluded from participating if they had a P.O. Box address. This exclusion criterion was chosen because otherwise it would have been difficult to guarantee that potential clients assigned to the letter conditions would receive their letters before their scheduled intakes. The 33 participants within the control condition received only an appointment time. No orientation letter (standard or acceptance-enhanced) was sent to these participants before their intake appointments. The show-rate data for this group was analyzed retrospectively as they had already been collected at the university-funded CMHC (in the previous six months).

Annual income

Marital status Note.

Levels 17 to 74 (average ⫽ 33) Male Female African American Caucasian Other (Hispanic, Asian American, American Indian, and biracial) Pre-high school Some high school Graduated high school Attended some college Associates degree Graduated from college Some graduate school Finished graduate school Master’s degree Technical school Unknown Employed Unemployed Disability Public assistance Fulltime students Employed students Retired Work release Unknown Less than $10,000 Between $10,000 and $20,000 Between $20,000 and $30,000 Between $30,000 and $40,000 Between $40,000 and $50,000 More than $50,000 Unknown Single Married

% of Subjects 100 43 57 46 32 22 0.5 13 23 27 1 12 5 2 0.5 1 15 53 24 4 1 15 0.5 1 0.5 1 39 16 15 10 3 4 13 70 30

Wolanin, Lee, & Dettore (2010).

call potential clients the day before to confirm their intake appointments. This policy remained in place during the time period that this study was conducted and was the policy throughout the time that the control condition clients were seen for intake as well.

Design and Procedure

Materials/Procedure

As per typical clinic policy, a clinic assistant completed a phone screening form, which consisted of gathering information concerning the potential client, including the person’s name, age, gender, race/ethnicity, marital status, education level, employment status, income, previous therapy experience(s), referral source, and a short account of current difficulties. Following the phone screen, the clinic assistant scheduled the client for an intake session with an appropriate clinician. Soon after this intake appointment time was established for a potential client, the principal investigator then randomly assigned the potential client to one of two letter conditions. A clinic policy stated that all intake clinicians should

Orientation statement letter prompt. The participants in this condition received a letter prior to their first scheduled appointment reminding them of the appointment day, time, and organization name. This letter also contained an orientation statement in addition to the prompt information. It described what a potential client should expect to occur throughout her or his intake appointment: (a) a short interview to gather essential background information and to set up a rate of charge, and (b) a conversation regarding the client’s reasons for seeking out psychological services at the time. It also addressed issues related to confidentiality. The content of this orientation statement was developed from

INCREASING INTAKE ATTENDANCE

suggestions by Levine, Stolz, and Lacks (1983) and its major content was based on a spoken orientation statement used by Kluger and Karras (1983) and a written orientation statement used by Swenson and Pekarik (1988). The content of the orientation letter was as follows: Dear [person’s name],

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

I would like to welcome you to [University’s Name] Community Psychological Services and tell you about what you might expect from your first visit on [day] at [time]: • It will take about 2 hours • You will see a therapist who will interview you to gather information about your history • Most of the time that you spend during this visit will consist of you talking about the issues that you present to this therapist • The therapist will talk with you about why you are coming to the clinic • The therapist will ask about what led to your concern (the past) and your present state of affairs • You will fill out some questionnaires As we know that the questions asked are personal, let me assure you of our respect for your privacy. Specifics related to confidentiality will be discussed during your visit. We work on a sliding fee scale so your charge will be based on your income. Payment will be due after each session. Our main concern is to help you deal with problems that you feel you may want to work on. We’re looking forward to meeting with you soon. Please bring this letter to your first appointment. Sincerely, [Name of principal investigator]

Acceptance letter prompt. The participants assigned to this condition received the same orientation letter as above with the same content as the previous group. However, the content of this orientation statement was enhanced with a brief acceptance intervention developed from instructions from Levitt et al. (2004), the major content being based upon the audiotaped emotion-regulation intervention that Levitt and colleagues employed. The acceptance letter was based on acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999, 2012); the major message communicated through this intervention is that attempts to hold back or otherwise control feelings and thoughts are not helpful, while focusing on behavior change in valued directions (i.e., coming in for an intake appointment) is a more functional way of living. The content of this acceptance-enhanced orientation letter (as adapted from Levitt et al., 2004) was as follows: Dear [person’s name], I would like to welcome you to [University’s Name] Community Psychological Services and tell you about what you might expect from your first visit on [day] at [time]: • It will take about 2 hours • You will see a therapist who will interview you to gather information and establish a fee for your sessions based on a sliding scale • This therapist will talk with you about why you are coming to the clinic • You will fill out some questionnaires

327

As we know that the questions asked are personal, let me assure you of our respect for your privacy. Specifics related to confidentiality will be discussed during your visit. As you anticipate your session, it may be helpful to keep the following in mind: • Being willing to experience your feelings and thoughts can free you up to focus on what really matters to you in your life • If you come to therapy sessions and in the process feel happy, sad, nervous, unsure, joyful, and any other feelings that may come up for you, you can decide what life activities you want to take part in • Don’t let your fear of (sometimes) uncomfortable feelings and thoughts make choices for you . . . Instead, choose your valued directions in life! We’re looking forward to meeting with you soon. Please bring this letter to your first appointment. Sincerely, [Name of principal investigator]

Potential clients were asked to bring in the letter to their intake appointments in order to determine whether it was received and whether or not it was read. Both the orientation and acceptance letters were aimed at a 6th grade reading level (by means of an online readability index calculator). Intake clinicians were trained to carry out certain duties. For example, each intake clinician kept a record of whether a client brought in her or his letter, failed to bring it in, or failed to bring it in but indicated that she or he had received it and read its content. The intake clinician also kept a record of whether a potential client attended, cancelled, or failed to attend her or his scheduled intake appointment. In this study, clients were recorded as a no-show if they failed to attend their first appointment, regardless of whether or not they were ultimately rescheduled for another intake appointment; those who were rescheduled did not receive a second letter. A manipulation-check questionnaire was given to those clients who came to their intake appointments. The procedures for training intake clinicians to carry out these duties regarding the manipulation-check questionnaire are explicated below. Manipulation-check questionnaire. Intake clients were given a feedback form labeled “MC Questionnaire.” The first item on this questionnaire asked them whether or not they had received a letter in the mail from the clinic. If they answered “yes” to this question (indicating that they had in fact received a letter), they were then asked if they had read its content; those who indicated that they did were asked additional questions regarding the material they read in their letters. Clients were asked to describe their letters, indicating the main messages. Clients were also asked to rate how familiar the approach to dealing with uncomfortable feelings and thoughts described in their letters felt to them in terms of how they usually deal with these internal experiences. This was rated on a 7-point Likert-type scale ranging from 1 (not at all familiar) to 7 (extremely familiar). In addition, clients were asked what they should do when they experience uncomfortable feelings and thoughts according to the instructions found in their letters. For this item, clients were asked to circle one response out of the following choices: (a) I should distract myself from uncomfortable feelings and thoughts; (b) I should recognize that I can live a valued life even when I experience uncomfortable feelings and thoughts (the

WILLISTON, BLOCK-LERNER, WOLANIN, AND GARDNER

328

correct response for those clients who received the acceptanceenhanced orientation letter); (c) I should recognize that I do not have to let negativity bother me, that I am strong enough to focus on the positive; (d) I should try to understand why I experience particular uncomfortable feelings and thoughts; or (e) no instructions were provided as to how I should experience my feelings and thoughts (the correct response for those clients that received the orientation-only letter). Finally, clients were asked to rate the effect, if any, they thought reading the letter had on their mood, using a 5-point Likert-type scale ranging from 1 (much worse) to 5 (much better).

Table 2 Attendance Percentages tor the “Treatment” and Control Groups Group

N

Orientation Acceptance Total treatment Control

33 33 66 33 N

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

66

Results Statistical Analyses The main variables of the study that were generated from the data collection process were show-rates for the control group and two treatment groups. In order test the aforementioned research hypotheses, chi-square statistical analyses were employed. Chisquare is a statistical test that is used to model categorical outcome variables (Plackett, 1983). The nominal alpha level for this chisquare was set by the researchers at p ⬍ .05. The statistical package that was employed was the Statistical Package for the Social Sciences-17th Edition (SPSS-17). Assumptions for the chisquare test were explored and found to have been met. Specifically, each person/case contributed to only one cell of the contingency table and all expected counts were above 1, with no more than 20% less than 5 (lowest value was 14.67; Field, 2013). Descriptive statistics. An intake clinician kept a record of whether a potential client attended, cancelled, or otherwise failed to present for her or his scheduled appointment. Seventeen out of 33 participants in the control group attended their first appointments, representing a ⬃52% show rate. Sixteen out of 33 participants in the orientation letter group attended their first appointments, representing a ⬃48% show rate. Twenty-two out of 33 participants in the acceptance letter group attended their first appointments, representing a ⬃67% show rate. Overall, out of the 66 participants assigned to both experimental groups, 38 (⬃58%) attended their first appointments. Of those 16 participants assigned to the orientation letter group who attended their first appointments, 6 (⬃38%) brought in the letter as instructed. Of those 22 participants assigned to the acceptance-enhanced letter group who attended their first appointments, 5 (⬃23%) brought in the letter. Overall, of those 38 participants assigned to both experimental groups who attended their intake appointments, 11 (⬃29%) brought in the letter. Of those 16 participants assigned to the orientation letter group who attended their first appointments, 14 (⬃88%) acknowledged reading the letter. Of those 22 participants assigned to the acceptance-enhanced letter group who attended their first appointments, 19 (⬃86%) acknowledged reading the letter. Overall, of those 38 participants assigned to both experimental groups who attended their first appointments, 33 (⬃87%) acknowledged reading the letter. Chi-square statistics. The first appointment no-show rates for the two groups in which participants received their assigned letter interventions and the control group are shown in Table 2. The no-show rates displayed inside this table were subjected to chi-

Note.

Percent show

X2 treatment vs. control

p Value

⬃48% ⬃67% ⬃58% ⬃52%

0.06 1.57 2.54 N/A X2 acceptance vs. orientation 2.23

.81 .21 .28

.14

All chi-square values are nonsignificant.

square analyses in order to determine if either of the two treatment groups had a significantly lower no-show rate than the control group. It was established that the show-rate for participants assigned to the orientation letter group was not significantly different from the show-rate for those in the control group (␹2 (1, N ⫽ 66) ⫽ .06, p ⫽ .81). The show-rate for those assigned to the acceptance-enhanced letter group was also not significantly different from the show-rate for those in the control group (␹2 (1, N ⫽ 66) ⫽ 1.57, p ⫽ .21). Finally, the show-rate for those assigned to the acceptanceenhanced letter group was not significantly different from the show-rate for those assigned to the orientation letter group (␹2 (1, N ⫽ 66) ⫽ 2.23, p ⫽ .14). Overall, the results indicated that the show-rates for the participants in the control group (⬃52%), orientation letter group (⬃48%), and acceptance-enhanced letter group (⬃67%) were not significantly different from each other (␹2 (2, N ⫽ 99) ⫽ 2.54, p ⫽ .28). Likelihood ratios, more accurate with small sample sizes than the Pearson chi-Square (Geweke & Singleton, 1980), corroborated nonsignificant differences among the groups. Manipulation-check statistics. Participants were asked the following question on the Manipulation-Check (MC) Questionnaire: “What effect, if any, do you think reading the letter had on your mood?” They were asked to rate this effect on a 5-point Likert-type scale ranging from 1 (much worse) to 5 (much better). On average, those who were assigned to the orientation letter group reported that the letter they received made their mood “slightly better” (␹ ⫽ 3.6). On average, those who were assigned to the acceptance-enhanced letter group also reported that the letter made their mood “slightly better” (␹ ⫽ 3.95). Overall, those assigned to both the orientation letter group and the acceptanceenhanced letter group reported that the letter they received made their mood “slightly better” on average (␹ ⫽ 3.76). An independent samples t test was conducted to compare the above means. There was not a significant difference between the orientation letter group and the acceptance-enhanced letter group in regard to reported effect on mood of reading the letter, t(34) ⫽ ⫺1.34, p ⫽ .19, two-tailed. Participants were asked what they should do when they experience uncomfortable feelings and thoughts according to the instructions in the letter. As indicated above, they were told to circle one of the following responses: (a) I should distract myself from uncomfortable feelings and thoughts, (b) I should recognize that I can live a valued life even when I experience uncomfortable

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

INCREASING INTAKE ATTENDANCE

feelings and thoughts, (c) I should recognize that I don’t have to let negativity bother me; that I am strong enough to focus on the positive, (d) I should try to understand why I experience particular uncomfortable feelings and thoughts, and (e) No instructions were provided as to how I should experience my feelings and thoughts. Fourteen out of the 16 participants assigned to the orientation letter group who attended their first appointments acknowledged having read the letter. Twelve of these 16 participants (75%) gave the correct answer to this question (i.e., option “e”). Nineteen out of the 22 participants assigned to the acceptance-enhanced letter group who attended their first appointments acknowledged having read the letter. Fifteen of these 22 participants (⬃68%) gave the correct answer to this question (i.e., option “b”). Participants who were assigned to the acceptance-enhanced letter group were asked the following additional question on the MC Questionnaire: “How familiar did the approach to dealing with uncomfortable feelings and thoughts described in the letter feel to you in terms of how you usually deal with these internal experiences?” They were asked to rate their familiarity with this approach on a 7-point Likert-type scale ranging from 1 (not at all familiar) to 7 (extremely familiar). On average, participants reported that the acceptance-based approach to dealing with uncomfortable internal experiences was “moderately familiar” to them (␹ ⫽ 4.8).

Discussion This study sought to increase intake attendance at a universityfunded community mental health center by employing a brief acceptance-based intervention. We had hypothesized that clients who received a letter prior to their intake would have a significantly lower rate of intake appointment failure than clients who did not receive such a letter. This was not found to be the case in this study. This result obtained from those who received an orientation letter prior to their intake is inconsistent with the findings of studies that have established letter prompts to be effective (e.g., Hochstadt & Trybula, 1980; Kitcheman et al., 2008). There are two possible explanations for this unexpected finding. First, the orientation letter used in this study may not have increased intake attendance due to the fact that it served a similar function to the reminder phone calls placed by intake clinicians before clients’ first appointments. The clinic policy of calling a client 24 hours before her or his intake appointment remained in place throughout the duration of this study (although the actual conduct of making these phone calls was not systematically assessed). Further, the “file drawer” phenomenon (Rosenthal, 1979) might offer an explanation for the abovementioned unexpected finding. Due to the fact that it is more difficult to get null results published in peerreviewed journals, researchers may not even try to present such findings. In this case, it is possible that other researchers have studied orientation letters and not found these interventions to be effective. A trend toward statistically significant efficacy was observed for the acceptance-enhanced letter group. We likely did not have sufficient statistical power for this difference to cross the threshold of statistical significance. Our study, overall, had close to the requisite number of participants to detect a medium effect (w ⫽ .3, desired power ⫽ .8; N ⫽ 108). In order to detect a small effect (w ⫽ .1), we would have needed 785 participants, a number that

329

would be prohibitive to most behavioral health clinics unless the study could be conducted over many years with large-scale commitment within the organization. In addition to employing larger samples, researchers should attend to increasing the “dose” of brief interventions such as the one utilized in our study. For example, research that builds on our pilot study could be conducted to more specifically pinpoint the active ingredients in the acceptance-based letter employed in this study. Possible active ingredients could be found within the content and/or form of this letter (and/or in other brief acceptance-based behavioral interventions). For example, while our letter focused on experiential acceptance, the importance of values-consistent behavior is also addressed. In some senses, the overall development of psychological flexibility (i.e., “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values” [Kashdan & Rottenberg, 2010, p. 866]) is highlighted. Eventually, dismantling or constructive studies could elucidate active ingredients (e.g., of the six components of the ACT “hexaflex”; McHugh, 2011) and these could then be highlighted in future intervention studies. In addition, the show-rate differences among groups may have clinical significance not illuminated by the lack of statistical significance for the findings of this study. Depending on the nature and scope of an agency or practice, a 15% increase in show rate (i.e., the difference between our acceptance-based letter condition and the no-letter control condition) would likely have clinical, training, and economic significance that would be meaningful for clients, providers, and organizations. For example, any increase in client show rate for a doctoral training clinic results in, in addition to increased clinical care for clients in need, increased opportunities for supervision, student competency evaluations, student clinical training hours, and training outcome data that is meaningful for multiple stakeholders of a doctoral training program. If the trend toward differences among the groups is born out with a larger sample, this finding will have implications for the application of brief acceptance-based orientation interventions at community mental health centers. For example, delivery of a brief acceptance-based orientation intervention through mailed letter represents an uncomplicated system. It overcomes the main drawbacks of providing brief spoken orientations via telephone (i.e., limited time of clinic assistants/intake clinicians and high nocontact rates; Burgoyne et al., 1983; Kluger & Karras, 1983); it also allows for a higher degree of standardization of the intervention. Furthermore, this study also suggests that the main messages of an acceptance-based stance toward experience may be conveyed via a very brief intervention (as evidenced by responses on the investigator-created MC Questionnaire). It should be noted, however, that future studies should attempt to make the message and/or manipulation checks even clearer (since only 68% of clients in this condition answered correctly). In light of the potential benefits of using this brief acceptancebased intervention at one university funded CMHC, this intervention represents a simple and potentially effective means of outreach at many (if not most) community outpatient settings/ programs. In particular, the finding that roughly two thirds of those assigned to the acceptance-enhanced letter group attended their appointments (vs. roughly one half of those assigned to the control group) has implications for these treatment settings. As addressed

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

330

WILLISTON, BLOCK-LERNER, WOLANIN, AND GARDNER

above, if an acceptance-based letter could increase the number of attended intakes per year from one half to two thirds, this could translate into greater benefits for clients and increased revenue for an agency. Moore, Wilson-Witherspoon and Probst (2001) highlighted the financial effects of missed appointments in a family medicine clinic; even with walk-in appointments filling slots of missed appointments, Moore and colleagues reported that they were unable to recoup up to 14% of revenue. While each agency, clinic, or independent practice will experience unique financial effects of missed appointments, it is clear that missed appointments invariably result in decreased revenue and professional time. It is important to keep in mind that the acceptance-based intervention employed in this study did not increase intake attendance to a statistically significant degree, though a trend toward significance was observed. Therefore, it will be very important for other researchers to investigate similar interventions on a larger scale and for community clinics to determine if this brief acceptancebased intervention represents a technique worthy of implementation. We found a 33% no-show rate among the group with the best attendance (i.e., those who received the acceptance-enhanced orientation letter). Though it is not possible to know the specific reasons for the absence of individual clients, one may make educated speculations. It is possible that a number of the no-shows in this study (across both letter conditions) did not receive their letters. Furthermore, there is no guarantee that those who did in fact receive their letters actually read them, though responses to the manipulation-check questions suggest that at least most individuals did. Finally, it is also likely that the intake no-shows of all three of this study’s groups failed to attend their intakes for a number of the same reasons reported by Swenson and Pekarik (1988) in a similar letter intervention study. When Swenson and Pekarik contacted those who failed to attend their intakes, many cited improved symptoms and practical problems (e.g., price, transportation, etc.) as reasons for first appointment failures. Studies have also reported that these reasons are among the most commonly cited by clients for drop-out toward the beginning of the treatment process (Chameides & Yamamoto, 1973; Shapiro & Budman, 1973). For example, Garfield (1963); Acosta (1980); Pekarik (1983), and Manthei (1996) found that clients cite spontaneous improvement in symptoms and environmental obstacles (e.g., transportation difficulties) as reasons for nonattendance. One methodological weakness of this study is its lack of control variables. The impact of demographic variables was not held constant when analyzing the relationship between letter type and intake attendance rates. Variables that could be considered identifying information (e.g., age, sex, etc.) were not collected in this study in an effort to protect the confidentiality of participants. Confidentiality was of heightened concern in this study because participants were not able to provide informed consent. Future research should address this weakness by collecting demographic data on participants enrolled in letter intervention studies and including those variables that previous research has demonstrated to be related to attendance rates as covariates. Another methodological weakness of this study is its lack of standardized manipulation-check questions. For the conduct of similar intervention studies in the future, researchers should develop and validate standardized manipulation-check questionnaires (vs. relying on

investigator-created measures) in order to address this particular limitation. It is also important to note that future research might focus on assessing potential clients’ levels of experiential avoidance as early as possible. This assessment would ideally occur during a phone screen or other initial contact, as a potential client’s level of EA may interact with experimental condition assigned (i.e., orientation letter group or acceptance-enhanced letter group). If measured EA level is shown to interact with condition (letter groups vs. control group), this information could be used to help inform participant assignment to specific letter interventions. An EA assessment would be especially important for those who might be scared away from attending their intakes. For example, in this study one participant reported that she/he found the acceptanceenhanced letter to be “a little frightening.” This participant obviously faced her or his fear by attending the intake, but others who might have been scared away could be targeted otherwise. For example, instead of mailing a letter containing an acceptancebased message, this same idea could be conveyed through a phone call, which could be more individually tailored. Though studies using phone calls can be difficult to carry out pragmatically due to high no-contact rates and the limited time of clinic administrative assistants/intake clinicians at CMHCs (e.g., Burgoyne et al., 1983; Kluger & Karras, 1983) and also involve tradeoffs with regard to standardization, such a study might still be worth considering. Recent research on interventions to increase intake attendance is lacking and additional study is needed on this important issue. Future methods to increase intake attendance will likely involve the incorporation of technological advances (e.g., Internet, text messaging, etc.) to remain consistent with health care administration developments. Our research suggests that these interventions of the future may be made to have a stronger impact by enhancing them with brief acceptance-oriented messages.

References Acosta, F. X. (1980). Self-described reasons for premature termination of psychotherapy by Mexican American, Black American, and AngloAmerican patients. Psychological Reports, 47, 435– 443. doi:10.2466/ pr0.1980.47.2.435 Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of co-morbid substance abuse and posttraumatic stress disorder: A case study. Clinical Case Studies, 4, 246 –262. doi:10.1177/ 1534650103259689 Boeschen, L. E., Koss, M. P., Figueredo, A. J., & Coan, J. A. (2001). Experiential avoidance and posttraumatic stress disorder: A cognitive mediational model of rape recovery. Journal of Aggression, Maltreatment & Trauma, 4, 211–245. doi:10.1300/J146v04n02_10 Burgoyne, R. W., Acosta, F. X., & Yomamoto, J. (1983). Telephone prompting to increase attendance at a psychiatric clinic. American Journal of Psychiatry, 140, 345–347. Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy, 44, 1251–1263. doi:10.1016/j.brat.2005.10.001 Chameides, W. A., & Yamamoto, J. (1973). Referral failures: A one-year follow up. The American Journal of Psychiatry, 130, 1157–1158. Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614 – 625. doi:10.1037/0003-066X.59.7.614

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

INCREASING INTAKE ATTENDANCE Dopke, C. A. (2008). Timely encouraging letters increase attendance at first consultations at outpatient psychiatric clinics. Evidenced-Based Mental Health, 11, 122. doi:10.1136/ebmh.11.4.122 Festinger, D. S., Lamb, R. J., Marlowe, D. B., & Kirby, K. C. (2002). From telephone to office: Intake attendance as a function of appointment delay. Addictive Behaviors, 27, 131–137. doi:10.1016/S03064603(01)00172-1 Field, A. (2013). Discovering statistics using IBM SPSS statistics. Washington, DC: Sage. Forsyth, J. P., Parker, J. D., & Finlay, C. G. (2003). Anxiety sensitivity, controllability, and experiential avoidance and their relation to drug of choice and addiction severity in a residential sample of substanceabusing veterans. Addictive Behaviors, 28, 851– 870. doi:10.1016/ S0306-4603(02)00216-2 Garfield, S. L. (1963). A note on patients’ reasons for terminating therapy. Psychological Reports, 13, 38. doi:10.2466/pr0.1963.13.1.38 Garrison, J. E. (1978). Written vs. verbal preparation of patients for group psychotherapy. Psychotherapy: Theory, Research & Practice, 15, 130 – 134. doi:10.1037/h0085851 Geweke, J. F., & Singleton, K. J. (1980). Interpreting the likelihood ratio statistic in models when sample size is small. Journal of the American Statistical Association, 75, 133–137. doi:10.1080/01621459.1980 .10477442 Hagan, L. D., Beck, N. C., Kunce, J. T., & Heisler, G. H. (1983). Facilitating psychiatric patient follow-up: A study of transfer attrition. Journal of Clinical Psychology, 39, 494 – 499. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1–25. doi:10.1016/j.brat.2005.06 .006 Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. (2004). DBT, FAP, and ACT: How empirically oriented are the new behavior therapy technologies? Behavior Therapy, 35, 35–54. doi:10.1016/ S0005-7894(04)80003-0 Hayes, S. C., & Pankey, J. (2002). Experiential avoidance, cognitive fusion, and an ACT approach to anorexia nervosa. Cognitive and Behavioral Practice, 9, 243–247. doi:10.1016/S1077-7229(02)80055-4 Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York: The Guilford Press. Hayes, S. C., Villatte, M., Levin, M., & Hildebrandt, M. (2011). Open, aware, and active: Contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annual Review of Clinical Psychology, 7, 141–168. doi:10.1146/annurev-clinpsy-032210-104449 Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168. doi:10.1037/0022-006X.64.6 .1152 Hochstadt, N. J., & Trybula, J. (1980). Reducing missed initial appointments in a community mental health center. Journal of Community Psychology, 8, 261–265. doi:10.1002/1520-6629(198007)8:3⬍261:: AID-JCOP2290080311⬎3.0.CO;2-N Hofmann, S. G., Heering, S., Sawyer, A. T., & Asnaani, A. (2009). How to handle anxiety: The effects of reappraisal, acceptance, and suppression strategies on anxious arousal. Behaviour Research and Therapy, 47, 389 –394. doi:10.1016/j.brat.2009.02.010 Huws, R. (1992). Non-attendees at a marital and sexual difficulties clinic: A controlled intervention study. International Journal of Social Psychiatry, 38, 304 –308. doi:10.1177/002076409203800409

331

Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865– 878. doi:10.1016/j.cpr.2010.03.001 Kazdin, A. E. (2012). Beyond psychotherapy: To meet the vast unmet demand for services, psychologists are seeking alternatives to traditional one-on-one therapy. Monitor on Psychology, 43, 46 – 47. Kitcheman, J., Adams, C. E., Pervaiz, A., Kader, I., Mohandas, D., & Brookes, G. (2008). Does an encouraging letter encourage attendance at psychiatric out-patient clinics? The Leeds PROMPTS randomized study. Psychological Medicine, 38, 717–723. doi:10.1017/S0033291707001766 Kluger, M. P., & Karras, A. (1983). Strategies for reduced missed initial appointments in a community mental health center. Community Mental Health Journal, 19, 137–143. doi:10.1007/BF00877606 Kruse, G. R., Rohland, B. M., & Wu, X. (2002). Factors associated with missed first appointments at a psychiatric clinic. Psychiatric Services, 53, 1173–1176. doi:10.1176/appi.ps.53.9.1173 Larsen, D. L., Nguyen, T. D., Green, R. S., & Attkisson, C. C. (1983). Enhancing the utilization of outpatient mental health services. Community Mental Health Journal, 19, 305–320. doi:10.1007/BF00755411 Lefforge, N. L., Donohue, B., & Strada, M. J. (2007). Improving session attendance in mental health and substance abuse settings: A review of controlled studies. Behavior Therapy, 38, 1–22. doi:10.1016/j.beth.2006 .02.009 Leong, F. T. L., & Lau, A. S. L. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3, 201–214. doi:10.1023/A:1013177014788 Levine, J. L., Stolz, J. A., & Lacks, P. (1983). Preparing psychotherapy clients: Rationale and suggestions. Professional Psychology: Research and Practice, 14, 317–322. doi:10.1037/0735-7028.14.3.317 Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747–766. doi:10.1016/ S0005-7894(04)80018-2 Manthei, R. J. (1996). A follow-up study of clients who fail to begin counseling or terminate after one session. International Journal for the Advancement of Counselling, 18, 115–128. doi:10.1007/BF01421563 Marx, B. P., & Sloan, D. M. (2005). Peritraumatic dissociation and experiential avoidance as predictors of posttraumatic stress symptomatology. Behaviour Research and Therapy, 43, 569 –583. doi:10.1016/j.brat.2004 .04.004 McHugh, L. (2011). A new approach in psychotherapy: ACT (Acceptance and Commitment Therapy). The World Journal of Biological Psychiatry, 12, 76 –79. Moore, C. G., Wilson-Witherspoon, P., & Probst, J. C. (2001). Time and money: Effects of no-shows at a family practice residency clinic. Family Medicine, 33, 522–527. Mulick, P. S., Landes, S. J., & Kanter, J. W. (2005). Contextual behavior therapies in the treatment of PTSD: A review. International Journal of Behavioral Consultation and Therapy, 1, 223–238. Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31, 371– 82. doi:10.1016/j.cpr.2011.01.008 Orsillo, S. M., Roemer, L., & Barlow, D. H. (2003). Integrating acceptance and mindfulness into existing cognitive-behavioral treatment for GAD: A case study. Cognitive and Behavioral Practice, 10, 222–230. doi:10.1016/ S1077-7229(03)80034-2 Pekarik, G. (1983). Improvement in clients who have given different reasons for dropping out of treatment. Journal of Clinical Psychology, 39, 909 –913. doi:10.1002/1097-4679(198311)39:6⬍909::AIDJCLP2270390614⬎3.0.CO;2-4 Plackett, R. L. (1983). Karl Pearson and the chi-squared test. International Statistical Review, 51, 59 –72. doi:10.2307/1402731

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

332

WILLISTON, BLOCK-LERNER, WOLANIN, AND GARDNER

Rawal, A., Park, R. J., & Williams, J. M. G. (2010). Rumination, experiential avoidance, and dysfunctional thinking in eating disorders. Behaviour Research and Therapy, 48, 851– 859. doi:10.1016/j.brat.2010.05 .009 Raynes, A. E., & Warren, G. (1971). Some characteristics of “dropouts” at first contact with a psychiatric clinic. Community Mental Health Journal, 7, 144 –150. doi:10.1007/BF01434750 Roemer, L., Salters, K., Raffa, S., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research, 29, 71– 88. doi:10.1007/s10608005-1650-2 Rosenthal, R. (1979). The “file drawer problem” and tolerance for null results. Psychological Bulletin, 86, 638 – 641. doi:10.1037/0033-2909.86 .3.638 Shapiro, R. J., & Budman, S. H. (1973). Defection, termination, and continuation in family and individual therapy. Family Process, 12, 55– 67. doi:10.1111/j.1545-5300.1973.00055.x Sparr, L. F., Moffitt, M. C., & Ward, M. F. (1993). Missed psychiatric appointments: Who returns and who stays away? The American Journal of Psychiatry, 150, 801– 805. Stewart, S. H., Zvolensky, M. J., & Eifert, G. H. (2002). The relations of anxiety sensitivity, experiential avoidance, and alexithymic coping to young adults’ motivations for drinking. Behavior Modification, 26, 274 –296. doi:10.1177/0145445502026002007

Swenson, T. R., & Pekarik, G. (1988). Interventions for reducing missed initial appointments at a community mental health center. Community Mental Health Journal, 24, 205–218. doi:10.1007/BF00757138 Thompson, B. L., & Waltz, J. (2010). Mindfulness and experiential avoidance as predictors of posttraumatic stress disorder avoidance symptom severity. Journal of Anxiety Disorders, 24, 409 – 415. doi:10.1016/j .janxdis.2010.02.005 Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. Journal of Nervous and Mental Disease, 192, 754 –761. doi:10.1097/01.nmd.0000144694.30121.89 Turner, A. J., & Vernon, J. C. (1976). Prompts to increase attendance in a community mental health center. Journal of Applied Behavior Analysis, 9, 141–145. doi:10.1901/jaba.1976.9-141 Wolanin, A. T., Lee, E. F., & Dettore, M. M. (2010, June). Examining the use of treatment manuals and outcomes in a graduate training clinic. Presentation at the Annual Convention of the World Congress of Cognitive and Behavioral Therapies, Boston, MA. Wolkon, G. H. (1972). Crisis theory, the application for treatment, and dependency. Comprehensive Psychiatry, 13, 459 – 463.

Received July 12, 2013 Revision received November 7, 2013 Accepted November 12, 2013 䡲