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Werbarta, A., Andersson, H., & Sandell, R. (2014). Dropout revisited: Patient- and therapist-initiated discontinuation of psychotherapy as a function of organizational instability. Psychotherapy Research, Online first publication: DOI: 10.1080/10503307.2014.883087.

Premature termination of psychotherapy in mental health care is a problem both in terms of patient outcomes and in terms of financial consequences for providers. Drop out rates for psychotherapy in general range from 20% to 75% with an average of 50%. In my April, 2013 blog I reported on a meta analysis by Swift and Greenberg (2012) in which they reported an overall drop out rate of 20% in randomized control trials; but the average drop out rate could be up to 38% in randomized trials depending on how premature termination was defined (failure to complete a treatment, attending less than half of sessions, stopping attending, or therapist judgment). Drop outs are commonly believed to represent therapeutic failures. Much of the research to predict psychotherapy non-completion has focused on patient variables like age, gender, symptom severity and others. This implicitly puts the responsibility for dropping out on the patient. Swift and Greenberg (2012) found that on average young, male, single patients with a personality disorder diagnosis were more likely to drop out. Therapist variables are less frequently studied, and the only therapist variable related to lower drop out was greater experience. Therapeutic orientations were not related to more or less dropping out. Very few studies have examined work conditions or organizational variables as predictors of premature terminations. Werbata and colleagues (2014) conducted a large study in 8 clinics in Sweden with 750 patients treated by 140 therapists. The clinics were three psychiatry outpatient units, three specialized psychotherapy units, one young adult psychotherapy unit, and one primary care setting that provided psychotherapy. Drop out was defined as unilateral termination in which either the patient or therapist discontinued the treatment. Of the patients who started therapy, 66% completed treatment and 34% terminated prematurely (19.7% of patients terminated the therapy, 14.3% were terminated by therapists). On average, clients were in their mid-30s, and most had a psychiatric diagnosis. The most common therapy was psychodynamic (59.1%) followed by integrative (19.0%), and cognitive behavioral (17.1%). The authors looked at patient variables (e.g., symptom severity), therapist variables (e.g., age, gender, etc.), and organizational stability. Ratings of organizational stability of the clinic were based on: the transparency of the clinic structure, the suitability of the organization to provide psychotherapy, the clarity of rules and decision-making policies regarding providing psychotherapy, and the clinic’s financial stability. Client variables such as: older age, greater level of psychopathology, and tendency to act out were moderately predictive of dropping out. Receiving treatment at a less stable clinic made it almost four times more likely for patients to initiate dropping out than to remain in therapy. Organizational instability was more important than patient factors in accounting for premature termination.

Practice Implications

Drop outs were almost four times higher in unstable clinics. Instability in organizations can create anxiety, cynicism, and disengagement in staff, which may have consequences for patient care. Financial and political problems within a clinic or institution, internal conflict related to treatment policy or disruptive administrative routines may affect the therapeutic relationship, which is generally more intimate and more important than in other health care contexts. Organizational instability can result in shortened or interrupted treatment, change in therapists, or therapists who are not fully engaged due to clinic stresses. For patients, these terminations may resemble earlier life losses or neglect that may have precipitated their need for therapy in the first place.

Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 394–404.

There are now a number of psychotherapies that the Society of Clinical Psychology list as effective psychotherapies available for posttraumatic stress disorder (PTSD). Approaches include prolonged exposure (PE), and cognitive processing therapy (CPT) among others (click here for examples). Therapies for PTSD also vary in how much they focus on retelling the trauma. Some treatments like trauma-focused CBT place a higher level of focus on retelling the trauma event, whereas Present Centred Therapy (PCT), which was originally conceived as a control condition, largely avoids the trauma. Patients may begin a treatment and find some aspect of it distressing resulting in discontinuation. There is ongoing debate regarding the belief that exposure-based treatments, which require the patient to retell traumatic events in detail to his or her therapist, are especially unacceptable or poorly tolerated by patients. Drop out rate is a common metric used to assess tolerability of a treatment. In the April 2013 blog I reported on a meta analysis that found that the average drop out rate in randomized controlled trials of adult psychotherapy was 19.7%. However drop out rates for PTSD in the community can be as high as 56%. Imel and colleagues conducted a meta analysis of drop out rates in randomized controlled trials of treatments for PTSD. They also assessed if drop out rates differed by the amount the therapy focused on retelling the trauma. In the meta analysis, 42 studies were included representing 1,850 patients; 17 of the studies directly compared two or more treatments. The aggregated drop out rates across all studies was 18.28%, which is not different from the rate in randomized trials of adult psychotherapy in general, but is much lower than reported in regular clinical practice. Group treatment was associated with a 12% increase in drop outs compared to individual treatment. In general, an increase in trauma focus was not associated with greater drop out rates. However, when trauma focused treatments were directly compared to PCT (a trauma avoidant intervention) in the same study, trauma-specific treatments were associated with a twofold increase in the odds of dropping out.

Practice Implications

Many have been concerned that exposure-based therapies can lead to symptom exacerbation and result in dropout. The findings of Imel and colleagues’ meta analysis suggest that dropout rates are not significantly different among active treatments. However, PCT may be an exception to this general pattern of no differences among active treatments. Perhaps PCT should be considered a first line treatment for those who do not prefer a trauma focused treatment. In addition, providing treatment for PTSD in groups was associated with greater drop out rates possibly due to shame related to public disclosure of the trauma. The authors suggest mimicking research trial procedures in community practice in order to reduce drop out rates, such as: providing therapist training, support, and supervision; careful patient screening; regular assessment of patient progress; and ongoing contact with assistants that may promote session attendance.

Author email: zac.imel@utah.edu

Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013, March 11). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration. Advance online publication. doi: 10.1037/a0031423

Client preferences consist of preferences regarding the type of treatment offered (e.g., preference for psychotherapy or medication, preference for a behavioral approach to treatment or an insight oriented one), desires for a certain type of therapist or provider (e.g., preference for an older therapist, a female provider, or a therapist who has a nurturing personality style), and preferences about what roles and behaviors will take place in session (e.g., preference for the therapist to take a listening role or an advice giving role). In a previously published meta analysis Swift and colleagues (2011) reviewed data from 35 studies that compared preference-matched and non-matched clients. A small but significant preference outcome effect was found, indicating that preference-matched clients show greater improvements over the course of therapy, and that clients whose preferences were not matched were almost twice as likely to discontinue treatment prematurely. In this follow up meta regression study, Swift and colleagues assessed whether preference accommodation is more or less important for types of disorders, types of treatments, or different demographics like sex or age. (Meta regression involves accumulating data from across many studies to assess predictors [e.g., sex, age, diagnosis, treatment type, etc.] of the preference effect). For example, some research has indicated that men prefer therapists with more feminine traits and that men prefer pharmacological interventions. But does accommodating these preferences affect outcomes and drop out rates? Is matching preferences essential for younger clients? Is matching preferences more important for women or ethnic minorities? The authors analysed data from 33 studies representing 6,058 clients to address some of these questions. The only variable that predicted the influence that preferences have on rates of premature termination was the length of the intervention. That is, it may be more important to accommodate client preferences for briefer therapies. Perhaps, as clients continue in therapy for longer durations, other variables such as the therapeutic alliance play a bigger role in determining whether or not one drops out prematurely. It is also possible that as treatment continues, clients may experience a shift in preferences to more closely match the treatment conditions that they were given. Once this shift in preferences has occurred, preferences are no longer mismatched, and the risk of dropping out may be diminished.

Practice Implications

This study provides evidence that incorporating client preferences may be important for all types of clients. Generally, when client preferences are accommodated, clients show greater improvements while in treatment and are less likely to discontinue the intervention prematurely. As much as is practical, practitioners might collaboratively work with clients to identify what preferences they hold for treatment, and to discuss those preferences in the context of what is the most effective treatment that is available. This is particularly important for psychotherapies of shorter duration..

Author email: joshua.keith.swift@gmail.com

Swift, J.K. & Greenberg, R.P. (2012). Premature discontinuation in adult psychotherapy: A meta analysis. Journal of Consulting and Clinical Psychology, 80, 557-589.

Premature termination or drop out from psychotherapy has long been a significant problem for the practice of psychotherapy. Drop out can be variously defined as: not completing the course of treatment, unilateral termination on the patient’s part without therapist input, and not attending a specified number of sessions, among others. One of the largest meta analyses on the topic was done in 1993, and at that time the average drop out rate was 46.86%. This is a serious problem for a number of reasons. First, the average patient needs approximately 18 sessions to improve, and so early dropping out means that these patients do not benefit. Second, therapists can become demoralized at such drop out rates, and therapists who are not confident in their procedures are less likely to be effective. Third, the agency or practice loses important sources of funding or revenue. And fourth, society in general continues to manage the burden of a significant portion of its population not being at their best. The meta analysis by Swift and Greenberg (2012) is the largest of its kind, comprising 669 studies representing 83, 834 patients. The average drop out rate, largely defined as not completing treatment and unilateral termination without therapist input, was 19.79%. This appears to be a substantial drop from the previous 1993 number of 46.86%, but still represents one in five psychotherapy patients. Swift and Greenberg suggest that perhaps the more recent focus on evidence based treatments and short term treatments, and more systematic and consistent reporting of drop outs from studies may account for the lower numbers. No differences were found in drop out rates between treatment orientations (e.g., CBT vs others) and no differences in treatment format (e.g., individual vs group). Time-limited (20.7%) and manualized (18.3%) treatments tended to have lower drop out rates than non-time-limited (29%) and non-manualized (28.3%) treatments. Patients with eating disorders (29.3%) and personality disorders (25.6%) had the highest drop out rates. As did patients who were younger and less educated. Drop out rates in effectiveness studies (26%), that are more similar to everyday clinical practice, was higher than highly controlled randomized trials (17%). Trainee therapists (26.6%) tended to have higher drop out rates than experienced therapists (17.2%).

Practice Implications

At least one in five clients are likely to drop out of psychotherapy. Clinicians should particularly work on retention with younger clients and those with a personality or eating disorder diagnosis. Extra efforts to prevent dropout should also be emphasized for trainees and in university-based clinic settings. A number of strategies for reducing premature discontinuation in therapy have been identified, including discussing expectations regarding therapy roles and behaviors, providing education about adequate treatment duration, addressing motivation, repairing alliance ruptures, using therapist feedback, addressing client preferences, providing time-limited interventions, and increasing perspective convergence in the psychotherapy dyad. A number of these are described in greater detail in the following blog entry.

Author email: Joshua.Keith.Swift@gmail.com

Swift, J.K., Greenberg, R.P., Whipple, J.L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology, 43, 379-387.

As discussed in a previous blog entry, Swift and Greenberg (2012) found that almost 20% of adult individual therapy patients drop out of therapy. Dropping out is generally defined as clients unilaterally terminating psychotherapy prior to benefitting fully and against their therapist recommendation. In this paper, Swift and colleagues review five methods with the best research evidence to reduce premature termination. (1) Providing education about duration and course of therapy. Research indicates that 25% of clients expect to recover after only two sessions of therapy, 44% after four sessions, and 62% expect to recover after 8 sessions. However the research literature indicates that it takes 13 to 18 sessions for 50% of clients to recover. Further, although some clients improve quickly and maintain that, some clients may feel worse before they get better, especially if the symptoms are related to painful feelings or events. So aligning client expectations about the length of treatment and the course of treatment may reduce dropping out. This education should be research based to increase the credibility of the information. (2) Providing role induction. Clients who are naıve to therapy may start not knowing what behaviors or roles are most appropriate on their part and could feel lost or like they are doing things wrong. Role induction refers to providing clients with some pre-treatment education or orientation about appropriate therapy behaviors. This could be done by video, verbally, or in writing. A meta analysis found that pre-therapy role induction increases attendance and reduces drop outs. (3) Incorporating client preferences. Client preferences include wants or desires concerning the type of treatment that is to be used, the type of therapist one would like to work with, and the roles and behaviors that are to take place in therapy. A recent meta analysis found that clients who had their preferences accommodated were almost half as likely to drop out of treatment prematurely compared with clients whose preferences were not taken into account. (4) Strengthening early hope. Although it is important that clients do not hold unrealistic expectations (i.e., recovery after only two sessions), it is also important that they have a general hope that therapy can help them get better. Research evidence shows that expectations for change explain as much as 15% of the variance in therapy outcomes. (5) Fostering the therapeutic alliance. The therapeutic alliance involves agreeing on goals and tasks of therapy, and a positive bond between client and therapist. A rupture in the alliance has been associated with dropping out of therapy, and a previous meta analysis found that a stronger alliance was associated with fewer drop outs.

Practice Implications

Therapists can do 5 things that are research supported to reduce patient drop outs. (1) Provide education about duration and course of therapy.  Practicing clinicians can help their clients to develop realistic expectations about duration and recovery prior to the start of therapy. Clinicians working with a more severely disturbed population or working from an orientation that espouses longer treatment durations may want to alter the education they provide to better fit their clients. (2) Provide role induction. Clinicians can provide education about the “jobs” of both the client and the therapist, such as who is expected to do most of the talking and who will be responsible for structuring or directing sessions. This type of induction should also include a discussion of the rationale for the approach that will be used. (3) Incorporate client preferences. Accommodating client preferences does not mean the therapist should automatically use the client’s preferred methods. Often clients are unaware of what treatment options are available or best suited for their particular problems. Instead, therapists should consider sharing their knowledge about the particular disorder and the nature of different approaches to the treatment of those problems with clients. Clients can then share their preferences regarding those treatment options with the therapist and work collaboratively toward a decision about which approach might be best. (4) Strengthen early hope. Therapists should express confidence that the therapy will work for their patient. Knowing the research evidence on the efficacy of psychotherapy will increase the therapist’s credibility in making such statements. (5) Foster a therapeutic alliance. Efforts to foster the therapeutic alliance should occur early on in therapy when the risk of premature termination is high, and as also therapy progresses. Early efforts should focus on making sure there is an agreement on the goals and tasks before jumping to treatment interventions.

Author email: Joshua.Keith.Swift@gmail.com

Oldham, M., Kellett, S., Miles, E., & Sheeran, P. (2012). Interventions to increase attendance at psychotherapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 80, 928-939.

A great deal of clinical time can be wasted because of patient nonattendance at scheduled psychotherapy appointments. The financial costs of nonattendance are also high, and patients who need help but do not attend are not receiving help. Premature termination from psychotherapy is associated with poor outcomes. Previous reviews reported that premature termination rates in regular clinical practice ranged from 40% to 46.8%. Clearly this is a big problem for many psychotherapists and patients. Oldham and colleagues (2012) conducted a meta analysis of interventions to increase psychotherapy attendance. Their meta analysis included 33 randomized controlled trials (RCTs) representing 4422 patients. Interventions had a significant moderate effect on reducing premature termination and increasing attendance. Effective interventions included: giving patients a choice of appointment times, giving patients a choice of therapists, motivational enhancement interventions, preparing patients prior to psychotherapy on what to expect, attendance reminders, and providing information on how to make the best use of therapy. Participants with single diagnoses made better use of interventions than those with multiple diagnoses.

Practice Implications

Psychotherapists can improve attendance in psychotherapy by providing patients with choice of appointment times and therapists, by taking the time to prepare patients prior to therapy for what to expect in treatment and how to best make use of therapy, using motivational interventions, and by providing appointment reminders.

Author email: s.kellett@sheffield.ac.uk or p.sheeran@sheffield.ac.uk