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Premature Termination of Psychotherapy: Causes, Consequences, and Prevention

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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