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.
Effects of Computerized CBT May be Overestimated
So, M., Yamaguchi, S., Hashimoto, S., Sado, M., Furukawa, T.A., & McCrone, P. (2013). Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity. BMC Psychiatry, 13, 113.
Depression is a major cause of disability in the world, and so efforts to improve access to its treatment have been ongoing for several decades. In particular, many researchers and clinicians propose cognitive behavioural therapy (CBT) as an effective treatment with a good evidence-base. There have been many clinical trials showing the efficacy of CBT. In recent years, there have also been attempts to computerize CBT (CCBT) as a self help intervention in order to increase its accessibility for those with depression, and perhaps also to improve its cost effectiveness. In fact, the Increasing Accessibility to Psychotherapy (IAPT) program in the UK provides CCBT as the most common first treatment for depression. However there remain questions about the longer term effectiveness of CCBT to reduce symptoms of depression, its potentially high patient dropout rate (a negative outcome), and its effects on quality of life of those burdened by depression. In this meta analysis, the largest of its kind, So and colleagues assess these issues with regard to CCBT. They reviewed 14 direct comparison randomized controlled trials that provided 16 comparisons of CCBT versus a control condition (wait list or treatment as usual) for adults with depression. At post-treatment, CCBT was more effective than controls in reducing depression −0.48 [95% CI −0.63 to −0.33]. However, at follow up (up to 6 months), the effects of CCBT disappeared −0.05 [95% CI −0.19 to 0.09]. Also improvement in functioning and quality of life were not significantly different between CCBT and control conditions, −0.05 [95% CI −0.31 to 0.22]. The rate of drop out from CCBT (32%) was almost double that of control conditions (17%), RR = 1.68 [95% CI 1.31 to 2.16]. There was also evidence of publication bias (i.e., a tendency for some researchers not to publish non-significant findings), so that the positive post-treatment results in favour of CCBT might be inflated.
Although CCBT may be touted as a way to increase access to treatment for depression, this meta analysis indicates some concerns about the widespread implementation of CCBT. The effects of CCBT appear to be limited to a short-term reduction of depressive symptoms that may not be sustained in the longer run. There was no appreciable impact of CCBT on quality of life relative to controls, and so CCBT may have a limited impact on the burden of depression. Most troubling was a high drop out rate of 32%. Drop out from CCBT in the IAPT program in the UK is about 50%, and this may be indicative of the actual drop out rate in real world practice.
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.
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.
Therapists Affect Patient Dropout and Deterioration
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. Advanced online publication, DOI: 10.1002/cpp.2028.
Outcomes for patients receiving psychotherapy are generally positive, but not always. For example, patients might drop out of therapy (i.e., unilaterally end therapy). In clinical trials, the average drop out rate is somewhere between 17% and 26% of patients. Also, patients might deteriorate during therapy (i.e., show a reliable negative change in symptoms from pre- to post-therapy). On average, about 8.2% of patients show a reliable deterioration after therapy. In this large study from a practice-based research network in the UK, Saxon and colleagues were interested in estimating the effect that therapists had on patient drop out and deterioration. Therapist effects refer to differences between therapists and the effects of this difference on patient outcomes. The authors were also interested in whether therapist effects predicted negative outcomes after controlling for therapist case-mix (i.e., patient variables like severity of symptoms, risk of self harm). Their study included 85 therapists who treated more than 10,000 adult patients over a 10-year period. Each therapist saw between 30 and 468 patients at one of 14 sites in the UK. About half of patients had moderate to severe depressive symptoms, and/or moderate to severe anxiety symptoms prior to starting therapy. Outcomes were measured with a reliable and valid psychometric instrument at pre- and post-treatment. The proportion of patients who dropped out of therapy was 33.8%. Patients who dropped out attended an average of 2.8 sessions (SD = 1.91), whereas treatment completers attended an average of 6.1 sessions (SD = 2.68). About 23.5% of therapists had drop out rates that were significantly worse than average. These below average therapists (n = 13) had 49% of their patients drop out, whereas above average therapists (n = 20) had only 12% of their patients drop out. Most patients who completed therapy improved (72.2%), but about 7.2% of patients deteriorated to some degree. The average therapist (i.e., 74% of therapists) had 4.6% of their patients who got worse, whereas below average therapists (i.e., 4.7% of therapists) had up to 14.9% of their patients who got worse. That is, almost 3 times as many patients deteriorated with below average therapists.
We know from previous studies that the type and amount of therapist training or theoretical orientation are not predictive of patient outcomes. However, previous research does suggest that therapists’ lack of empathy, negative countertransference, over-use of transference interpretations, and disagreement with patients about therapy process was associated with negative outcomes. Patient safety concerns might necessitate below average therapists to be identified and provided with greater support, supervision, and training.
Attrition from Cognitive Behavioral Therapy
Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015, August 24). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of Consulting and Clinical Psychology. Advance online publication.
“Dropping out” refers to clients who discontinue therapy prematurely and against professional advice. In contrast, “refusing” refers to clients who do not start a therapy that is made available to them. Together, both dropping out and refusing are referred to as “attrition” from therapy. Attrition is a problem for clinicians because of loss of revenue and time, and a problem for clients because their mental health needs remain unmet. In a previous meta analysis that included 669 studies, Swift and Greenberg (2012) reported that the average drop out rate across all therapies was 19.7%. In this meta analysis, Fernandez and colleagues looked specifically at drop outs and refusers in cognitive behavioral therapy (CBT). The authors reviewed 115 studies that reported drop outs, 36 of which also reported on the number of participants who refused treatment before starting. The average percent of patients who refused CBT prior to starting treatment was 15.9%, and the average percent of patients who dropped out after starting CBT was 26.2%. So the total average attrition rate was 42.1%. Compared to any other disorder, patients with depression were significantly more likely to refuse CBT (21.6%) or to drop out (36.4%). It is possible that depressed patients have a harder time summoning the energy to participate in therapy, and experience lower hope, greater social withdrawal, and lower motivation once they initiate CBT. For those receiving e-therapies (e.g., internet, phone, and CD-based treatments), pre-treatment refusal rates were 10% to 15% higher than individual or group CBT, and drop outs from e-therapies were 10% higher compared to individual or group CBT. Those offered e-therapy might be ambivalent about its utility, the therapeutic alliance might be limited, and they might have a lower sense of engagement in the therapeutic process. Finally, a greater number of planned therapy sessions was related to lower attrition rates. Perhaps the promise of more sessions raised clients’ hopes of achieving better outcomes.
These findings suggest that engaging and encouraging clients to participate in the therapy may have to start even before therapy begins. This may involve enhancing readiness by means of motivational interviewing, for example. Clients who are depressed are particularly likely to refuse treatment or drop out, and so clinicians must pay particular attention to the level of motivation and engagement of depressed clients. Although e-therapies are promising in that they may allow a therapist or agency to reach more people including those who live in remote areas, the attrition rate of e-therapies may be unacceptably high. Attrition may lead to demoralization and lowered expectations for treatment among these patients, which may negatively impact future treatment. Perhaps e-therapies should not be considered as a first-line treatment for those who can easily access individual or group therapy. Alternatively, the high attrition rates of e-therapies may be reduced by supplementing the intervention with some in-person therapy sessions to enhance engagement and a therapeutic alliance.