Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
In this part of the chapter, Lutz and colleagues review research methods related to patients dropping out of psychotherapy. Drop outs represent an important problem. For the clinician, a patient who drops out may represent loss of income due to missed appointments, extra work, administrative costs, and a lower sense of professional self-efficacy. Not all patients who terminate therapy early have a poorer outcome. But the research indicates that overall, patients who drop out of treatment do have poorer outcomes, higher hospitalization rates, lower work productivity, and higher social costs than patients who complete treatment. Hence, when a patient drops out of therapy it should be defined as a failure of the treatment that could lead to further demoralization of the patient. Defining a drop out is tricky in that some studies indicate that if a patient does not attend a minimum number of sessions, then they have dropped out. However, a more realistic definition might be that if a patient unilaterally decides to end therapy against a therapist’s advice, then the patient can be considered to have dropped out. Estimates of patient drop out from therapy vary widely depending on the treatment context and patient characteristics. For example, highly controlled studies report dropout rates of about 19.7%, but less controlled studies that might be closer to real world practice report average dropout rates of 26%. But the range of dropout rates across studies was very wide from 0% to 74.2%. Patient characteristics that led to higher dropout rates included higher initial impairment, younger age, lower level of education, a personality disorder diagnosis, and negative expectations about treatment. Therapists had a significant impact on dropping out as well. Therapist effects accounted for 12.6% of the variance in dropping out – that is a moderate but important effect. That is, some therapists have higher dropout rates than others, and this is likely independent of patient characteristics. This is like therapist effects on patient outcomes, in which it is estimated that about 10.1% of patient deterioration is predicted by the therapist’s effect.
Patients dropping out from psychotherapy is an important problem that negatively affects the patient, the therapist, and that has broader social, health, and economic consequences as well. Aligning the patient’s and therapist goals for the therapy, coming to a collaborative agreement on how therapy will work, and developing an emotional and empathic bond with the patient may be ways of reducing the number of dropouts from therapy. These are all elements of the therapeutic alliance that must be negotiated very early in therapy to forestall a negative outcome such as the patient dropping out.