Premature therapy terminators, dropouts, or unilateral terminators?

I was recently asked by one of my board members if we asked people who dropped out of services why they left. I had to admit that we didn’t do that. Like most, we conduct a very large client satisfaction survey annually and get good feedback from clients and parents of children in treatment.

We also conducted a referral source satisfaction survey for  many years, but seldom got any good actionable feedback. Mostly we got the same complaints from the same people every year, who did not like some of our policies.

Always one to blame the patient, Freud  believed  that premature termination of psychoanalysis was generally related to being unsuitable for therapy, due to  insufficient intelligence, the presence of psychosis, socioeconomic factors, or an early and dramatic manifestation of resistance that could not be overcome or worked through. 

Freud said, “The patient now regards the analyst as no more than a stranger who is making disagreeable demands on him and he behaves towards him exactly like a child who does not like the stranger and does not believe  anything he says.

Studies back in the 1950s indicated that 30% to 60% of those who initiated psychotherapy terminated  within the first six months and the modal number of visits for psychotherapy often ranged from one to three visits.

By the 1980s, conventional  wisdom was that about one-third of clients would  be premature terminators. In 2012 Joshua Swift from the University of Alaska conducted a meta analysis and  found a 20% drop out rate among adults in psychotherapy.

In 1974 Stanley P. Rosenzweig, From the Veteran Aministration's (VA) Clinic in Boston, examined dropout rates for group psychotherapy in a VA clinic setting. He looked at a number of patient and therapist variables but only found that lower levels of  education were associated with higher dropout rates.    

A 2007 Brazilian study, by Simone Hauck from the Hospital de Clinicas de Porto Alegre and her associates, examined  a sample  of  psychoanalytic  psychotherapy patients. They  found a modest dropout rate of only 12.5%. They concluded that the severity of psychopathology alone didn’t predict dropout, but patients with lower levels of insight, and immature defenses, especially narcissistic,  had higher  premature termination rates. 

In  a 1985 study, Marie Greenspan and Nancy Kulish from the Northland Clinic in Southfield Michigan studied the characteristics of 273 cases of “premature terminators”  from long term psychotherapy. They found that PhD psychologists had lower rates of premature terminators than MD or MSW therapists. Also therapists who had undergone personal therapy  tended to have lower rates of dropouts. Higher dropout rates were also seen  in patients who were Afro-American, had complaints of family or marital discord, were diagnosed as “depressive reactions” and were not middle-aged. 

In 1987 Anna Kokotovic and Terence Tracy  from the University of Illinois  looked at therapy dropouts  from a University Counseling Center and found that client satisfaction and the client’s  perception of the therapist’s  trustworthiness and expertise were associated with keeping scheduled appointments. Therapist attractiveness and client-therapist agreement on problem  identification were unrelated to appointment keeping.

Robert Hoffman from the Knoxville, Iowa VA Medical Center examined differences  between early terminators and  remainers from a mental health center and found three significant predictors. Remainers  were likely to: 1) have had previous psychiatric treatment; 2) be diagnosed with a psychosis, and 3) have thought disorder as a presenting  problem.

Nancy Murdock and her associates from the University of Missouri examined what they called  “unilateral termination." They felt that “premature termination” was a pejorative judgment made by  therapists. They found that  therapists tend to be somewhat self-serving in attributing unilateral terminations to things such as financial concerns and client dysfunction, rather than  dissatisfaction with the therapist.  

Murdock  says there are three main reasons people do terminate: 1)  About 35% of clients feel they have improved enough and stop treatment; 2)  In about 20% of cases  external factors force termination (e.g. client moved); and 3)  In  about 8% of cases the client is dissatisfied with the  therapist or the therapy. Therapists are most likely  to cite reasons one and two but seldom three.  In one study, "client inability to benefit   from therapy" was the top (self-serving) reason cited by therapists.

In the case of child therapy,  Alan Kazdin from Yale University found that the same barriers  preventing the start of  treatment were associated with early or premature termination of  treatment. These include  factors such as 1) presence of external stressors, 2) perceptions that treatment was not relevant or effective, and 3) poor relationship of the parent with the therapist.

C. Kroger, from the Bruswick Technical University in Germany, reported  that dropout rates for inpatient  Dialectical Behavior Therapy  ranged from  4% to 32%. He studied 541 inpatients and found a 19% patient-initiated dropout rate. He asserts that that dropping out was associated with lack of motivation, disagreements with others, and poor distress tolerance. Dropouts also had higher incidences of suicide attempts, anti-social personality diagnoses, and greater than  86 days of psychiatric hospitalization.

Following up on therapy  unilateral termintors  can be difficult  and time consuming. It is a bit intrusive and often impossible  to  get  responses. People obviously leave therapy  for a variety of reasons. Many do have very low motivation for treatment  and are what Lynn Johnson has called  "visitors" or "complainants." They may come to therapy only to  complain about someone else or only because they have been pressured by others to attend.  

“Complainants”  often leave after they have had  their say and “visitors" are quick to terminate and  then tell others that they tried it and it didn’t work for them. These folks are usually  in the pre-contemplative stage of change and may later drift into treatment,, if  good patient education and or  motivational interviewing is provided.

Since  crises and  many other conditions are time-limited,  other clients   simply feel better and stop coming. Still others may certainly dislike their therapist or his or her approach (e.g. too confrontive, too preachy, too indirect, too disinterested,  too unfriendly, etc.).

At one center where I worked in Florida, we spent a lot of time and effort conducting  follow-up interviews with people who left therapy. Surprisingly the vast majority simply said they didn't feel the need to come in any more. There was no smoking  gun, They cited no  significant or dramatic issue as a reason. I remember when we pressed and  asked them it there was  anything else we could have possibly done differently to keep them in treatment and the answer was invariably “no.” 

We have also tried to  conduct client focus groups to look at unilateral termination with little success in getting terminators to attend, as you might suspect. A colleague and I once studied the reasons patients cited for stopping their psychotropic medications. There were major differences between what the patients said and what the staff thought. Most patients said they stopped their medications because they were feeling better and it was just too much of a hassle. Staff were sure it was mostly because of side effects or the expense.

In our center we occasionally look at dropout rates by clinician. With some exceptions, we don't see a lot of differences. This is usually confounded by the fact that some  therapists are seeing  see numerous clients who are  under duress from the State Children and Family Services or the criminal justice system. It also seems to make a difference if you're seeing children or adults, or primarily addictions as opposed mental health cases.

Often treatment doesn’t  end very cleanly, and frequently there is an  unresolved remnant in even the best of cases. I have always thought that even in some of my most successful cases, the client knew better than I,  when to terminate treatment and simply canceled appointments and never rescheduled, because they had gotten all they really wanted out of  therapy. That's my own self-serving rationalization. Without formal termination, they could always come back, without feeling they were a failure. They could also take full credit for the change they made, which I always thought was a quite positive development.

In a 1993 article, however, in Psychotherapy in discussing unilateral terminators, therapist Michael Hoyt from Hayward California said, “It may be more useful to ask "What should I have done differently?’ rather than wonder why the patient finally declined more of the same."

Joshua Swift from the University of Alaska and hos colleagues,  recommended a variety of concrete strategies  to help  reduce  therapy dropouts including: 1) early client education about treatment duration and the timetable  of change; 2) Educating clients about the role expectations of successful clients; 3) incorporating/accommodating client therapy preferences; 4) fostering the therapeutic alliance to develop trust and  finally; 5)  Joint assessment  and discussion of  treatment progress.  

As more therapists adopt concurrent documention practices, there may be a greater focus on such discussions of treatment  progress.   

In a comprehensive 1999 review article in  Psychotherapy Brendali Reis from the University of Pennsylvania and Lillian Brown from the California School of Professional Psychology  say that the literature on psychotherapy dropouts  is highly contradictory and results are difficult to reconcile. Only socioeconomic status and ethnicity emerge as consistent predicators of dropout and neither of these are amenable to change. In a 1984 study Francis Terrell and Sandra Terrell from North Texas State University presented evidence that clients tend to remain longer  with therapists who are more like themselves and that when African American clients are beeing seen by white therapists, trust issues need to be specifically addressed.

Reis and Brown say, “while many unilateral terminators leave having achieved  their goals, it is important to remember that many failed to return precisely because they did not get  what they wanted.”  They stress collaborative  therapy models  and the importance  of closing the gap between the therapist’s and client’s perspectives on the therapeutic enterprise.

Finally, some theorists suggest that mental health and addictions treatment should function more like primary care, in terms of providing open-ended periodic -episodic treatment, losing the distinction between an open and a closed case. Since people’s lives are messy and dynamic, depending on the circumstances, clients may need therapy to a greater or lesser degree at various times in their lives.  

What do you think?