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%).
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