Shubhi Pal
When to conclude therapy is ideally a decision that is
based upon mutual discussion and agreement of both parties involved in therapy:
the therapist and the client. However, in several cases this decision is made solely
by the client, in opposition to the advice of the therapist and original agreement
by both individuals. This is termed as premature termination of therapy (Ogrodniczuk
et al., 2005). Estimates on the extent of this phenomenon are reported to be as
high as 47% by several studies (Barrett et al., 2008). More recent studies
estimate that one out of every five clients drop out of therapy before it is completed
(Swift & Greenberg, 2012, as cited in Swift et al., 2018)1.
Additionally, this phenomenon is observed across therapy settings and therapy
types (Anderson, 2015).
Dropping out of treatment before its successful resolution
poses a major barrier to the efficacy of therapeutic approaches. Clients who terminate
therapy early are more likely to experience discontentment with the therapy, and
often report less progress (Ogrodniczuk et al., 2005; Swift et al, 2018). More alarming
are the reports of greater incidence of psychological distress, and greater
likelihood of developing chronic symptoms, among such clients (Ogrodniczuk et
al., 2005).
However, this issue has wide-ranging effects that
often cascade beyond the clients themselves (Ogrodniczuk et al., 2005; Swift et
al, 2018). Premature loss of clients might also impact the therapists, especially
those who are at early-stages of their careers. Therapists often report feelings
of failure, anger, disappointment, and loss of self-confidence, which may transfer
to their personal lives and affect their behavior with other clients. Other
parties impacted include the client’s family and friends, along with agencies
and mental health service providers who lose valuable time and financial resources,
which could have been put to use helping others.
So, why do clients drop out of therapy? Apart from
unavoidable reasons such as shifting house locations, or unexpected illnesses, several
reasons have been attributed to this decision (Ogrodniczuk et al., 2005). In a
study that utilized telephonic interviews of individuals who dropped out of treatment,
Behl and Rajagopal (2018) reported intrinsic factors such as loss of
motivation, denial of problems, and stigma to be potential contributors to premature
termination of therapy. Other factors include anxiety associated with sharing
private feelings, disagreement with therapists, “unrealistic expectations” regarding
recovery, and failure of therapeutic alliance due to lack of empathy or perceived
judgment by the therapist (Ogrodniczuk et al., 2005, p. 59; Behl &
Rajagopal, 2018).
An interview-based study wherein therapists were asked
to reflect on factors that could have contributed to the clients leaving
prematurely, revealed that they attributed the termination to factors such as client’s
resistance to change, and challenges associated with the therapeutic
relationship. Several therapists also mentioned that they recognized these
issues early on in the treatment, however they failed to identify them as “warning
signs,” and hence address them adequately (Piselli, 2010, p. 40).
A question that further probes inquiry is: what can practitioners
do to prevent premature termination? Ogrodniczuk et al.
(2005) segregated the most common strategies suggested by literature into
nine categories: “pretherapy preparation, client selection, time-limited or
short-term contracts, treatment negotiation, case management, appointment
reminders, motivation enhancement, facilitation of a therapeutic alliance, and
facilitation of affect expression” (p. 57).
Pretherapy preparation, the most extensively studied
technique, represents attempts to familiarize the client with the aims of therapy,
roles and expectations of the therapist and client, and potential challenges,
before the beginning of the therapy. This helps dissipate unrealistic expectations
or misconceptions that the clients may hold about therapy. Role induction is
the most common type of pretherapy technique, which utilizes interviews, videotapes,
and audiotapes to deliver key instructions. Careful allocation of therapeutical
approaches, to match the needs of the clients, has been suggested to enhance
outcomes, which can prevent client dissatisfaction. Owing to lower dropout
rates in ‘time-limited’ therapies, setting definite timelines for therapy have
been suggested. Another important measure is for the clinician to pay significant
attention on the successful formation of, and maintenance of a healthy therapeutic
relationship with the client, through display of empathy and authenticity, along
with attempts to continually resolve any issue that may damage this relationship
(Ogrodniczuk et al., 2005). Inclusion of the preferences of the client, into
the treatment plan, and discussing progress to enhance motivation are also
important (Swift et al., 2012).
While some of these are strategies that are to be utilized
in the beginning of the treatment, others represent actions by the therapist throughout
the duration of the treatment. Keeping in mind the diversity of therapeutical orientations
and approaches along with the specific nature of treatment plans, several strategies
may have to be used in conjunction, attuned to the specificities of the paradigm
and client (Swift et al., 2012).
High rates of prevalence coupled with wide-ranging consequences
alert us to the importance of developing and implementing strategies to prevent
the instance of premature termination of therapy. Identification of the reasons
for attrition has helped guide the research and development of such strategies.
Given that only some of these strategies were supported by evidence of efficacy
from research, further research is needed to demonstrate the effectiveness of
specific strategies, especially with populations prone to premature termination
(e.g., adolescents) (Swift et al., 2012). Such evidence may also help back any policy
changes that may be required on the part of agencies and/or mental health institutions,
and help in issuing specific recommendations for certain disorders, and theoretical
orientations.
An important observation is that most of these studies
and thus their findings are contextually limited to the United States. Given
the significance of socio-cultural factors especially with relation to societal
acceptance of mental health concerns and treatment, research on the prevalence,
predictors, and reasons of premature termination of therapy relevant to Indian
contexts is important, to devise appropriate and effective measures for its
prevention.
1 Kindly
note that the above figures are primarily indicative of populations in the
United States.
References
Anderson, Kristin N. (2015). Premature Termination of
Outpatient Psychotherapy: Predictors, Reasons, and Outcomes. Theses,
Dissertations, and Student Research: Department of Psychology - 74. https://digitalcommons.unl.edu/psychdiss/74/
Barrett, M. S., Chua, W. J., Crits-Christoph, P.,
Gibbons, M. B., Casiano, D., & Thompson, D. (2008). EARLY WITHDRAWAL FROM
MENTAL HEALTH TREATMENT: IMPLICATIONS FOR PSYCHOTHERAPY PRACTICE. Psychotherapy
(Chicago, III.), 45(2), 247–267. https://doi.org/10.1037/0033-3204.45.2.247
Behl K & Rajagopal M (2018). Reasons for dropout
of clients from therapy. International Journal of Indian Psychology,
6(2), 135-150. DOI:10.25215/0602.014
Ogrodniczuk, J. S., Joyce, A. S., & Piper, W. E.
(2005). Strategies for reducing patient-initiated premature termination of
psychotherapy. Harvard review of psychiatry, 13(2), 57-70. DOI:
10.1080/10673220590956429
Piselli, Alessandro T. (2010). What Went Wrong?
Therapists' Reflections on Their Role in Premature Termination. Masters
Theses 1911 - February 2014. 379. https://scholarworks.umass.edu/theses/379
Swift, J. K., Greenberg, R. P., Whipple, J. L., &
Kominiak, N. (2012). Practice recommendations for reducing premature
termination in therapy. Professional Psychology: Research and Practice,
43(4), 379. DOI: 10.1037/a0028291
Swift, J. K., Spencer, J., & Goode, J. (2018).
Improving psychotherapy effectiveness by addressing the problem of premature
termination: Introduction to a special section. Psychotherapy Research,
28(5), 669-671. DOI: 10.1080/10503307.2018.1439192
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