This article clarifies the distinction between compliance and engagement, highlighting how they influence therapeutic outcomes, and what therapists can do to foster engagement.
Related articles: The What and Why of the Therapeutic Alliance, Assessing Therapist-Client Fit, Balancing Professionalism and Authenticity.
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Introduction
In mental health care, clinicians often use the terms “compliance” and “engagement” interchangeably when describing how clients interact with therapeutic processes. However, there is a nuanced yet critical distinction between these two concepts. Compliance typically refers to a client’s adherence to prescribed therapeutic tasks, such as taking medication as directed, completing homework assignments, or attending scheduled appointments. Engagement, in contrast, goes beyond mere adherence and involves genuine involvement, emotional investment, and collaborative participation in therapy.
Recent research underscores that compliance, while necessary for some aspects of clinical treatment (e.g. medication schedules in psychiatric care), does not always predict positive long-term outcomes (Swift & Greenberg, 2014). Compliance may reflect passive acceptance of instructions rather than an active, internalised commitment to change. On the other hand, engagement connotes a deeper sense of ownership over the therapeutic process, marked by intrinsic motivation, a collaborative relationship with the therapist, and a clear sense that therapy aligns with personal values and goals (Norcross & Lambert, 2019).
Understanding the difference between compliance and engagement is vital because it shapes how treatment is delivered and how outcomes are measured. Mental health professionals who are adept at fostering engagement, rather than simply seeking compliance, can achieve more robust therapeutic results, sustained progress, and higher client satisfaction. Moreover, engaged clients are less likely to drop out prematurely and are better equipped to generalise skills learned in therapy to their daily lives (Flückiger, Del Re, Wampold, & Horvath, 2018).
This article aims to (1) define and clarify the distinction between compliance and engagement; (2) summarise key research on how these two concepts affect outcomes; (3) discuss client traits, attitudes, and behaviours that signify true engagement; and (4) explore strategies and techniques clinicians can use to foster genuine engagement. These insights will help mental health professionals refine their approaches to treatment and ultimately improve therapeutic efficacy.
Defining compliance vs engagement
Compliance in a therapeutic setting typically centres on the concept of following directives, guidelines, or routines provided by a mental health professional. For instance, a client attending each session punctually, taking prescribed medication exactly as instructed, or completing a certain number of worksheets per week is demonstrating compliance. This behaviour is often externally motivated; the client follows through because of the expectation set by the professional or because of immediate external reinforcements (e.g. needing a medication refill, wanting positive feedback, or avoiding negative consequences).
Engagement, in contrast, represents an internalised, active, and collaborative involvement in the therapeutic process. Engaged clients do not just follow instructions—they internalise the rationale behind the interventions, reflect on how these apply to their own lives, and actively collaborate in setting goals and evaluating progress. Engagement is characterised by an ongoing sense of curiosity, self-reflection, and personal ownership of the therapeutic journey. Engaged clients often come to sessions prepared with questions and insights, and they readily provide feedback about their experiences with therapeutic tasks. Importantly, engagement suggests that clients have a stake in the process and view therapy not just as a series of “to-dos” but as a meaningful endeavour that aligns with their personal values and long-term aspirations.
From a theoretical standpoint, compliance is often associated with the behavioural level of a therapeutic alliance—doing what is asked. Engagement, however, resonates more strongly with the relational and experiential dimensions of that alliance. In other words, engagement reflects a robust therapeutic bond that includes mutual trust, empathy, and collaboration (Flückiger et al., 2018). The outcome of such a bond tends to be improved emotional openness, enhanced motivation to change, and a greater willingness to try out new coping strategies outside the therapy room.
One of the important distinctions to be noted here is that compliance can exist without engagement, but true engagement usually includes at least some degree of compliance. A person can show up to therapy sessions or take medication without genuinely believing in the process or without an active commitment to making life changes. Conversely, it is rare for someone to be deeply engaged in therapy and simultaneously defy basic therapeutic tasks. Engaged individuals typically comply with tasks, but their compliance is grounded in internal motivation rather than obligation or fear.
Research on compliance vs engagement and their impact on therapeutic outcomes
Scholarly interest in differentiating compliance from engagement has grown significantly in the past decade. This is partly due to consistent findings that merely “doing what you’re told” (compliance) does not necessarily translate to positive, long-lasting change (Swift & Greenberg, 2014). Compliance-based approaches were more common in traditional medical models, where success was measured by adherence to dosages, schedules, and procedures. However, in the mental health context, recent studies highlight the importance of the therapeutic relationship, the client’s sense of agency, and the collaborative nature of treatment as predictors of outcome (Flückiger et al., 2018).
A meta-analysis by Flückiger and colleagues (2018) explored the therapeutic alliance and found that the quality of the alliance (which is tightly linked to engagement) accounts for as much as 5–7% of the variance in therapeutic outcomes—an effect size comparable to that of specific therapeutic modalities. In other words, no matter which evidence-based practice is employed (e.g. cognitive behavioural therapy, dialectical behaviour therapy, psychodynamic therapy, etc.), outcomes are generally better when clients are truly engaged. This suggests that engagement is not merely a peripheral or “nice to have” ingredient; it is central to effective therapy.
Furthermore, Swift and Greenberg (2014) examined rates of dropout from psychotherapy and found that low engagement at the outset was a strong predictor of premature termination. Clients who attended sessions but did so half-heartedly, or those who felt coerced or obliged, were more likely to drop out and were also more likely to report less satisfaction with therapy. Importantly, the concept of “low engagement” in these studies was measured via a combination of self-report (e.g. a client’s rating of their commitment to therapy) and therapist evaluations (e.g. therapist’s observations of participation and collaboration).
Conversely, the APA Task Force on Evidence-Based Relationships and Responsiveness concluded, based on its 16 meta-analyses on aspects of the therapy relationship, that a number of relationship factors which signify high engagement—such as agreed therapy goals, clients giving feedback throughout the course of treatment and both parties repairing ruptures—are at least as vital to a positive outcome as using the right treatment method. The research found that the client engagement stemming from a good therapeutic relationship is essential to helping the client connect with, remain in, and get the most from therapy.
High engagement has been linked not only to reduced dropout but also to better overall outcomes in symptom reduction and quality-of-life improvements. For instance, clients who reported feeling emotionally invested in therapy showed marked improvements in measures of depression and anxiety, as well as in interpersonal functioning. These clients were also more likely to continue practising coping skills well beyond the conclusion of formal treatment, indicating that the changes they made were more durable (DeAngelis, 2019).
It is also worth noting the potential cultural and contextual factors that shape compliance and engagement. Some cultures may place a high value on authority and following professional advice, leading to high compliance but possibly lower intrinsic engagement if the client does not feel personally aligned with the interventions (Norcross & Lambert, 2019). Clinicians must therefore remain culturally sensitive, ensuring that they address both the external and internal motivations for therapy. In sum, the current body of research consistently underscores that while compliance might be an important component of treatment, genuine engagement is the engine that drives meaningful and sustained therapeutic change.
Client traits, attitudes, and behaviours that signify real engagement
Although “engagement” is sometimes used interchangeably with “attendance” or “adherence,” clinical reality is more nuanced than that. A growing body of work underscores that real engagement in psychotherapy entails a deeper, more active involvement in the therapeutic process. According to a systematic review by Holdsworth, Bowen, Brown, and Howat (2019), engagement is strongly associated with not only the frequency of attendance or completion of prescribed tasks, but also the client’s motivation, sense of ownership, and emotional investment.
A key theme emerging from Holdsworth et al. (2019) is the willingness to collaborate—a client who is genuinely engaged typically shares insights openly, provides feedback on interventions, and partners with the therapist in tailoring techniques to their circumstances. Rather than passively accepting directions, these clients demonstrate a proactive stance; for instance, they may suggest alternative coping strategies or ask thoughtful questions to refine their understanding of therapeutic principles.
Engaged clients also exhibit sustained motivation, which can be seen when they continue to explore therapeutic materials between sessions. While life circumstances or psychological barriers might hamper progress, motivated individuals tend to reflect on what they learned, journal insights, and return to therapy with fresh observations or questions. This cyclical process—gaining knowledge in session, applying it in daily life, and returning for further clarification—fosters a deeper level of engagement.
Moreover, emotional investment is identified as a decisive factor. Clients who view therapy as central to their personal growth often report a sense of genuine curiosity and readiness to face discomforting feelings or challenging topics, rather than avoiding them. This willingness to remain in contact with difficult emotions, as highlighted in the review, strengthens the therapeutic alliance and enhances overall outcomes.
Finally, Holdsworth et al. (2019) emphasise that these engaging traits develop most robustly in contexts where therapists also demonstrate empathy, respect, and a non-judgemental stance. When clients feel safe and validated, they are more inclined to share vulnerabilities, address setbacks collaboratively, and maintain a long-term commitment to change. Through an iterative process of openness, collaboration, and mutual trust, clients are better able to move beyond mere compliance towards truly meaningful engagement in psychotherapy.
How clinicians can foster engagement
Cultivating genuine engagement is a multi-faceted process that involves establishing a strong therapeutic alliance, personalising interventions, and skilfully navigating resistance or ambivalence. Below are several strategies supported by contemporary research and practice guidelines (Norcross & Lambert, 2019; Leahy, 2017).
1. Establish a strong therapeutic alliance early on
The therapeutic alliance is often described as the cornerstone of engagement (Flückiger et al., 2018). This alliance comprises three key components: (a) agreement on therapy goals, (b) collaboration on tasks, and (c) the development of a personal bond involving warmth, empathy, and trust.
Practical tip: In the initial sessions, invite clients to share what they hope to gain from therapy. Consider collaboratively drafting a “therapy contract” that outlines goals, preferences, and expectations. Use reflective listening to ensure the client feels heard and validated.
2. Use motivational interviewing principles
Originally developed for addiction treatment, motivational interviewing (MI) principles have broad applicability for enhancing engagement (Miller & Rollnick, 2023). MI emphasises empathy, softening the sustain talk, and evoking the client’s own motivations for change.
Sample dialogue:
- Therapist: “It sounds like a part of you wants to continue with the status quo, but another part is really frustrated and wants to see change. Can we explore what both sides are telling you?”
- Client: “Yes, it’s like I’m stuck between wanting to stay comfortable and wanting to feel better.”
- Therapist: “That ambivalence is completely understandable. Let’s unpack what ‘feeling better’ means for you and what obstacles are making it hard to move forward.”
3. Personalise therapeutic tasks
Clients are more likely to engage if they perceive therapy tasks as relevant and meaningful. This means tailoring homework assignments, psychoeducational materials, or specific interventions to the client’s lifestyle, cultural background, and personal interests (Koerner, 2021).
Practical tip: If a client loves art, consider incorporating art-based expressions of their emotions or journalling exercises that include drawing. If they have a busy schedule, discuss how to integrate brief mindfulness breaks into their day.
4. Maintain transparency and collaboration
Avoid “mystifying” the therapy process. Explain the rationale behind each intervention or exercise. Encourage questions and be open about the evidence base, potential benefits, and possible limitations of different approaches.
Sample dialogue:
- Therapist: “We’re introducing a new technique called a ‘behavioural experiment.’ The idea is that we hypothesise what might happen in a challenging situation and then gather real-life data to see if our assumptions are accurate. How does that sound?”
- Client: “It sounds interesting, but I’m not sure I’ll have time.”
- Therapist: “We can adapt it to fit into your schedule. Let’s find a 5-minute window each day where you can try a small version of this.”
5. Validate and normalise ambivalence or resistance
Resistance or reluctance to engage is a normal part of the therapeutic process, especially if therapy challenges long-standing beliefs or behaviours. Instead of confronting resistance aggressively, normalise it, and explore its roots.
Practical tip: Use statements like, “It makes sense that you feel uncertain about trying something new. It can be scary to move outside your comfort zone. Let’s talk about what you find most challenging about this next step.”
6. Involve clients in treatment decisions
Empowering clients to make informed choices about their therapy can significantly increase engagement. This might include letting clients choose which skills to learn first, which areas of their life to focus on, or how frequently they want to schedule sessions (within reason).
Practical tip: Present clients with multiple therapeutic options, such as mindfulness exercises, cognitive restructuring, or behavioural activation techniques, and invite them to consider which they feel most drawn to at this stage.
7. Tailor feedback and reinforcement
Positive feedback can boost motivation, but it needs to be genuine and tied to specific actions or insights. Avoid generic praise like “Good job”; instead, highlight what the client did effectively and how it connects to their goals.
Sample dialogue:
- Therapist: “You mentioned you felt uncomfortable doing the exposure exercise, yet you still gave it a try. That perseverance tells me you’re really committed to facing your fears. How do you feel about that accomplishment?”
- Client: “I’m surprised at how brave I felt, even though I was anxious.”
- Therapist: “Exactly. That’s important evidence that you can tolerate discomfort and move through it. Let’s capture this moment so we can remind ourselves of it next time anxiety arises.”
8. Monitor and adjust
Engagement is not static; it fluctuates over time and across sessions. Regularly check in with clients about their level of motivation, sense of progress, and alignment with therapy goals. Adjust interventions accordingly (Leahy, 2017).
Practical tip: Incorporate brief check-in measures or scaling questions such as, “On a scale of 1–10, how motivated do you feel about continuing therapy this week?” Explore shifts in these ratings collaboratively.
By integrating these strategies, clinicians can shift the therapeutic dynamic from one focused on external adherence (compliance) to one marked by mutual participation and investment (engagement). The emphasis should be on building a genuine partnership with the client, in which the therapist’s expertise and the client’s personal experiences intersect to create an environment conducive to meaningful change.
Additional considerations
While fostering engagement is critical for all clients, certain populations or treatment contexts may require specialised considerations. For example, adolescents may present challenges in engagement due to developmental factors such as a heightened sensitivity to authority or social pressures (Leahy, 2017). Clinicians working with young clients often find that incorporating creative and interactive methods—like gamification or multimedia—can enhance engagement.
In group therapy settings, engagement is influenced not just by the therapist-client relationship but also by the group dynamic. Facilitators must be attentive to peer support, group cohesion, and the ways in which clients interact with each other. A sense of collective purpose can be a powerful driver of engagement, but group conflict or interpersonal triggers can hinder it. There are also specific ethical considerations in group therapy to take into account.
Trauma survivors may experience heightened ambivalence about exploring painful memories or emotions, making engagement a delicate process. Establishing safety, providing psychoeducation about trauma responses, and pacing the therapy sessions to respect the client’s window of tolerance become crucial (Norcross & Lambert, 2019).
Cultural context also shapes engagement. Clients from cultures that emphasise collectivism may be more comfortable engaging with family-involved therapeutic approaches, while those from more individualistic cultures might value personal autonomy in treatment decisions. Examples of culture-centred or adapted approaches include positive psychology, person-centred, and narrative and solution-focused interventions for First Nations Australians, and culturally adapted CBT for diverse populations (CA-CBT). It is essential for therapists to employ culturally sensitive strategies, such as adapting communication styles, incorporating interpreters when needed, and acknowledging cultural beliefs about mental health and healing.
Ultimately, the clinician’s role is to recognise these unique factors and adapt engagement strategies to fit the client’s developmental stage, cultural background, and specific mental health challenges. By doing so, mental health professionals can reduce barriers to engagement, improve the therapeutic alliance, and promote more significant, sustained outcomes.
Conclusion
Understanding the difference between compliance and engagement is far from a semantic exercise; it lies at the heart of effective mental health treatment. Compliance might ensure that clients follow through on immediate tasks, but engagement fosters a deeper, more enduring connection to therapy. When clients are genuinely engaged, they are more likely to become active agents in their own healing processes—showing curiosity, persistence, and self-reflection.
Research underscores that engaged clients not only exhibit lower dropout rates but also tend to achieve better and longer-lasting therapeutic outcomes (Swift & Greenberg, 2014; Flückiger et al., 2018). As mental health professionals, prioritising engagement means cultivating a strong therapeutic alliance, maintaining a collaborative approach, and employing evidence-based strategies that recognise the client’s autonomy, context, and individual goals (Norcross & Lambert, 2019).
In practice, fostering engagement entails validating the client’s experiences, normalising ambivalence, personalising interventions, and staying attuned to shifts in motivation over time. By doing so, therapists move beyond one-way directives and instead build a relationship where clients feel a genuine sense of ownership and hope. In essence, compliance may check the boxes of a treatment protocol, but engagement propels the transformative process that leads to real, sustained change.
Key takeaways
- Compliance involves adherence to treatment directives, while engagement is marked by internalised motivation, collaboration, and emotional investment.
- High engagement correlates with lower dropout rates, better symptom reduction, and more durable improvements across mental health conditions.
- Curiosity, openness, collaboration, active reflection, and persistence are key indicators that a client is more deeply invested in therapy.
- Strategies to foster engagement include building a strong therapeutic alliance through empathy, goal alignment, and a collaborative stance; using motivational interviewing techniques to explore and resolve ambivalence; tailoring interventions to the client’s lifestyle, cultural background, and preferences; maintaining transparency about the rationale for therapeutic exercises; validating and normalising resistance; encouraging a non-judgmental environment; and involving clients in treatment decisions, empowering them to shape their therapy experience.
- Adapt engagement strategies for specific populations (e.g., adolescents, trauma survivors, diverse cultural backgrounds) to ensure inclusivity and relevance.
References
- DeAngelis, T. (2019). Better relationships with patients lead to better outcomes. American Psychological Association, 50(10). Retrieved on 19 February 2025 from: https://www.apa.org/monitor/2019/11/ce-corner-relationships
- Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172
- Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2019). Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors: A systematic review. Psychotherapy Research, 29(2), 183–196. https://doi.org/10.1080/10503307.2017.1392965
- Leahy, R. L. (2017). Cognitive therapy techniques: A practitioner’s guide (2nd ed.). The Guilford Press.
- Koerner, K. (2021). Doing dialectical behavior therapy: A practical guide (2nd ed.). The Guilford Press.
- Miller, W.R., & Rollnick, S. (2023). Motivational interviewing, fourth edition: Helping people change and grow. New York: Guilford Press.
- Norcross, J. C., & Lambert, M. J. (2019). Psychotherapy relationships that work (3rd ed.). Oxford University Press.
- Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193-207. https://doi.org/10.1037/a0037512