Psychotherapy discontinuation, also known as unilateral termination, patient dropout, and premature termination, is a patient's decision to stop mental health treatment before they have received an adequate number of sessions. In the United States, the prevalence of patient dropout is estimated to be between 40–60% over the course of treatmenthowever, the overwhelming majority of patients will drop after two sessions. An exhaustive meta-analysis of 146 studies in Western countries showed that the mean dropout rate is 34.8% with a wide range of 10.3% to 81.0%. The studies from the US (n = 85) had a dropout rate of 37.9% (range: 33.0% to 43.0%).
Psychotherapy discontinuation can mean different things to different researchers or clinicians. Although the important aspects of what discontinuation consist of (client's decision, symptoms not adequately reduced) typically remain constant, there can still be differences of how these are measured. For example, one researcher may designate that completing 50% of sessions will mark the client as a treatment completer, where another may designate this amount at 75%. When looking at patient dropout rates, these inconsistencies can make the data difficult to understand. But the same patients might be considered non-completes in another study.
Patient dropout is associated with numerous problems, such as: loss of potential patient improvement, poorer outcomes, increased likelihood of over-utilizing resources, and disruption in group therapy settings.Intuitively, these patients lose out on the benefits they may have received if they continued treatment. They also face poorer outcomes and fewer benefits of therapy compared to those who continue with treatment. Further, patients who discontinue treatment are more likely to be characterized as chronic patients, resulting in over-utilization of services, up to twice as much as "appropriate" terminators. In a group therapy session, premature discontinuation of one member may in turn adversely affect the other members of the group.
Narcissistic injury is a possible outcome of patient dropout, where therapists and clinicians may feel a diminished sense of self and may even feel inadequate. They may interpret a patient's discontinuation of treatment as a direct result of something they did. This can lead to lower self-esteem, confidence, and thus their effectiveness which will negatively impact their delivery of treatments to other patients.There is no current research as to how often this occurs in patient dropout cases.
Less apparent are the effects non-completes have on the entire mental health care system. Clinicians experience losses in the form of time spent on patient intakes, missed appointments prior to termination, and other diagnostic work performed.Administratively, these inefficiencies contribute to long waiting lists, which in turn: deny services to others, worsen community perception, and create lost income for clinics. Cyclically, long waiting lists have shown some increased dropout effects, further exacerbating the problem.
Predicting patients at risk of dropping treatment is a difficult task that is still being researched. However, there are different factors associated with patient dropout that are worth identifying. There are several meta-analysis studies that addressed these issues.
Patient characteristics are anything innate about the patients themselves. These include: age, race, gender, education, and socioeconomic status. Several studies identify minorities as more likely candidates for dropping psychotherapy treatment.Young clients are also more likely to drop out compared to older clients. Further, socioeconomic status has been linked to client dropout, where poorer patients drop out more frequently.
Environmental factors relate both to the environment of the patient and to the physical environment of the clinician's office. Research has shown that refurbishing the waiting room of an urban office resulted in a 10% increase in attendance at the first session. Also included as an environmental factor is the patient's access to care. In the United States, many insurance companies do not cover mental health treatment. This denial of care can quickly lead to patient dropout.
Social stigma of mental health treatment may also result in increased patient discontinuation. This is particularly true amongst ethnic minorities. In the Latino community, the male value of machismo can often increase shame of seeking mental health due to beliefs that the individual should be able to overcome problems on their own.
Perceptions of mental health may also alter patient beliefs about the effectiveness of mental health treatment. Patients receive cues on therapist expertise through their interactions, and may feel the therapist is inadequate. They may also feel that they do not share the same treatment goals. It's also possible that the initial perception that treatment is ineffective can lead to patient's seeking a reason to end treatment. Lastly, a client may have an expectation about how many sessions they will be attending. This number strongly predicts the number of sessions actually attended, which may differ from the number the therapist feels is necessary, leading to dropout.
Role induction involves preparing clients for what to expect in therapy. It consists of educating patients about the nature and process of therapy, aimed to offer clients an expectation of success and to dispel therapy misconceptions. This has been found to effectively reduce discontinuation, and even to help reduce client distress.
The therapeutic relationship is generally based on three concepts: a collaborative relationship, an affective bond between the therapist and patient, and the ability of both the client and therapist to agree on treatment goals. To strengthen this alliance, research suggests to reaffirm the main therapeutic conditions of warmth, positive regard for the client, and empathy. Communicating both respect for the patient's perspective and one's interest in working with them will help develop trust.
Motivational interviewing (MI) or motivational enhancement is defined as "increasing a person’s willingness to enter into, continue, and adhere to a specific change strategy.”MI is typically seen broken into the acronyms FRAMES (Feedback, Responsibility, Advice, Menu of strategies, Empathy, and Self-efficacy) or OARS (Open questions. Affirmation, Reflection, and Summary). Other strategies have included: correcting patient misconceptions, creating incentives for change, eliciting self-motivational statements, praising patient's serious consideration of change, and refraining problem behaviors so that they appear less formidable.
By consistently checking in with patient goals and progress, therapists can detect patient deviation from the intended path and thus consider changing treatment plans or other strategies before the patient drops. An example of therapist feedback would be a chart that displays client progress. This is a concrete picture of how the client is progressing, and will engage the client to take an active role in their treatment.
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing unhelpful cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play, such as sandplay. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticized as pseudoscience.
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including Art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.
Clinical psychology is an integration of science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro starting in 1988 in which the person being treated is asked to recall distressing images; the therapist then directs the patient in one type of bilateral stimulation, such as side-to-side eye movements or hand tapping. According to the 2013 World Health Organization practice guideline: "This therapy [EMDR] is based on the idea that negative thoughts, feelings and behaviours are the result of unprocessed memories. The treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements."
Art therapy is a distinct discipline that incorporates creative methods of expression through visual art media. Art therapy, as a creative arts therapy profession, originated in the fields of art and psychotherapy and may vary in definition.
Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension.
The Dodo bird verdict is a controversial topic in psychotherapy, referring to the claim that all empirically validated psychotherapies, regardless of their specific components, produce equivalent outcomes. It is named after The Dodo character of Alice in Wonderland. The conjecture was introduced by Saul Rosenzweig in 1936, drawing on imagery from Lewis Carroll's novel Alice's Adventures in Wonderland, but only came into prominence with the emergence of new research evidence in the 1970s.
Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed, and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.
Play therapy refers to a range of methods of capitalising on children's natural urge to explore and harnessing it to meet and respond to the developmental and later also their mental health needs. It is also used for forensic or psychological assessment purposes where the individual is too young or too traumatised to give a verbal account of adverse, abusive or potentially criminal circumstances in their life.
Ego-dystonic sexual orientation is an ego-dystonic mental disorder characterized by having a sexual orientation or an attraction that is at odds with one's idealized self-image, causing anxiety and a desire to change one's orientation or become more comfortable with one's sexual orientation. It describes not innate sexual orientation itself, but a conflict between the sexual orientation one wishes to have and the sexual orientation one actually possesses.
Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice.
Gay affirmative psychotherapy is a form of psychotherapy for non-heterosexuals, specifically gay and lesbian clients, which focuses on client comfort in working towards authenticity and self-acceptance regarding sexual orientation, and does not attempt to "change" them to heterosexual, or to "eliminate or diminish" same-sex "desires and behaviors". The American Psychological Association (APA) offers guidelines and materials for gay affirmative psychotherapy. Affirmative psychotherapy states that homosexuality or bisexuality is not a mental illness, in accordance with global scientific consensus. In fact, embracing and affirming gay identity can be a key component to recovery from other mental illnesses or substance abuse. Clients whose religious beliefs are interpreted as teaching against homosexual behavior may require some other method of integration of their possibly conflicting religious and sexual selves.
Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment. This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors that are suited to treatment of particular problems. According to one review, "it is widely recognized that the debate between common and unique factors in psychotherapy represents a false dichotomy, and these factors must be integrated to maximize effectiveness". In other words, "therapists must engage in specific forms of therapy for common factors to have a medium through which to operate". Common factors is one route by which psychotherapy researchers have attempted to integrate psychotherapies.
The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.
Exposure to trauma induces an intense amount of stress as a result of an individual directly or indirectly experiencing some type of threat, also referred to as a Potentially Traumatic Experience (PTE). PTEs can include—but are not limited to—sexual violence, physical abuse, unexpected death of a loved one, witnessing another person badly hurt, exposure to natural disaster, being a victim of a serious crime, car accident, combat, interpersonal violence and many other stressful experiences. PTEs can also include learning that a traumatic event occurred to another person or witnessing the traumatic event; an individual does not have to experience the event themselves to develop Posttraumatic Stress Disorder (PTSD). PTEs are labeled as such because not everyone who experiences one or more of the events listed will develop PTSD. However, PTSD is estimated to develop in about 4% of individuals who experience some type of traumatic experience. Approximately 8% of adults the United States population will have PTSD at some point in their lives. That means about 8 million U.S. adults have PTSD during a given year, which is only a small portion of individuals who experience traumatic events. Biological stress responses can be adaptive at the time of the traumatic event, but prolonged biological stress responses can lead to impairing symptoms known as PTSD.
Intake interviews are the most common type of interview in clinical psychology. They occur when a client first comes to seek help from a clinician.
Accelerated experiential dynamic psychotherapy (AEDP) is a mind-body psychotherapy that is informed by research in the areas of attachment theory, emotion theory, and neuroscience of change. This model of psychotherapy incorporates techniques from experiential therapies and ISTDP.
Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.
Co-therapy or conjoint therapy is a kind of psychotherapy conducted with more than one therapist present. This kind of therapy is especially applied during couple therapy. Carl Whitaker and Virginia Satir are credited as the founders of co-therapy. Co-therapy dates back to the early twentieth century in Vienna, where psychoanalytic practices were first taking place. It was originally named "multiple therapy" by Alfred Alder, and later introduced separately as "co-therapy" in the 1940s. Co-therapy began with two therapists of differing abilities, one essentially learning from the other, and providing the opportunity to hear feedback on their work.