Treatment courts face persistent challenges with participants failing to fully engage in treatment or dropping out altogether. Because engagement and retention are critical to public safety and outcomes, treatment courts must understand why nonparticipation occurs and how to respond when it does. This paper summarizes major predictors of nonparticipation and dropout and outlines practical principles and processes—especially the 5 As framework—for cultivating engagement and collaboration in treatment court settings.
Nonparticipation is common across healthcare and behavioral health. Roughly half of patients prescribed psychiatric medications do not adhere as recommended, psychotherapy dropout rates hover around 20%, and treatment court dropout rates are frequently about 40% (Laranjeira, 2023) (de Las Cuevas, 2023) (Linardon, 2018) (Coy & Estrellado, 2024). Nonparticipation is consistently associated with poorer long-term outcomes, higher relapses and recidivism, and greater costs for individuals and communities (Evans E, 2009) (Shannon LM, 2018). These realities underscore the need for treatment courts to identify participants at greatest risk of dropout and to use strategies that promote engagement from the outset.
Participant Contributors to Nonparticipation and Dropout
Several individual factors reliably predict nonadherence or premature termination from treatment programs.
Unemployment and socioeconomic stress: Unemployment and unstable work histories predict lower treatment adherence. Individuals without steady income often face housing instability, transportation barriers, and competing demands that interfere with regular attendance (Åhs A, 2012).
Lower education: Lower educational attainment is associated with fewer coping resources, less familiarity with formal systems, and a more limited understanding of treatment concepts, all of which may contribute to confusion or disengagement (Silva M, 2022).
Severity of addiction and co-occurring mental illness: Greater addiction severity and co-occurring psychiatric disorders increase the risk of nonparticipation (Daigre C, 2021). Severe symptoms, chaotic lifestyles, and hopelessness can make consistent engagement in structured services feel overwhelming.
Structural barriers and stigma: Nonparticipation is also shaped by structural factors: limited treatment capacity, unstable program funding, fragmented services, and stigma—particularly around medications for opioid use disorder (Dickson-Gomez J, 2022).
Criminal justice history, motivation, and perceived program difficulty: Participants with more extensive criminal justice involvement may experience greater distrust in systems and anticipate failure. Low intrinsic motivation for treatment and perceptions that the program is too difficult, punitive, or irrelevant further increase dropout risk (Evans E, 2009) (Shannon LM, 2018).
Clinical Factors Affecting Dropout and Nonparticipation
Many influences on participation lie within the control of clinicians and treatment teams.
The therapeutic alliance and formulation: A strong therapeutic alliance is one of the most robust predictors of successful outcomes across therapies and populations (Wampold BE, 2023) (Flückiger C, 2020) (Duncan, 2010). The alliance involves:
- A safe, trusting, respectful relationship in which the participant feels valued.
- Shared goals that make sense to both clinician and participant.
- Agreement on strategies and tasks for reaching those goals (Frank, 2025).
Engagement improves when the alliance is grounded in a shared formulation: a collaborative understanding of who the participant is, what has happened to them, their values, strengths, community, identity, and aspirations (Cruwys T, 2023) (Nezu CM, 2015) (Johnstone, 2013). When treatment is adapted to participants’ cultural identities, preferences, and lived experiences, the alliance is strengthened and outcomes improve ((COPPS), 2021).
Individualizing treatment: Standardized program requirements that do not flex to participants’ needs can feel irrelevant or coercive. Tailoring services—type, intensity, format, language, and focus—to match participant preferences increases satisfaction, completion rates, and clinical gains (Lindhiem O, 2014).
Addressing basic needs: Unmet basic needs such as housing, food, transportation, safety, and childcare create constant crises that crowd out treatment. Addressing these needs directly, or by coordinating with social services and natural supports, is foundational to engagement (Medine, 2021).
Aligning motivation: Treatment is most effective when the participant’s own reasons for change align with the purposes of the treatment court. If participants do not see how treatment helps them get more of what matters most to them, attendance quickly becomes about “doing time” rather than “doing treatment.”
Co-occurring illness: Co-occurring mental health conditions—including depression, anxiety, psychosis, ADHD, and personality disorders—can impair insight, emotional regulation, and executive functioning, making consistent participation difficult (A., 2024).
Factors Promoting Participation
Despite the risks, several factors consistently support engagement in treatment court programs (Canada KE, 2020) (Patten R, 2015) (Randall-Kosich O, 2022).
Personal motivation and accountability: Participants who feel personally responsible for their recovery tend to remain more engaged. Clinicians and court staff can help evoke this sense of ownership by inviting self-reflection, supporting meaningful goal setting, and reinforcing small steps toward change.
Structured support systems: Peer support, mentoring, family involvement, and community-based resources provide emotional, practical, and social support that make adherence more feasible.
Quality and availability of services: Access to skilled clinicians, evidence-informed therapies, mental health care, and addiction medicine—including medications for addiction treatment when appropriate—improves retention (Medicine, 2024).
Judicial engagement and incentives: Active, respectful involvement by judges and court personnel can powerfully shape motivation. Clear incentives—such as privileges, phase advancement, or reduced supervision—combined with consistent, fair responses to nonadherence, reinforce accountability and progress.
Treatment duration and intensity: Programs that offer a flexible continuum of care allow participants to receive more intensive services when risk is high and step down as stability improves.
Promoting Participation: Cultivating Constructive Collaboration
Promoting participation requires more than enforcing compliance. It calls for a collaborative approach that emphasizes safety, respect, empathy, and shared responsibility (Law, 2020) (AllRise, 2025). Successful engagement is built on three interlocking elements:
- Therapeutic engagement
- Participant-centered formulation and recovery planning
- Ongoing monitoring and adaptation
Therapeutic engagement: A strong therapeutic relationship is the cornerstone of effective treatment. Master clinicians continually cultivate both their therapeutic spirit and their relational skills (Miler, 2021). These manifest as:
- unconditional positive regard
- warmth and acceptance
- genuineness
- evoking hope
- affirmation
- empathy
- collaborative, participant-centered guidance
These capacities are developed over a professional lifetime through feedback, reflection, deliberate practice, supervision, and coaching (Chow, 2020). Building cultures of clinical excellence within treatment courts helps support this development.
Clinicians should begin where participants are, engaging first with what participants most want that led them to accept treatment court, rather than focusing solely on program rules. Mutual respect, open communication, and consistent support help participants feel seen and valued rather than managed or judged.
Participant-centered formulation and recovery planning: Engagement makes it possible to co-create a shared, compassionate, and coherent understanding of the participant—the formulation. This shared story includes problems and risks but also strengths, values, culture, community, hopes, and identities. Based on this understanding, clinicians and participants co-author the recovery plan, with the participant positioned as the primary author of their healing journey.
A good recovery plan addresses clinical needs (e.g., substance use, mental health) and broader human service needs (e.g., housing, employment, family relationships) for both the participant and their ecosocial system. It should be understandable in the participants’ own words and clearly linked to outcomes that matter to them.
Monitoring and adapting: Participant needs and circumstances change over time. Effective care plans are therefore adaptive, iterative, and feedback informed. Routine monitoring of progress, satisfaction, and engagement—using brief tools and collaborative conversations—helps identify problems early. Clinicians then adjust goals, methods, or intensity to maintain relevance and effectiveness.
Motivation management: Motivation is not a fixed trait; it fluctuates. Techniques such as motivational interviewing, values clarification, and collaborative goal setting help participants explore ambivalence, strengthen commitment, and build confidence. Recognizing small successes, celebrating incremental change, and setting achievable milestones all foster a sense of efficacy and hope.
Rewards, privileges, and accountability: Positive reinforcement—verbal recognition, incentives, privileges, and visible acknowledgment of achievement—can be powerful in sustaining participation. Sanctions are often more effective when framed as loss of privileges or missed opportunities rather than punishment, and when they are delivered predictably, proportionally, and respectfully.
Transparency and expectations: Participants need a clear understanding of program expectations, roles, and potential consequences. Transparent communication about requirements, available supports, and decision-making processes fosters accountability and allows participants to make informed choices about their recovery (Stinson, 2017).
What to Do When Participants Aren’t Participating: The 5 As
Even in the best programs, disengagement is inevitable. The question is not whether participants will struggle, but how teams respond when they do. The 5 As framework—Attend, Abstain, Appreciate, Assess, Act—offers a structured, humane process for understanding and addressing nonparticipation.
1. Attend – The first step is to pay close attention. Clinicians and teams should systematically monitor attendance, participation, attitudes, and outcomes, watching for signs that participants are “doing time” rather than “doing treatment.” Feedback-informed methods can help track well-being, progress, and satisfaction in real time.
Attending also includes checking in on the therapeutic alliance. Brief tools and open conversations about “how we are working together” can reveal ruptures in trust, misaligned goals, or tactics that are not meaningful to the participant. Clinicians must also attend to their own internal reactions—frustration, anxiety, hopelessness.
2. Abstain – Once problems are noticed, the second step is to abstain—from blame, impulsive action, and premature conclusions. It is tempting to label participants as unmotivated or resistant, but such labels close curiosity and can damage the alliance. Except in situations of imminent risk, it is usually best to refrain from action until the situation is better understood.
Clinicians also have a professional duty to maintain hope. Losing faith in the participant’s capacity to change is itself a powerful barrier to engagement.
3. Appreciate – The third step is appreciation—accepting the situation as it is and recognizing its complexity. Approaching nonparticipation with an “of course” mindset (“Of course there are obstacles; of course, engagement is hard”) cultivates equanimity and compassion (Holiday, 2014). Participants often face trauma histories, mental health symptoms, poverty, unstable relationships, and discrimination. Staff may be overextended and working in under-resourced systems.
Appreciation means allowing the reality of the moment without harsh judgment—toward the participant or oneself. This stance creates space for curiosity rather than anger and makes it more likely that participants will feel safe enough to be honest about their struggles.
4. Assess – With curiosity and acceptance in place, the team moves to assessment: a collaborative inquiry into what is and is not working, involving the participant, clinicians, court staff, and—when appropriate—family or other supports.
The team should revisit the original assessment, formulation, and care plan: Have circumstances changed? Are the goals still meaningful to the participant? Are services mismatched to their stage of change or cultural context?
A key task is to distinguish “can’t” from “won’t.” Some participants cannot engage because of low self-efficacy, inadequate coping skills, cognitive limitations, severe psychiatric symptoms, external stressors, or lack of support. Others technically can engage but are not doing so because of waning motivation, ruptures in the alliance, competing loyalties, or trauma-based “hidden agendas.” Understanding these drivers allows interventions to be targeted rather than generic.
5. Act – Only after careful assessment is it time to act. Action should flow from what has been learned, and whenever possible, be co-designed with the participant.
Maintain equipoise: Clinicians and court personnel should maintain calm, balanced, and compassionate demeanors. Participants need to see that the team is both invested in their success and steady enough to tolerate setbacks without retaliation.
Strengthen relational skills: Teams may need to refine foundational interpersonal skills—empathy, acceptance, warmth, clarity, and evocation of hope. Seeking supervision, peer consultation, and training communicates that the system is willing to grow alongside the participant.
Seek feedback and reflect: Soliciting feedback from participants, supervisors, and colleagues—and engaging in honest self-reflection—helps clinicians recognize when their own behavior, assumptions, or blind spots are contributing to disengagement (de Cossart L, 2012).
Review the treatment contract and goals: When appropriate, teams can revisit treatment contracts and expectations, emphasizing both autonomy and accountability. The message should be: “This is your life and your recovery, and we are here to support you within real-world constraints.”
Repair ruptures and renegotiate the plan: If the alliance has been damaged, explicit rupture repair is crucial. This may involve naming the rupture, apologizing for mis attunements, clarifying misunderstandings, or, at times, changing clinicians. The care plan may need to be renegotiated to better reflect the participant’s preferences, capacities, culture, and current priorities.
Arrange additional supports: When disengagement is driven by external barriers—housing, transportation, childcare, legal stress, lack of social support—the team should collaborate with community partners, families, and peer supports to secure needed resources.
Reinforce motivation: When motivation is low, targeted motivational interventions can help participants clarify values, envision desired futures, and explore discrepancies between their goals and current behavior.
Ongoing Monitoring and When Engagement Cannot Be Sustained
Re-engagement is rarely a single event. Teams must continually cycle through the 5 As—attending to new information, abstaining from premature reactions, appreciating evolving realities, reassessing, and adjusting actions.
Sometimes, despite thoughtful and persistent efforts, participants continue to disengage. In these situations, treatment teams should maintain open communication with the court, provide honest information about progress and risk, and advocate for responses that balance accountability with compassion. Even when a participant leaves or is terminated from the program, clinicians can convey that the door remains open for future help.
Post-program reviews (“post-mortems”) can identify lessons learned for the team and highlight structural barriers that could be addressed for future participants.
Conclusion
Nonparticipation is not an aberration but an expected feature of treatment court work. Rather than interpreting disengagement as failure, teams can approach it as a signal that something in the complex interaction among participant, provider, program, and context needs to change. The 5 As framework—Attend, Abstain, Appreciate, Assess, and Act—offers a practical, compassionate roadmap for responding.
By emphasizing strong therapeutic alliances, participant-centered planning, flexible and feedback-informed care, and collaborative responses to nonparticipation, treatment court teams can enhance engagement and outcomes. Expecting, monitoring, and thoughtfully addressing participation problems is essential to the long-term success of treatment courts and to the healing of the people they serve.
Michael McGee, M.D., DLFAPA, is President of WellMind Inc., providing training and consulting services. He can be reached at 9496 Caymas Terrace, Naples, FL 34114, by phone at 978-360-6071, or by email at mdm@drmichaelmcgee.com. Additional information is available at www.drmichaelmcgee.com.
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