The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Predicting Not Starting and Dropping Out From Publicly Funded Psychotherapy
Andrzej Werbart & Mo Wang (2012). Predictors of not starting and dropping out from psychotherapy in Swedish public service settings, Nordic Psychology, 64, 128-146.
There are few empirical studies looking at patients who are offered but who do not take up psychotherapy. This is a particularly important issue in publicly funded psychotherapy programs in which large numbers of patients who need mental health services to not access the service or leave before receiving adequate treatment. Evidence from the Improving Access to Psychotherapy (IAPT) program in the United Kingdom suggests that about half of patients who are offered psychotherapy either do not take it up or drop out prematurely and unilaterally. Knowledge about what determines treatment rejection or dropping out is critical in designing and developing publicly funded psychotherapy so that not only access but also patient outcomes are improved. In this study from the national Swedish psychotherapy program that is publicly funded, Werbart and colleagues looked at data from 13 clinics in which 189 therapists treated almost 1400 patients. Therapists were experienced (median experience = 5 years), and most received advanced psychotherapy training. Patients had a wide array of problems and severity. Of the patients, 13.6% never started therapy even though they were referred and assessed for treatment, and of those who started 17.4% dropped out of treatment. So a total of 31% never received adequate treatment and did not benefit for psychotherapy. Patients who never started therapy tended to be younger, unemployed, and with higher levels of mental illness. Patients who remained in therapy once they started tended to be older, had more problems with trauma or loss, and had more severe illness although they were not a danger to themselves or others. Never starting treatment and dropping out were both associated with clinics that had greater institutional instability. Clinic instability was defined as a clinic with: unclear treatment goals and guidelines, not well adapted to providing psychotherapy, unclear policies around who and how therapy is conducted, less cooperation among professionals, and financial problems.
Jurisdictions around the world, including in Canada, are looking to offer publicly funded psychotherapy, yet there is little research to guide how to improve uptake and retention of patients within the system. Such systems might focus pre-therapy efforts to retain patients who are younger and with greater mental health problems. In particular, public systems need to pay attention to clinic and institutional stability. How patients experience the clinic environment (as welcoming and integrated), how treating professionals cooperate, the clarity and structure of treatment guidelines and goals, and the financial stability of a clinic all appear to have an impact on whether patients actually access and complete a course of psychotherapy.
Therapists’ Perspectives on Psychotherapy Termination
Westmacott, R. & Hunsley, J. (2017). Psychologists’ perspectives on therapy termination and the use of therapy engagement/retention strategies. Clinical Psychology and Psychotherapy, 24, 687–696.
The average psychotherapy client attends a median of about 3 to 5 sessions, which is substantially less than the number of sessions the average client needs to realize a clinically significant decline in symptoms. Premature termination (clients ending therapy unilaterally) occurs in 19% of cases in research trials and in as many as 38% of clients in community practices. And so premature termination is mental health problem for clients and an economic problem for therapists and agencies. Clients terminate therapy prematurely for a variety of reasons including: dissatisfaction with therapy or the therapist, achieving their goals, and practical barriers (appointment times, travel, cost). Therapists tend to underestimate the proportion of unilateral terminations from their practice, and underestimate negative outcomes and client negative perceptions of therapy and therapists. In this study, Westmacott and Hunsley, surveyed psychologists who provide psychotherapy (N=269) on their perspectives on their clients’ reasons for termination and the strategies they use to retain their clients in therapy. Therapists reported that 33.3% of their clients terminated prematurely, which is somewhat lower than the percentage reported in previous research. Most psychologists (65.7%) tended to attribute the most important reasons for premature termination before the third session to clients’ lack of motivation to change (rated as very important or important on a scale). A much smaller percentage (15.8%) attributed waiting too long for services as the most important reason for premature termination before session 3. The most important reason for premature termination after the third session was most often attributed to clients reaching their treatment goals (54.8%). Regarding strategies to retain clients - almost all psychologists (96.8%) indicated that they fostered a strong alliance, 74.3% indicated that they negotiated at treatment plan, 58.0% prepared clients for therapy, 38.7% used motivational enhancement strategies, 33.0% used client outcome monitoring, and 17.8% used appointment reminders.
This survey of psychologists suggests that psychotherapists may somewhat underestimate the number of clients who prematurely terminate therapy. Psychotherapists may also overly attribute dropping out to client-focused factors (low motivation, achieving outcomes), rather than therapist-focused factors (dissatisfaction with therapist or therapy), setting-focused factors (negative impression of the office and staff), or practically-focused factors (appointment times, cost). Many therapists reported using alliance-building and negotiating a treatment plan to retain clients. However, few therapists used other evidence-based methods like systematic outcome monitoring, and fewer still used appointment reminders. Therapists should consider therapist-focused and setting-focused reasons for client termination, and to use outcome monitoring and appointment reminders to reduce drop-outs from their practices.
What is the Therapist’s Contribution to Patient Drop-out?
Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2028.
Sometimes patients experience negative outcomes in psychotherapy. For example, some patients drop out of therapy (i.e., they unilaterally decide to leave therapy before making any progress or before the endpoint planned with the therapist). In a previous meta-analysis of 669 studies, dropout rates ranged from 17% to 26% in psychotherapy trials. In this study, Saxon and colleagues were interested in the therapist effect on drop out. In other words, what is the impact of the individual therapist on negative outcomes like patients unilaterally terminating treatment? To examine the therapist effect one can look at differences between therapists in the average number of patients who drop out within their caseload. The authors looked at over 10,000 patients seen by 85 therapists from 14 sites in the United Kingdom initiative for Improving Access to Psychological Therapies. Therapists were selected if they saw more than 30 patients, and patients were included if they attended more than one session of therapy. Patient mean age was 40.3 (SD = 13.0), 71.2% were women, most were White (95%) and employed (76%). Of all the patients, 76.8% had some level of depression and 82.7% had some level of anxiety. Over 90% of the patients scored in the clinical range for symptom severity at pre-treatment. Patient symptom severity seen by a particular therapist was controlled in this study so that therapists who tended to treat severe cases were not penalized (i.e., case mix was controlled). Patients who dropped out represented 33.8% of the sample, with over half of these patients unilaterally terminating before the third session. The mean number of sessions for treatment completers was 6.1 (SD = 2.68). Therapist differences (i.e., the therapist effect) accounted for 12.6% (CI = 9.1, 17.4) of the patient drop out variance. In other words, about a quarter of therapists had a significantly greater number of drop outs compared to the average therapist. The mean dropout rate for the average therapist was 29.7% (SD = 6.4), the mean dropout rate for the above average therapist was 12.0% (SD = 7.3), whereas the mean dropout rate for the below average therapist was 49.0% (SD = 10.4).
Who a patient gets as a therapist appears to have an important impact on whether the patient remains in therapy. Almost half of clients dropped out if they saw a poorly performing therapist (and nearly a quarter of therapists were poorly performing). By contrast, highly performing therapists only had a 12% drop out rate. Therapist variables that are known to be related to negative outcomes like dropping out include: lack of empathy, negative countertransference, and disagreements with patients about the therapy process. Previous research showed that therapeutic orientation is not related to negative outcomes. Therapists who are perform below average on when it comes to patient dropout might be able to use progress monitoring or some other means of measuring their patients’ outcomes to their advantage. These therapists may require more support, supervision, or training to improve their patients’ outcomes.
Do All Therapists Do That When Saying Goodbye?
Norcross, J.C., Zimmerman, B.E., Greenberg, R.P., & Swift, J.K. (2017). Do all therapists say that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54, 66-75.
One of the things common to all psychotherapy relationships is that they come to an end. The endings may be premature or planned. They may be well managed or poorly managed. In this article by Norcross and colleagues, the authors ask: what do expert therapists typically do when there is a planned termination with a client? A planned termination is “an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons”. By contrast, premature termination occurs when the client ends treatment unilaterally. In successful cases the client and therapist typically predetermine the end date and have time to work toward the ending. Different theoretical orientations write about different aspects of termination. For example, from a psychodynamic perspective, therapists focus on clients’ old and new methods of coping, feelings related to the impending loss of the relationship, review gains, and work to equalize the relationship. From an experiential perspective, therapists might recognize that clients continue to change after therapy, help clients work through feelings of loss and separation of the therapeutic relationship, and consolidate new meanings. Cognitive-behavioral therapists might help clients to maintain gains made in therapy, review new skills, and prevent relapse. Do therapists who practice these and other theoretical approaches differ in terms of how they manage termination in psychotherapy? Norcross and colleagues surveyed 65 nominated experts representing six theoretical orientations of psychotherapy (psychodynamic, humanistic, CBT, interpersonal, multicultural, and integrative). Each orientation was represented by at least 10 expert therapists. The survey included 80 items related to termination that were drawn from books, chapters, and treatment manuals. The experts indicated the frequency with which they engaged in each behavior or the task related to termination. Therapist behaviors or tasks that received very strong consensus (>90% of therapists reporting “frequently” or “almost always” doing these) included: supporting the client’s progress, helping to consolidate gains made in therapy, following ethical practice (e.g., avoiding abandonment), attributing gains to the client’s effort, talking about what helped or went well, and collaborating with the client to set a date and pace of termination. Strong consensus (80% to 90% of therapists reported frequently doing these) behaviors or tasks included: focus on processing feelings around termination, having the client practice new skills, normalizing the probability of relapse, and prompting the client to think of a future without therapy. Of the 80 Items, 27 did not reach consensus among the therapists (i.e., only 21% to 59% of therapists agreed on these items). Out of the 80 items, only 8 (10% of items) showed significant differences between theoretical orientations (e.g., compared to other orientations, CBT therapists tended to do more of: preparing clients for relapse, and systematically assessing client outcomes near termination).
This survey of 65 experts of varying psychotherapy orientations highlighted a wide range of commonalities in terms of how they managed termination with clients. While there was some uniqueness among orientations, most therapists tended to: process feelings about termination and the relationship with clients, discuss future functioning and coping, helped clients to use new skills, framed the client’s personal development as ongoing beyond therapy, prepared explicitly for termination, and reflected on the client’s gains.
Patients are More Likely to Refuse and Drop Out of Pharmacotherapy Than Psychotherapy
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.
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.
Organizational Instability May be Related to Premature Termination from Psychotherapy
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.
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.