If your appointment book is more open than you'd like, it might be time to rethink how you're engaging your clients. Consider this fact: One in five clients will drop out of psychotherapy before completing treatment, according to a 2012 meta-analysis of 669 studies on dropout by Joshua K. Swift, PhD, and Roger Greenberg, PhD, published in the Journal of Consulting and Clinical Psychology.
Clients who are most likely to drop out early include those in their 20s and clients seeking therapy for personality disorders and eating disorders. Research also suggests that novice clinicians are the most likely to lose clients prematurely, with some reporting dropout rates as high as 75 percent.
Reducing dropout is arguably the best way psychotherapists can boost their effectiveness, since studies show that clients who terminate therapy early have poorer outcomes compared with clients who complete treatment, says Greenberg, a distinguished professor of psychology at the State University of New York Upstate Medical University.
"Even the most expert clinicians using treatments with the strongest empirical support cannot be effective if patients drop out of treatment prematurely," he says.
To help keep patients on course, Greenberg and Swift, an associate professor of psychology at the University of Alaska Anchorage, identified eight evidence-based strategies to reduce dropout in a new APA book, "Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes."
The two spoke to the Monitor about the strategies (see "Eight strategies to keep patients on track" for the full list), as well as the importance of clear endings and why dropouts can be hard on clinicians.
What are the most common reasons that clients stop coming to therapy?
Greenberg: Often, patients come in with unrealistic assumptions about therapy, both in terms of the roles of the therapist and the patient, the degree of commitment that's required and their feelings of how quick the benefits should appear. There is a fast-food element in terms of wanting things to happen very quickly, [yet recovery] is not something that will happen in a week or two. That's a surprise to many patients. Also, there are a number of external difficulties, such as child care or transportation or cost. Another big reason is anxiety about revealing their feelings and impulses and experiences that may have been traumatic.
Swift: Here's where psychologists can help prevent many of their clients from dropping out. Although the therapist may not be able to do anything about external factors such as child care or transportation, many of the other reasons patients might drop out can be addressed.
For example, if a client comes in with misperceptions about treatment or is unsure what is going to happen in psychotherapy, then the therapist can seek to provide that client with some education to help him or her feel more comfortable. If a client is feeling anxious about sharing some of his or her feelings, then the therapist can work hard to foster the therapeutic alliance and to increase that client's motivation for treatment. These strategies are not too difficult, it is just a matter of recognizing why many clients choose to discontinue prematurely and then putting the strategies in place early on in treatment before the dropout actually happens.
One strategy you suggest is talking with clients at the start of therapy about how therapy will end. Why is that such an important conversation to have?
Swift: Mainly because it builds hope for a client. When clients come into therapy, they are not sure what to do next and where to go from here. By talking about the end of therapy, it promotes the expectation that eventually we will be able to address these problems and take care of things. It gives them a goal to work toward right from the beginning. It reminds them that in maybe six months or a year they may be done.
Greenberg: There is also a sense that the end justifies the means. Talking about the end and how we are going to get there, what's involved and the complexity of their problem indicates to them, "OK, this is going to take a bit of time." It readjusts their expectations to something reasonable.
Swift: It's also important for clinicians to talk with the client about the possibility that he or she may think about dropping out and that it can be helpful to discuss it with the psychologist. If a clinician never talks about that, a client may have that feeling at some point and just act on it or feel bad about bringing it up. But if the therapist starts by opening up that possibility, it later frees the client up to talk about it when those feelings do arise.
Another strategy you suggest to keep clients engaged is to have them play a role in choosing the type of treatment they will get. Why is this important and what are the challenges to putting it into practice?
Swift: This is part of building collaboration with clients. Part of the clinician's job is to give the client the information so he or she can offer an informed opinion. It's not about giving clients what they want. It's about helping them feel they have a voice in that decision-making process. It can be strange for clients to offer their preferences if they are used to just doing what a health professional says. But the more that we can get them to play that bigger role, the more invested they will be in the treatment.
Greenberg: One useful way to get into the issue of preferences is to ask them if they have ever been in therapy before, to talk about past treatments and to discuss what seemed helpful or wasn't helpful. It's a very cooperative way for the two of you to examine where this person has been before and to get at preferences without a formal checklist.
Beyond the economics, how does dropout affect the clinician?
Greenberg: It's demoralizing for a therapist to put a lot of time and effort into making something work and hoping to be helpful and feeling rejected to some degree if a client doesn't come back. Especially when a therapist realizes he or she could have been helpful had a patient stayed in treatment. You do think about these people that you are working with, and it does filter into your own life.
Swift: There was one study conducted by Barry Farber, published in 1983, where therapists were asked to identify the most stressful patient behaviors from their practice. No. 1 was suicidal statements by clients, No. 2 was aggression and hostility and No. 3 was premature termination, which was rated higher than things like impulsive behavior, intense dependency, paranoid delusions and even home phone calls. Like Roger says, we think about our clients, and when they drop out we don't have closure and we have to guess about how they are doing and their future. We are often left wondering.
Most of the advice in the book is framed in terms of working with adults, but you emphasize that these strategies are equally important for psychologists who work with children.
Swift: [Dropouts] can even be more frustrating for therapists working with children because perhaps the treatment is going great with the child and they are really connecting, but parents decide they won't bring the child in anymore. When working with children, it's important to remember that our strategies need to be used with the parents or adults in charge. They are the ones looking for the changes; they are the ones who want to be hopeful that things will get better for their child.
How can clinicians keep things in perspective when patients terminate therapy?
Greenberg: Therapists should remind themselves that the experience isn't unique, that there are ways of getting more feedback from clients on how therapy is going for them, that they can consult with colleagues on why they are having frequent dropouts and how things are going. By talking to a number of colleagues, you usually discover similar things are happening for them. That helps to cushion the loss.
Swift: It's also good to remember that clients are the ones in charge. Although you can use these strategies and put forth your best effort, some clients are going to decide that they just don't want therapy right now. That is the client's decision and you can't take too much ownership. Dropouts are often over-utilizers of services. Some bounce around from one type of treatment, clinic or therapist to another.
What can a clinician do if dropouts keep happening?
Greenberg: Therapists should consult with other colleagues to determine whether it's something they are doing or not doing. This is a difficult profession. There is an art to this, as well as a science. The fit isn't always as good as it could be. To be able to take a step back at times and to look at what you are doing and who you are is an important element in all of this. Elicit feedback from clients on a regular basis about how you are doing and whether there is something getting in the way of where we want to go. One of the hallmarks of a successful therapist is to handle the ruptures in the therapy. The smoother you can be, the better outcomes you'll get.
Swift: Therapists can learn from their own mistakes. Also, if they have open communication with clients, the client will feel comfortable saying, ‘Hey, this upset me,' or ‘I was feeling like dropping out.' If you don't get too demoralized or defensive from a rupture or a dropout, you can instead learn from it and grow as a therapist.
Are certain types of therapy more prone to dropouts?
Greenberg: One thing we found is that all of the brands of therapy seem to be similar in terms of dropout. Psychologists sometimes assume that one brand is superior to another, but research on outcomes shows that most brands have very similar success rates. It parallels that they have similar dropout rates.
Where is more research on dropouts needed?
Swift: It has become standard practice to report dropout rates, but often there's nothing else reported with it. Such as: What were the differences between dropouts and completers in treatment A and treatment B? We also need to gain a deeper understanding of why clients are deciding to drop out. Some of the good qualitative studies that have followed up with clients who have dropped out are dated. Most of it often breaks down to dissatisfaction, but we need a way to break that down and get more detail. What exactly did the therapist do that was dissatisfying? What could the therapist have done differently? We need to give more depth to those questions, and we need more research to develop and test out these strategies.
Slides, discussion questions, role-play activities and other teaching materials are available for each chapter of "Premature Termination of Psychotherapyopens in new window".
