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LILLIAN G. BROWN
University of Pennsylvania
School of Medicine
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in terms of outcomes, but also in terms of termination antecedents; and UTs, completers, and continuers often show no outcome differences at all.
This phenomenon tends not to be recognized by
therapists, who are prone to see all UTs as treatment failures. UTs who reported "no need for
(further) services" (39%) and "environmental
constraints" (35%) as reasons for terminating
scored less symptomatically on the Brief Symptom Inventory (Derogatis & Spencer, 1982) than
did patients citing "dislike of services" (26%) in
a 3-month follow-up study (Pekarik, 1983b, p.
909). In a similarly designed 4-month follow-up,
those reporting improvement displayed outcomes
comparable to completers and better than continuers. Notwithstanding, therapist ratings of problem
improvement were higher for continuers and completers (Pekarik, 1992), suggesting that therapist
judgment of improvement is strongly related to
duration of treatment. Therapists expect improvement to require lengthy treatment.
In addition, the use of the median number of
sessions (5) in an outpatient community mental
health center (CMHC) misclassified 40% of clinically defined appropriate terminators as dropouts.
The use of the mean number of sessions (12) also
yielded unsatisfactory results, as 71% of clinically defined appropriate terminators were misclassified as dropouts (Morrow, Del Gaudio, &
Carpenter, 1977). Regardless of the duration criterion used, therapists display a negative attitude
toward brief stays and toward UTs (Buddeberg,
1987) and seem to fail to recognize that UTs
are not necessarily treatment failures. This bias,
conveyed by many of the results described above,
has been demonstrated in numerous other studies
(Ellingson, 1990; Papach-Goodsitt, 1986; Schwartz,
1991).
Despite therapists' tendency to overlook potentially positive outcomes, their clinical judgment
is still more useful than number of sessions or
any other criterion for defining the highly heterogeneous population of UTs. Analyses revealed
that UTs differed from completers on 11 of 18
client and therapist variables when the criterion
was therapist judgment, whereas no differences
at all emerged between the two groups when a
duration criterion was used (Pekarik, 1985b). Because of the reliability problems inherent in therapist judgment, failure to keep the last appointment
scheduled has been used occasionally as an alternative. This method, however, can misclassify
(as dropouts) both appropriate terminators who
Psychotherapy Dropouts
would be discharged by the therapist within a few
sessions and symptomatic patients (as appropriate
terminators) when they refuse to schedule another
session and declare treatment finished (Pekarik,
1985b).
Scope and Severity of the Problem
Regardless of definition, UT rates across different ages, client groups, settings, diagnoses, and
treatment modalities range from 30 to 60%
(Baekeland & Lund wall, 1975). Studies variously
find the mean or median number of sessions ranging from 3 to 13 and clustering around 6 (Ciarlo,
1979; Garfield, 1994; National Institute of Mental
Health, 1981).
In an outpatient psychiatric clinic of a large
health maintenance organization, approximately
30% of the clients attend only one session, despite
the fact that their prepaid plan entitles them to
more sessions (Rosenbaum, Hoyt, & Talmon,
1989). Similarly, at the Columbia Medical Plan,
a prepaid group practice that serves more than
20,000 enrollees, the mean number of visits per
episode is 4.9, and the rate of single-visit episodes
is 38% (Kessler, Steinwachs, & Hankin, 1980).
Although this might be viewed positively by administrators in terms of cost containment, UTs
actually raise costs considerably because they
tend to be chronic utilizers, with poor outcomes
that frequently require expensive, intensive treatment (e.g., emergency room visits).
What the foregoing data make evident is that
most patients attend only a few therapy sessions.
Garfield (1994) provided an eloquent illustration
of this state of affairs by describing a study whose
population included only well-educated persons
who made the choice to enter long-term therapy
in a private practice setting and "decided to commit a sizable amount of time and money in their
treatment" (DuBrin & Zastowny, 1988, p. 393).
Notwithstanding, 13% failed to return after intake
and 28% terminated unilaterally by the eighth
session, for an overall UT rate of 41%.
Because 20 to 57% of patients do not return
after the first visit and 37 to 45% attend only one
or two sessions (Ciarlo, 1979; Hester & Rudestam, 1975; Pekarik, 1983a), the early phase of
psychotherapy seems crucial for continuation, as
UT rates level out after that (Baekeland & Lundwall, 1975; Pollack, Mordecai, & Gumpert,
1992). In a study where new intake procedures
reduced UT rates from 54 to 19% in a CMHC,
the authors reported that UT rates dropped sig-
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Psychotherapy Dropouts
1983; Tyson & Reder, 1979), but the literature
is far from conclusive. While a retrospective
study of 595 patient files at a rural CMHC indicated fewer UTs for more experienced psychotherapists (Scogin, Belon, & Malone, 1986), two
university-based investigations yielded no significant effects (Jenkins et al., 1986; Krauskopf
et al., 1981). In a meta-analysis of 125 studies
of UT no significant effect sizes were reported
for any of the therapist variables investigated,
including experience (Wierzbicki & Pekarik,
1993).
Interpersonal dyadic variables. Apparently,
there are factors interacting with therapist level
of experience. For example, while experience
level did not differentiate return rates after intake
of 539 college students, agreement between the
parties on the definition of the problem as educational, vocational, or personal did. When there
was agreement, 83.6% returned versus 72.9%
when there was no agreement, a difference that
was highly significant (Krauskopf et al., 1981).
A study of 533 clients and 34 clinicians at a university counseling center supported these findings
and shed further light on potential second-order
factors mitigating the effect of experience level
on UT (Epperson, Bushway, & Warman, 1983).
This investigation revealed a main effect of counselor recognition of client's definition of problem
on termination status as well as an intriguing interaction between problem recognition and counselor experience. When problem recognition was
present, trainees experienced more UT than did
the more experienced counselors (27% vs. 17%).
When problem recognition was absent, however,
higher UT rates occurred for experienced counselors (59% vs. 32%). Problem recognition is paramount for experienced therapists. For less experienced therapists, however, lack of problem
recognition (perspective divergence) does not
produce comparably high UT rates. Perhaps when
inexperienced therapists fail to acknowledge the
patient's perspective, therapist-client similarity
plays a compensatory role and helps avoid some
UTs. Inexperienced trainees working with clients
whose perspectives they do not share may concentrate on developing rapport and may benefit by
similarity to their clients (in age and trainee or
novice status), while experienced counselors who
"move more rapidly with clients" (Epperson et
al., 1983, p. 314) may alienate clients whose
perspectives differ, resulting in greater attrition
for the latter.
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Psychotherapy Dropouts
(Sue, 1977). This suggestion is supported by data
indicating that therapists high in ethnocentrism
are more likely to lose their patients than are less
ethnocentric clinicians (Baekeland & Lundwall,
1975). In corroboration, "negative attitude
toward therapist" and "no benefit from therapy"
were the main reasons provided by low income,
ethnically diverse patients for their unilateral termination of psychotherapy (Acosta, 1980, p.
439).
Even though racial status, income, and education are strongly related to UT, their mean effect
size was only of moderate magnitude, ranging
from .23 to .37 in Wierzbicki and Pekarik's
(1993, p. 193) meta-analysis. These authors concluded that "more complex variables, such as client's intentions and expectations and clienttherapist interactions" may be more useful
because they are "far more powerfully related to
dropout than simple client and therapist variables"
(p. 194).
Minimizing Perspective Divergence
Matching studies have evaluated the effects of
maximizing similarity (or convergence) and minimizing divergence within the therapeutic dyad.
The rationale is that outcomes will improve and
there will be fewer UTs when clients are offered
types of treatment and are seen by the type of
therapist best suited to (compatible with, not divergent from) their specific needs. Nine of the 14
studies reviewed by Luborsky, Chandler, Auerbach, Cohen, and Bachrach (1971) showed a positive relationship between outcome and similarity
of patient and therapist. Although this line of
research has been considered promising (Luborsky et al., 1980), systematic studies are still rare.
Some studies have attempted to identify optimal
matches between specific patient characteristics
(e.g., diagnosis) and types of treatments (Piper,
Azim, McCallum, & Joyce, 1990; Stotsky et al.,
1991). Greater attention, however, has been dedicated to potentially optimal combinations of patients and therapists in terms of sociodemographic
variables, particularly ethnicity.
Sociodemographic variables. Culture-compatible
approaches have proved effective in increasing
service utilization of CMHC patients (e.g., Flaskerud, 1986). UT predictors were examined in
1,746 Asian clients in several CMHCs. Results
revealed that client-therapist language and ethnic
matches significantly increased the number of sessions attended. No other variable produced sig-
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process variables, referred to "a sense of collaboration and mutual involvement" between the parties and the establishment of a relationship. The
second factor, "Patient Satisfaction with Intimate
Therapist," included "a serious patient working
with a therapist described as being close" and the
fulfillment of the patient's expectations of finding
out what was wrong (Fiester & Rudestam, 1975,
p. 534).
Satisfaction. Dissatisfaction with services or
therapists is frequently mentioned by UTs as their
reason for quitting (Acosta, 1980; DuBrin & Zastowny, 1988; Gill, Singh, & Shanna, 1990; Pekarik, 1983b, 1992). UTs' levels of satisfaction
with therapy or therapist tend to be significantly
lower than are continuers' or completers'
(McNeill, May, & Lee, 1987; Papach-Goodsitt,
1986; Zisook, Hammond, Jaffe, & Gammon,
1978).
Expectations. Satisfaction has been repeatedly
associated with confirmed expectations toward
treatment (Goin, Yamamoto, & Silverman, 1965;
Sabourin, Gendreau, & Frenette, 1987; Silverman & Beech, 1979). Unconfirmed expectations have consistently emerged in review of factors bearing a systematic relationship with UT
(Garfield, 1994; Mennicke, Lent, & Burgoyne,
1988). They were associated with UT in 100%
of the studies reviewed by Baekeland and Lundwall (1975).
The expectations of 15 UTs who terminated on
or before the fourth session were compared to
those of 30 continuers at a university clinic. While
therapist empathy levels, warmth, genuineness,
and level of activity did not differentiate the two
groups, UTs were less likely than continuers to
report that the first session fulfilled their expectations (Gunzburger et al., 1985). Consistent results
were provided by studies targeting specific subsets of the general outpatient clinical population.
Reasons for withdrawing from treatment of 15
obsessive-compulsive UTs were compared to
those of 15 age- and diagnosis-matched successful completers. Besides being less symptomatic,
more critical of the therapist, and experiencing
less anxiety in carrying out homework assignments, UTs reported more incongruent treatment
expectations than did completers (Hansen, Hoogduin, Schaap, & Haan, 1992). Expectations were
significantly related to continuing in a sample of
147 depressed women, of whom 34 were classified UT and 9 did not even attend the first session
Psychotherapy Dropouts
(refusers). Completers endorsed expectations
congruent with the treatment rationale significantly more often than did UTs or refusers
(Rabin, Kaslow, & Rehm, 1985). Similarly,
lower SES patients indicated before their first interview how active, passive, or supportive they
anticipated the therapist would be and the extent
to which they anticipated that their intake clinician would focus on organic or emotional problems. Responses were compared to their perceptions of the first interview on the same
dimensions, provided immediately after the intake. Discrepancies between pre-intake expectations and post-intake perceptions were significantly greater in the nonreturn group than in the
return group (Overall & Aronson, 1963).
Client likability. Perspective divergence comprises a process variable that seems to work recursively. Just as divergence interferes with a patient's perseverance and willingness to continue
in therapy, it affects a therapist's ability to relate
to the patient optimally. In perspective-divergent
treatment dyads, patients are less likely to be attractive for therapists, and this decreases the likelihood of a successful encounter. Therapists are
less likely to feel congenial toward clients who
do not want or do not understand what they (therapists) have to offer. Similarly, clients are unlikely
to feel congenial toward therapists when they feel
embarrassed or ashamed because of lack of familiarity with the rules of the therapy enterprise.
The positive role played by patients' likability has
been reported both for outcomes (e.g., Staples,
Sloane, & Whipple, 1976) and for termination
status (Lothstein, 1978).
Client attractiveness is one of the components
of the concept of engagement in therapy developed by Tryon(1989a, 1990,1992). Her research
revealed that, besides promoting patient return
for a second session, an interview is engaging
when (a) both patient and therapist describe it as
deep and valuable, (b) patients are educated about
their problems and behaviors by therapist, (c) duration is longer, and (d) clients are rated as attractive by their therapists. Data also indicated that
likable clients elicited a "warmer, friendlier reaction from the therapist" (Tryon, 1992, p. 311)
and agreed with therapists about concerns and
desired course of action. Therapists of likable
patients indicated a greater understanding of the
patients' feelings, saw them as more motivated,
and were more confident that the client would
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personal style. Whether it be SES, ethnicity, language, or issues related to the therapeutic enterprise (e.g., the etiology of or solution for problems) that differentiate them from their patients,
therapists must acknowledge perspective divergence and take to heart the idea that therapy is a
collaborative endeavor. Openness to modifying
their perspectives, as they expect patients to modify theirs, will enhance treatment and reduce UT.
In summary, though we cannot change many
of the factors involved with UT (e.g., ethnicity,
gender, SES), research suggests clinicians can
significantly reduce UT by implementing some
practical strategies. Although many psychotherapists have traditionally resisted appointment reminders, perhaps because no-shows and cancellations were grist for the interpretive mill, for
therapists whose orientation does not preclude appointment reminders, this seems an effective way
to reduce UTs. More importantly, putting into
practice some form of pretreatment preparation
procedures, and implementing a treatment negotiation process in the initial phase of treatment are
all likely to enhance engagement and prevent UT.
Underlying these practices, particularly the latter
two, is a genuine willingness on the part of the
therapist to view the client as a partner with
unique and legitimate perspectives on the treatment process.
Just as therapists expect clients to come in with
problems, they should expect them to bring different perspectives. Just as clinicians' training and
experience provide them with expertise about
treatment, clients' unique experiences provide
them expertise about their lives. UT is minimized
when perspective divergence is expected, recognized, acknowledged, and incorporated into the
process.
While many UTs leave having achieved their
goals, it is important to keep in mind that many
fail to return precisely because they did not get
what they wanted. When patient and therapist
differ about treatment dimensions, it is part of the
clinician's job to elicit and address the difference,
accept the client's perspective as understandable,
and then adapt the treatment plan so that the client
will engage in the process. Ultimately, the therapist may succeed in closing the perspective gap
so that the patient can accept the utility of the
clinician's perspective. This job requires the attitude and ability to bracket one's own perspective
and work around the patient's views. The ultimate
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