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Swift, J.K., Greenberg, R.P., Tompkins, K.A., & Parkin, S.R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54, 47-57.

Treatment refusal occurs when a patient is offered an intervention but then fails to begin it. In treatment studies, this may occur when a patient initially agrees to participate in a trial but then discontinues immediately after finding out what intervention they will receive. In a clinic setting, a patient might call a mental health professional to schedule an initial appointment but not show up. This causes problems for the patient who is not receiving treatment, and for the professional who has an unfilled therapy hour. Premature termination, on the other hand occurs when a patient begins treatment but ends unilaterally against the provider’s recommendations and prior to recovery. Again, these patients typically do not improve and they do not receive an adequate dose of the treatment. Barriers to accepting or completing psychotherapy might include the cost, and the time and effort involved to engage in the therapeutic process. Barriers to accepting or completing pharmacotherapy might also include cost, unpleasant side effects, and fewer contacts with a non-judgemental listening professional. The aim of Swift and colleagues’ meta-analysis was to compare rates of treatment refusal and premature termination between psychotherapy and pharmacotherapy. The meta-analysis included 186 studies, 57 of which (with 6,693 participants) reported data on treatment refusal. A significant number of patients (8.2%; 95% CI: 7.0, 9.6%) failed to start treatment after they were told what treatment they would receive. Participants were 1.76 times more likely (95% CI: 1.27, 2.45) to refuse treatment if they were offered pharmacotherapy compared to psychotherapy. The average premature termination rate from treatment was 21.9% (95% CI: 20.6%, 23.3%). Patients assigned to pharmacotherapy were 1.2 times more likely (95% CI: 1.03, 1.41) than those who were assigned to psychotherapy to discontinue treatment prematurely.

Practice Implications

Participants were almost 2 times more likely to refuse treatment if they were offered pharmacotherapy compared to psychotherapy, especially for social anxiety disorder, depression, and panic disorder. Similarly, premature termination was higher for pharmacotherapy compared to psychotherapy, especially for eating disorders and depressive disorders. Previous research indicated that patients are 3 times more likely to prefer psychotherapy over medications for mental disorders. Research indicates that mental health professionals should work to incorporate patient preferences, values, and beliefs when making treatment decisions in order to reduce premature termination and treatment refusal.

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

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