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Decreasing treatment dropout by addressing expectations for treatment length



Therapy dropout or premature termination is a significant problem which impedes the delivery of psychotherapy services. In this study, a method aimed to reduce the occurrence of premature termination by addressing clients' duration expectations was examined. Sixty-three adult clients seeking psychotherapy services from a psychology department training clinic were randomized into control (n=32) and education groups (n=31). On average, those clients in the education group, who were provided information about the dose-effect model prior to their intake appointment, were found to stay in treatment significantly longer (d=0.55) and were more likely to be classified as therapy completers (RR=3.55) when compared to clients in the control group.
Decreasing treatment dropout by addressing expectations for
treatment length
University of Alaska Anchorage, Psychology, Anchorage, Alaska, USA &
University of North Texas, Psychology, Denton,
Texas, USA
(Received 1 September 2010; revised 7 October 2010; accepted 8 November 2010)
Therapy dropout or premature termination is a significant problem which impedes the delivery of psychotherapy services. In
this study, a method aimed to reduce the occurrence of premature termination by addressing clients’ duration expectations
was examined. Sixty-three adult clients seeking psychotherapy services from a psychology department training clinic were
randomized into control (n32) and education groups (n31). On average, those clients in the education group, who were
provided information about the dose-effect model prior to their intake appointment, were found to stay in treatment
significantly longer (d0.55) and were more likely to be classified as therapy completers (RR3.55) when compared to
clients in the control group.
Keywords: dropout; duration; expectations; premature termination; pre-therapy education
Therapy dropout is a significant problem that fre-
quently impedes the delivery of psychotherapy ser-
vices. It has been defined by others as occurring when
a ‘‘client has left therapy before obtaining a requisite
level of improvement or completing therapy goals’’
(Hatchett & Park, 2003), and is referred to in the
literature by a number of different names, including
attrition, early withdrawal, premature termination,
and client-initiated unilateral termination. While
researchers have disagreed as to how exactly this
phenomenon should be operationalized (Hatchett &
Park, 2003; Pekarik, 1985b; Swift, Callahan, &
Levine, 2009; Wierzbicki & Pekarik, 1993), there is
a clear consensus concerning the deleterious effects
dropout has on both clients (exhibiting poorer
treatment outcomes) and service providers (experi-
encing a loss of revenue, underutilization of time, and
demoralization) (Barkham et al., 2006; Barrett,
Chua, Crits-Christoph, Gibbons, & Thompson,
2008; Pekarik, 1985a; Reis & Brown, 2006).
Furthermore, the problem of client dropout is
common and widespread in therapy; reviews have
estimated that between 30% and 60% of all clients
discontinue therapy prematurely (Clarkin & Levy,
2004; Garfield, 1994; Wierzbicki & Pekarik, 1993),
with even higher rates observed in some settings
(Callahan, Aubuchon-Endsley, Borja, & Swift, 2009;
Swift et al., 2009; Tryon, 1999).
In an effort to better understand therapy dropout,
researchers have attempted to identify the variables
related to its occurrence. In an early review of the
dropout literature, Baekeland and Lundwall (1975)
found only slight evidence that the client demographic
variables of age, gender, and socioeconomic stat us can
predict who will terminate prematurely. In a more
recent review, Garfield (1994) concluded that there
were no consistent study findings linking prema-
ture termination to any client demographic variables.
Similarly, in a 1993 meta-analysis Wierzbicki and
Pekarik found that attrition was not significantly
related to client age, gender, or marital status, and
was only modestly related to socioeconomic status.
Other reviews of the literature have likewise reported a
lack of a relation between dropout and client demo-
graphic variables (Barrett et al. 2008; Clarkin & Levy,
2004; Reis & Brown, 1999).
In contrast to the null or weak findings linking
dropout to demographic variables, each of the re-
views previously mentioned and more recent research
have found that premature termination is strongly
linked to unmet client expectations (Arnkoff, Glass,
& Shapiro, 2002; Aubuchon-Endsley, & Callahan,
2009; Greenberg, Constantino, & Bruce, 2006;
Correspondence concerning this article should be addressed to Joshua K. Swift, Ph.D., Department of Psychology, University of Alaska
Anchorage, 3211 Providence Drive SSB214, Anchorage, AK 99508, USA. Email:
Psychotherapy Research
2011, 18, iFirst article
ISSN 1050-3307 print/ISSN 1468-4381 online #2011 Society for Psychotherapy Research
DOI: 10.1080/10503307.2010.541294
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Hansen, Hoogduin, Schaap, & de Haan, 1992; Nock
& Kazdin, 2001; Orlinsky, Grawe, & Parks, 1994;
Reis & Brown, 1999; Walitzer, Dermen, & Connors,
1999). This relation is particularly strong for expec-
tations concerning treatment length in which most
clients expect therapy to be very brief. For example,
Pekarik (1991) in one study found that 20% of clients
surveyed expected to attend two sessions or less, and
roughly 50% expected five sessions or less. Unfortu-
nately, the duration expectations that clients hold are
typically much lower than expectations held by
therapists (Mueller & Pekarik, 2000; Pekarik &
Finney-Owen, 1987; Pekarik & Wierzbicki, 1986;
Tryon, 1999) and are also lower than what is needed
for therapy to be effective (Swift & Callahan, 2008).
Unrealistically low duration expectations become
a problem in therapy because clients typically do not
attend more sessions than they originally expect. For
example, Scamardo, Bobele, and Biever (2004)
found that of 74 clients seen in a psychology
departments clinic, only four underestimated the
number of sessions they actually attended. A number
of other studies have found similar results (Mueller
& Pekarik, 2000; Pekarik, 1985a, 1991; Pekarik &
Wierzbicki, 1986; Tryon, 1999). Given that many
clients hold unrealistically low expectations for
treatment duration and that expected duration has
been found to be the best predictor of actual
duration, it is perhaps not surprising that studies
have found that clients who hold unrealistic duration
expectations are more likely to be classified as
treatment dropouts (Mueller & Pekarik, 2000;
Tryon, 1999).
Addressing Duration/Attendance Expectations
With unrealistic duration expectations being linked
to premature termination, one might hypothesize
that efforts aimed at altering clientsduration and
attendance expectations could result in reduced
occurrences of therapy dropout. In an effort to
reduce rates of premature termination, Sheeran,
Aubrey, and Kellett (2007) asked clients to build
attendance intentions by repeating three times ‘‘As
soon as I feel concerned about attending my
appointment, I will ignore that feeling and tell myself
this is perfectly understandable!’’ In this study, those
clients who were randomized to repeat this statement
were significantly more likely to show up to their
initial appointment compared to clients randomized
to a control group (75% versus 63% attendance).
More recently, Buckner et al. (2009) compared
attendance rates between clients who were asked to
spend 10 minutes imagining attending therapy ses-
sions and control group clients who were merely
provided 10 minutes of information about the clinic.
Although a significant manipulation effect was not
found for the entire sample of clients, those in the
imagination group with anxiety disorders attended
close to double the number of sessions compared to
control group clients with anxiety disorders.
Others have attempted to address clientsunrea-
listic duration and attendance expectations by pro-
viding clients with pre-therapy training or education.
In one study, Reis and Brown (2006) provided a
group of adult outpatient clients the opportunity to
estimate and discuss their expectations for treatment
duration with their therapists. Despite Reis and
Browns‘‘strong theoretical’’ belief that this proce-
dure would be effective in reducing premature
termination, they found no differences in dropout
rates between clients who did and did not discuss
their expectations with their therapists. Unfortu-
nately, methodological limitations with this study
prevent us from drawing any major conclusions from
the results. Clients in the discussion group of this
study were first asked to estimate how many sessions
they planned to attend. If the initial estimates were
deemed unrealistic, their therapists were then in-
structed to help them develop more realistic expec-
tations. In this study the definition of a realistic
duration estimate was three or more sessions. How-
ever, expected recovery in three sessions is still very
unrealistic for most clients. Thus, even in the
discussion group many clients with unrealistic
expectations were not provided any realistic duration
In a second study that attempted to use education
to alter unrealistic duration expectations, Swift and
Callahan (2008) provided 155 participants with
education about the general effectiveness of therapy
based on the dose-effect literature (i.e., chances of
recovery are greater as one attends more therapy
sessions and in general it takes about 13 to 18
sessions for 50% of clients to recover). Participants
were then asked to state the number of sessions that
they would expect to attend if they were seeking
treatment. Compared to participants randomized to
a control group, those who received the duration
education expected to attend over twice the number
of sessions (17 sessions versus eight sessions
expected by control participants). Although signifi-
cant results were found, because Swift and Callahan
used a student population the results may not fully
generalize to actual clinical settings. Additionally,
although this study found that expectations could be
altered, it did not examine whether pre-therapy
education could improve actual treatment atten-
dance or decrease the rate of therapy dropout.
Given the limitations of these previous studies, we
felt that further research was needed to examine the
effectiveness of pre-therapy duration education. In
2J. K. Swift & J. L. Callahan
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this study we aimed to examine whether pre-therapy
education based on the dose-effect literature would
have an influence on (1) clientsexpectations for
treatment length, (2) actual treatment length, and (3)
rates of premature termination. Due to the relatively
high attrition rates that have previously been docu-
mented in training clinic settings (Aubuchon-
Endsley & Callahan, 2009; Swift et al., 2009; Tryon,
1999), we believed such a setting would be ideal
for testing our hypotheses. Given that Swift and
Callahan (2008) found this type of pre-therapy
education to be useful in creating more realistic
duration expectations, and expectations have been
found to be related to actual attendance and therapy
dropout, we hypothesized that the duration educa-
tion would have a significant impact in each of the
three areas of examination.
Client Participants
Participants in this study were 60 adult clients who
sought individual therapy services from a univer-
sity-based psychology department clinic (see
Figure 1 for participant flow). This particular
clinic offers reduced fee services to both students
enrolled in the university and individuals from the
larger community. During the study time period
there were a total of 69 clients who presented at
the clinic; however, four clients were not offered
participation by their intake therapists, two clients
refused participation, and three did not complete
any of the study measures. Of the 60 participating
clients, 62% were female, 54% were single, and
78% were Caucasian. Another 6.3% of partici-
pants self-identified as African American, 1.6%
Hispanic, 11.1% Native American, and 3.2% as
Bi/Multi-Racial American. The average age of
these clients was M28.68 (SD11.12) ranging
from 18 to 65 years old. Roughly half of the
participants were current university students,
12.7% had not graduated from high school,
15.9% had graduated from high school only, and
11.1% had obtained a college degree. The majority
of these clients were given a diagnosis of a mood,
anxiety, or adjustment-based disorder at intake.
About 41% of the sample had previous therapy
experience. The average score on the Outcome
Questionnaire 45.2 (OQ-45.2: Lambert et al.,
1996) for participating clients at intake was M
74.02 (SD25.41), falling in the clinical range for
the measure.
Clients agreeing to study
participation (N = 63)
Control group (N = 32) Education group (N = 31)
Started the study (N = 31) Started the study (N = 29)
Assigned a therapist according to normal intake procedures
Dropped out
of therapy
(N = 24)
Dropped out
of therapy
(N = 9)
(N = 7)
(N = 20)
Adult clients presenting at
the clinic for individual
therapy during the study
period (N = 69)
Not recruited due to
clinician error (N = 4)
Refused participation
(N = 2)
Figure 1. Flow of participants through the study.
Addressing treatment length expectations 3
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Procedure and Measures
Prior to the start of their intake appointments clients
were consented for participation. Those 63 clients
who agreed to participate were then asked to
complete a short survey that included demographic
information and questions that were used for other
ongoing research projects in the clinic. Clients were
next randomized into one of two conditions: control
(n32) and education groups (n31). One client
in the control group and two clients in the education
group failed to complete any of the remaining parts
of the study and thus were dropped from further
analyses. Clients in both groups were then provided
a handout with some basic information about
therapy services at the clinic (e.g., sessions typically
last 1 hour and occur once per week) and those in
the education group were provided additional in-
formation covering the dose-effect model of therapy.
The dose-effect model (Howard, Kopta, Krause, &
Orlinsky, 1986) indicates that there is a positive, but
negatively accelerated relationship between treat-
ment length and the percentage of clients who
recover. For example, Lambert, Hansen, and Finch
(2001) analyzed data from over 10,000 clients and
found that approximately 20% of clients had recov-
ered by five sessions, 35% by 10 sessions, 50% by 20
sessions, and 70% by 45 sessions of therapy. In a
review of seven dose-effect studies, Hansen,
Lambert, and Forman (2002) concluded that it
takes roughly 1318 sessions for 50% of clients to
show a clinically significant change. Based on this
information, clients in the education group were
provided the following script: ‘‘An extensive body of
research looking at psychotherapy outcomes indi-
cates that on average it takes approximately 1318
therapy sessions for 50% of clients to recover. Some
clients may recover in a shorter amount of time while
other clients may take longer, depending on a
number of factors. However, on average it takes
approximately 1318 sessions for 50% of clients to
recover.’’ Clients in both groups were then asked to
indicate how many sessions they expected to attend.
After this point, the remainder of therapy services
proceeded as usual according to regular clinic pro-
cedures without study interference. Clients met with
an intake therapist for roughly 2 hours, were placed
on a waitlist, and then were assigned to a therapist by
the student clinic director according to caseload and
client fit. Therapy was provided by one of 17 trainees.
Each was a graduate student enrolled in an APA-
approved clinical psychology scientist-practitioner
PhD program at the same university and each
received weekly supervision on his/her clinic
cases by a member of the psychology departments
clinical faculty. In general, this programs theoretical
orientation can be described as cognitive-behavioral;
however, trainees in this program are encouraged to
use evidence-based interventions when working with
clients, rather than sticking to one set orientation.
The therapists were unaware of the purposes of this
study and were blind to the study conditions of the
clients. After the termination of therapy for each
participating client, charts were reviewed to deter-
mine the total number of sessions that were attended.
In addition, therapists were asked to classify each of
their clients as therapy dropouts(client-initiated
unilateral terminators) or therapy completers.
Clients were randomized into control and education
groups. To check the randomization procedures and
to ensure comparability between conditions, partici-
pating clients from the two groups were first
compared on demographic (age, gender, race, mar-
ital status, student status, and highest level of
education) and pre-therapy variables (previous ther-
apy experience and OQ-45.2 scores). No significant
differences were found between the two client
groups (control and education) on any of the
variables of comparison.
Expected Duration
Given the results previously found by Swift and
Callahan (2008), we were first interested in examin-
ing whether the duration-based education would
influence the number of therapy sessions clients
expected to attend. Of the 60 participating clients,
10 failed to provide an expected duration estimate.
Many of these clients either filled in the space
provided with question marks or wrote ‘‘I dont
know.’’ Interestingly, all 10 of these clients were from
the control group. An additional two participants
(one from each condition) reported duration expec-
tations that were greater than three standard devia-
tions from the mean (e.g., expecting 100 sessions).
Although some may not consider this an unrealistic
expectation, in terms of data management these two
scores were extreme compared to the averages.
Thus, these scores were considered outliers and
were not included in this analysis. However, data
from these two clients were maintained for the
remaining analyses.
Clients in the control group (n20) on average
expected to attend M6.43 (SD4.86) sessions of
therapy. In contrast, clients in the education group
(n28) on average expected to attend M15.16
(SD3.50) sessions of therapy. An independent
samples t-test indicated that these expectations
4J. K. Swift & J. L. Callahan
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were significantly different from each other [t(46)
7.25, pB.001], demonstrating a large effect (d
Actual Duration
We were next interested in examining whether the
duration-based education would influence the actual
number of therapy sessions attended by clients.
While clients in the control group (n31) attended
an average of M5.9 (SD7.3) therapy sessions,
clients in the education group (n29) attended an
average of M10.59 (SD9.91) sessions. An
independent samples t-test indicated that the num-
ber of actual sessions attended was significantly
different between the two groups [t(58) 2.09,
pB.05], demonstrating a medium-sized effect (d
Premature Termination
Although we found that on average clients who
received the duration-based education attended
more sessions compared to clients who did not receive
the education, this information does not tell us
whether the duration-based education had an influ-
ence on therapy dropout. The dose-effect literature
has generally found that with an increased number of
sessions attended there is a greater likelihood of
improvement and recovery (Hansen et al., 2002;
Howard et al., 1986); however, a number of research-
ers have found that treatment length does not always
correspond to treatment success (Baldwin, Berkeljon,
Atkins, Olsen, & Nielsen, 2009; Barkham et al., 2006;
Hatchett & Park, 2003; Swift et al., 2009). We were
thus further interested in examining whether the
duration-based education would have an influ-
ence on eventual therapy dropout.
Of the 31 control group clients, seven were
identified by their therapists as completerswhile
24 were identified as dropouts. In contrast, of
the 29 clients who received the duration-based
education, 20 were classified as treatment comple-
tersand only nine were classified as treatment
dropouts. A chi-squared test based on the 2 2
cross-classification table found this difference to be
significant [x
(1, 60)13.03, pB.001]. Calculation
of the Relative Risk ratio (representing the prob-
ability of event occurrence between groups) indi-
cated that clients who received the duration-based
education were more than three and a half times as
likely (RR 3.55) to be identified as treatment
completerscompared to the clients who did not
receive the education.
In this study we sought to examine the effects of
providing clients with pre-therapy duration educa-
tion based on the dose-effect literature. In summary,
we found that clients who received the brief educa-
tion prior to their first therapy session predicted to
attend a greater number of therapy sessions (d
2.14), actually attended more sessions of therapy
(d0.55), and were more likely to be classified by
their therapists as therapy completersrather than
dropouts(RR 3.55). While previous research has
demonstrated the importance of addressing clients
role expectations prior to the start of therapy
(Acosta, Yamamoto, Evans, & Skilbeck, 1983;
Orlinsky et al., 1994; Reis & Brown, 2006; Walitzer
et al., 1999), these findings demonstrate the value of
providing clients with pre-therapy education that
also addresses treatment duration and outcome
To our knowledge this study was the first to
attempt to alter clientsduration expectations by
providing them with education about the general
effectiveness of therapy. Although novel, the results
of this study fit well with the existing research on
duration expectations. First, we found that clients
expectations for treatment length could be altered by
providing them an anchor with which they could
base their own expectations. Swift and Callahan
(2008) found very similar results with their under-
graduate student population. It is thought that
clients come to therapy with low duration expecta-
tions not because they believe that they are different
from the norms and thus will recover much quicker
than the average client, but because they are not
aware of what the norms are for treatment length.
The fact that clients may not be aware of what to
expect was demonstrated by the finding that while
10 of the participants (one-third) who did not
receive education were not able to provide an
expectation, all of the clients who were given a
reference point were able to state a prediction of
treatment length. Interestingly, clients in the control
group on average made a duration estimate (M
6.43) similar to what has been found in previous
research [Pekarik (1991) found 50% expected five
sessions or less]. In contrast, clients in the education
group made estimates (M15.16 sessions) that
were almost identical to the education they were
given (1318 sessions). These results further support
the idea that clients used the education as a reference
point on which they based their own expectations.
A number of previous studies have found that
clientsexpected duration for treatment is closely
related to their actual duration (Mueller & Pekarik,
2000; Pekarik, 1985a, 1991; Pekarik & Wierzbicki,
Addressing treatment length expectations 5
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1986; Tryon, 1999). Thus, the finding that clients in
our education group attended more sessions of
therapy may be due to the fact that we were able
to alter their expectations. Additionally, comparing
the expectations of our clients to their actual
attendance, we found that in both groups clients
attended fewer sessions than they originally
expected. This finding matches what has been
observed by others (Scamardo et al., 2004; Tryon,
In contrast to Reis and Browns (2006) findings,
the pre-therapy duration education used in this
study did have an impact on rates of premature
termination between the education and control
groups. The main difference between ours and
Reis and Browns study is the manner in which
clients were provided duration education. Whereas
in Reis and Browns study clients were only asked to
state their expectations and then had a discussion
with their therapists if the expectations seemed
unrealistic, in our study we provided clients with
factual statements based on the dose-effect litera-
ture. Clientsexpectations may be influenced to a
greater degree when information based on research
is presented to them (our study) rather than merely
discussing expectations with their therapists (Reis
and Browns study). In our study no client-therapist
discussion of expectations, including duration ex-
pectations, was systematically included (although
this may have occurred in some cases for both study
conditions as part of ‘‘treatment as usual’’). Addi-
tionally, our studies differed in our definitions of
‘‘realistic’’ duration expectations. In Reis and
Browns study, three sessions was deemed an appro-
priate treatment length and only clients who stated
they expected two sessions or less were encouraged
to attend more. In our study we provided clients with
an anchor of 1318 sessions for 50% of clients to
recover; an anchor much higher than Reis and
Browns cut off, and we believe it is a more
‘‘realistic’’ estimate of what is needed for therapy
to be successful. This higher estimate may explain
why we observed an effect on treatment dropout
while they did not.
Study Considerations
In considering the applications of the findings from
this study, some limitations should first be consid-
ered. First, this study took place in a psychology
department training clinic. It should be noted that
the rate of dropout observed in the control group
was high (77.42% prematurely terminated in
this group). Although this rate is higher than what
has been estimated in general [Wierzbicki and
Pekariks (1993) meta-analysis found an average
rate of approximately 47%], this rate is similar to
what has been found in other training clinic settings
[Aubuchon-Endsley & Callahan (2009) found a
67.92% client dropout rate in the same clinic used
in this study, but with a different sample; Swift et al.
(2009) found 77.04% of their clients from a different
psychology department clinic dropped out; Tryon
(1999) reported 71.21% of clients at a university
counseling center either dropped out after only one
appointment or unilaterally terminated]. Given the
high base rate of termination in the training clinic
setting, it may have been easier for our pre-therapy
manipulation to have had an effect on reducing
Although it is believed that the duration education
would still have an effect on reducing dropout in
other settings, the sample of clients used in this study
may also limit the generalizability of the results.
First, even though the sample size was large enough
to detect differences, it was relatively small (only 20
participants in the control group for one of the
comparisons). Also, the clients who were included in
this sample were primarily Caucasian, female, single,
and were seeking treatment for a mood, anxiety, or
adjustment-based disorder. Additionally, although
on average the intake OQ-45.2 scores of this sample
were in the clinical range, scores indicated less severe
disturbance than what has been reported in
the measures manual for other various clinic set-
tings. Further research is needed to test whether the
duration education used in this study would have
similar effects in other settings and with other types
of client populations.
Additionally, the clients were all seen in a setting
that generally espouses a cognitive-behavioral model.
Although clinicians were encouraged to use whatever
evidence-based interventions were deemed most
appropriate for their individual clients, the focus
was on briefer courses of therapy. The expectations
found in this setting may be different from those
found in settings that encourage longer durations of
treatment. However, this clinic was not known in the
community as a ‘‘cognitive-behavioral’’ clinic, and
clients seeking services at this clinic did not generally
request a specific type of treatment. Thus it is
thought that the pre-therapy expectations that these
clients held were not overly influenced by a specific
mode of therapy that they were expecting to receive.
Another consideration that should be kept in mind
when interpreting the results of this study is the
method we used to assess treatment dropout. Pre-
mature termination has been operationalized in a
number of different ways, including failure to attend
a given number of sessions, attending an intake
appointment only, missing the last scheduled ap-
pointment without returning to the clinic, and by
6J. K. Swift & J. L. Callahan
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therapist judgment. Studies have shown that differ-
ent results are obtained depending on the operatio-
nalization used (Hatchett & Park, 2003; Pekarik,
1985b; Swift et al., 2009; Wierzbicki & Pekarik,
1993). In this study we measured dropout based on
therapist judgment, which historically has been
regarded as the most accurate method of classifying
premature termination (Pekarik, 1985b). However,
studies have found that therapists sometimes classify
their clients as dropouts erroneously*when clients
themselves believe that they have completed treat-
ment (Beckham, 1992; Scamardo et al., 2004) or
when outcome measures have shown clinically sig-
nificant change (Swift et al., 2009). Swift et al.
(2009) recommend an operationalization for drop-
out based upon whether the client has made a
clinically significant change prior to discontinuing
therapy. However, because in this clinic therapists
did not routinely use an outcome measure with their
clients, we were left to base our results on therapist
judgment. Future studies may want to examine the
effect of pre-therapy duration-based education on a
measure of dropout based on clinically significant
change or more generally on treatment outcomes.
Clinical Recommendations and Future
In our study we found that providing clients with
pre-therapy duration-based education was effective
in altering duration expectation, leading clients to
attend more sessions of therapy and being less likely
to be rated by their therapists as treatment dropouts.
Based on these results we would recommend that
duration expectations be discussed with all clients
prior to treatment. This education should include
some type of education addressing a recommended
number of sessions for recovery to occur. In our
study the education was very brief (a few sentences
only), was provided in paper format, was based on
research findings from the dose-effect literature, and
was provided prior to the first therapy appointment.
These procedures could easily be implemented in
other clinic settings without much effort on the part
of staff or therapists or interference of client care.
More detailed discussions, different educational
formats (e.g., via the computer, therapist discus-
sions, or video presentations), and different recom-
mendations for treatment length (perhaps therapists
working from an orientation espousing a more long-
term model or perhaps those working with more
seriously impaired clients may want to help their
clients develop expectations for even longer treat-
ment durations) may also prove useful in addressing
clientsduration expectations. It is also recom-
mended that discussions of treatment length should
occur in conjunction with routine outcome monitor-
ing throughout the course of therapy. This would
perhaps be the best approach to preventing clients
from dropping out of treatment. Further research is
needed to study each of these possibilities. Addi-
tionally, due to the relatively small sample size and
limitations in the generalizability of this study,
replication is warranted.
Portions of this article were completed while the first
author was a graduate student at Oklahoma State
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8J. K. Swift & J. L. Callahan
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... While the treatment non-compliance rates were at the upper end of treatment non-compliance rates as assessed in the literature (Swift & Greenberg, 2012), this study had elements that likely contribute to higher rates of treatment discontinuation. This would include recruiting participants with more serious psychiatric diagnoses, not excluding individuals with active substance use disorders, providing a combined group and individual treatment intervention, and the fact that, given participants were randomly assigned to the intervention, not all clients necessarily received their preferred treatment option, something that can contribute to decreased treatment engagement (Swift & Callahan, 2011). ...
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To evaluate the effectiveness of two different smoking cessation interventions for individuals with severe mental illness. Study participants (N = 61) randomly assigned to the SC-R group (n = 29) were offered 24 weeks of no cost Nicotine Replacement Treatment (NRT); participants assigned to the SC + group (n = 32) were offered 24 weeks of no cost NRT plus two initial individual counselling sessions of motivational interviewing and weekly psychosocial group support for 24 weeks. At 6 months the smoking cessation outcome was 7% for the SC-R group and 14% for the SC + group, but there was no statistically significant difference between the groups. Both groups showed a significant decrease in the number of cigarettes smoked per day and significant improvement in physical health functioning. Clients with severe mental illness, high prevalence of co-occurring substance use and experience of homelessness, are both interested and able to quit smoking and reduce cigarette use.
... e. less representative) samples which dominate the literature (Simmons, Nelson, & Simonsohn, 2011). In addition, most explanatory studies have looked at a specific type of predictors in isolation such as comorbidity (Hoyer et al., 2016), chronicity (Richards & Borglin, 2011) and treatment expectations (Swift & Callahan, 2011), which would likely lead to weak predictive models in a real-world scenario given that they do not capture the multifaceted nature of treatment response. ...
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Cognitive-behavioural therapy (CBT) is the first line of treatment for several mental health disorders. However, not all patients show clinical improvements after receiving CBT. Machine learning allows inferences at the individual level and therefore is a promising approach for predicting who will and will not benefit from CBT. A comprehensive literature search was conducted to identify all studies that used machine learning to predict clinical response to CBT. A random-effects meta-analysis of proportions was used to estimate an overall performance accuracy across all studies. Twenty-four studies (N = 7497) were identified, covering five diagnostic groups: Major Depressive Disorder (k = 4), Obsessive-Compulsive Disorder (OCD, k = 5), Post-Traumatic Stress Disorder (k = 2), Anxiety Disorders (AD, k = 7), Substance Use Disorders (k = 4) and two transdiagnostic models. Studies used clinical, neuroimaging, cognitive and genetic data, or a combination of these, as predictors. The overall performance accuracy across studies was 74.0% [70.0–77.8]. Accuracies differed significantly between diagnostic groups and was highest in PTSD (78.7%, 69.1–87.0), AD (77.6%, 67.5–86.4) and OCD (76.1%, 67.3–84.0). Some studies were at a high risk of bias due to how the outcome was operationalised and/or how the analyses were conducted/reported. There are many challenges to overcome before these promising results can be applied to real-world clinical practice.
... First, we did not include help seeking as a search term (we decided to focus our search on the more general areas of readiness, preparation, and motivation); therefore, our coverage of help-seeking interventions was not comprehensive. Furthermore, our digital-only inclusion criteria excluded some interesting interventions that could easily be reproduced digitally (eg, a postal survey on implementation intentions [102] and an educational handout about the dose-effect relationship of therapy and expectation setting around treatment length [103]). ...
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Background: Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy. Objective: This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature. Methods: A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment. Results: A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures. Conclusions: Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.
... One possibility is that the therapists may not have provided accurate client expectations of therapy. Where clients are provided with accurate education regarding therapy duration, they remained in treatment for longer (Swift & Callahan, 2011). Alternatively, clients may have wanted different or quicker-acting interventions which were less emotion-focused, slower-paced and less experiential as the literature describes clients who not only have preferences regarding the type of therapy they engage with but also the therapeutic techniques used within (Roe et al., 2006;Roos & Werbart, 2013). ...
Objective: Client experience of psychotherapy is an important resource for our understanding of psychotherapy and deserves relevant attention in psychotherapy research. Emotion-focused therapy (EFT) is a relatively new adaptation of a humanistic therapy that has a tradition of giving a voice to the clients in therapy. Despite the number of qualitative studies looking at the experience of clients in EFT, there was no formal qualitative meta-analysis conducted synthesising the existing qualitative research on the clients' experience of EFT METHOD: A sample of 11 primary qualitative studies was selected through a systematic search of the literature. Primary studies were critically appraised, and data (findings) from them extracted and meta-analysed RESULTS: All eleven studies featured experiences of helpful aspects of therapy, with difficult but helpful aspects reported in seven studies and unhelpful aspects reported in six studies. Most studies reported chair and experiential work and intense emotional work in EFT as helpful, with fewer reports and fewer clients finding them difficult but helpful, or unhelpful. The multidimensional nature of the therapist and therapeutic relationship in EFT included emotional connection and support, validation, and understanding, and was commonly experienced as helpful to clients. Other client experiences reported included practical aspects of EFT such as session length, in-session outcomes such as clients' transformative experiences, and internal and external factors which were experienced by clients such as determination or reluctance to commit to therapy CONCLUSIONS: Most clients experience EFT as an intense, challenging, but productive psychotherapy, but it appears a minority of clients experience aspects of EFT as challenging.
... In contrast with the present study, however, many of the cited works addressed and changed other facets of expectations. These include, for example, control expectations (39), expectations regarding the length of treatment (40), or the acceptance of treatment (19,38). The results show greater methodical parallels with the studies by van Osch et al. (21) and by Kazdin and Krouse (20). ...
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Introduction Therapy expectations contribute substantially to the outcome of psychotherapy. In contrast, psychotherapy expectations are rarely addressed and systematically optimised in studies on psychotherapy. Materials and Methods A total of 142 mostly healthy participants with critical attitudes towards psychotherapy were randomised into two groups: (1) a control group that watched a video with patients who gave information about their symptoms or (2) an experimental group that watched an expectation-optimised video with the same patients giving additional information about their mostly positive therapy outcomes. The primary outcome was the Milwaukee Psychotherapy Expectation Questionnaire (MPEQ), which was filled in before and after watching the video. Results Both groups showed a significant improvement of their process expectations and attitudes towards psychotherapy after watching the video. Participants in the experimental group changed their therapy outcome expectation while there was no change in the control group [ F (1,140) = 9.72, p = 0.002, η2 = 0.065]. Conclusion A video intervention with patients presenting their positive therapy experiences improves therapy expectations in persons with critical attitudes. Expectation-optimised videos could be used for prevention programmes and when starting therapy. Trial Registration Trial was registered at (NCT03594903) on November 2018.
... The results reported in this study have several clinical and methodological implications. Studies indicate that recognition of the differences between patients' and therapists' views of the therapeutic enterprise might minimize the rate of therapy dropout (Swift & Callahan, 2011) as well as affect premature treatment termination (Aubuchon-Endsley & Callahan, 2009). The results suggest that patient process expectations do not necessarily shift naturally based on the type of therapy patients experience, but might only be transformed through a deliberate intervention. ...
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Recent studies suggest that patient-therapist congruence of expectations affects psychotherapy outcome. Nonetheless, most studies assessing expectations in their dyadic context have focused on outcome expectations. This study was aimed to assess whether patients and therapists view expected processes similarly, and whether these beliefs change over time to become more congruent or more dissimilar. Patients (N = 75) were assessed for process expectations at baseline and at 3 months into treatment, and their therapists (N = 17) reported on their general expectations only once, prior to the initiation of treatment. Multilevel models were fitted to assess differences between patients' and therapists' process expectations at baseline and after 3 months and changes in level of congruence. The results indicated that at baseline, therapists perceived the processing of therapist-patient relations as the expected therapeutic process, whereas patients viewed the provision of tools of cognitive control as such. No significant changes in patients' expectations after 3 months of treatment were detected; however, therapists' higher expectations of the provision of tools for cognitive control predicted increases in patients' rankings of this process. These results suggest that patients and therapists are incongruent in their views of the expected therapeutic process, and that therapists' initial views of the therapeutic process affect patients' beliefs. These findings highlight the importance of investigating process expectations in the dyadic context and set the stage for subsequent process-outcome demonstrations, focusing on the effect of patient-therapist congruence of process expectations as a potential predictor or mediator of psychotherapy outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
This third edition provides a thorough real-world exploration of the scientist-practitioner model, enabling clinical psychology trainees to develop the core competencies required in an increasingly interdisciplinary healthcare environment. The book has been comprehensively revised to reflect shifts towards transdiagnostic practice, co-design principles, and personalized medicine, and features new chapters on low intensity psychological interventions and private practice. Fully updated for the DSM-5 and ICD-11, provides readers with a contemporary account of diagnoses. It covers practical skills such as interviewing, diagnosis, assessment, case formulation, treatment, case management, and process issues with emphasis on the question 'how would a scientist-practitioner think and act?' The book equips trainees to deliver the accountable, efficient, and effective client-centred service demanded of professionals in the modern integrated care setting by demonstrating how an evidence-base can influence every decision of a clinical psychologist. Essential reading for all those enrolled in, or contemplating, postgraduate studies in clinical psychology.
Objective: to estimate structural and attitudinal reasons for premature discontinuation of mental health treatment, socio-demographic and clinical correlates of treatment dropout due to these reasons, and to test country differences from the overall effect across the region of the Americas. Methods: World Health Organization-World Mental Health (WMH) surveys were carried out in six countries in the Americas: Argentina, Brazil, Colombia, Mexico, Peru and USA. Among the 1991 participants who met diagnostic criteria (measured with the Composite International Diagnostic Interview (WMH-CIDI)) for a mental disorder and were in treatment in the prior 12-months, the 236 (12.2%) who dropped out of treatment before the professional recommended were included. Findings: In all countries, individuals more frequently reported attitudinal (79.2%) rather than structural reasons (30.7%) for dropout. Disorder severity was associated with structural reasons; those with severe disorder (versus mild disorder) had 3.4 (95%CI=1.1-11.1) times the odds of reporting a structural reason. Regarding attitudinal reasons, those with lower income (versus higher income) were less likely to discontinue treatment because of getting better (OR=0.4; 95%CI= 0.2-0.9). Country specific variations were found. Limitations: Not all countries, or the poorest, in the region were included. Some estimations couldn´t be calculated due to cell size. Causality cannot be assumed. Conclusion: Clinicians should in the first sessions address attitudinal factors that may lead to premature termination. Public policies need to consider distribution of services to increase convenience. A more rational use of resources would be to offer brief therapies to individuals most likely to drop out of treatment prematurely.
Purpose The purpose of this paper is to explore service users’ experiences of the process of ending from national health service (NHS) community personality disorder services. Design/methodology/approach Semi-structured interviews were conducted with eight participants recruited from four NHS community personality disorder services. Findings Three main themes emerged; “Service users” experiences in the context of “Reflective versus Reactive practice”, “Endings held in mind” and “What next”? Originality/value Further recommendations are provided for practitioners supporting individuals managing endings alongside a “readiness to end” model which may be used in clinical practice.
Background In New Zealand and elsewhere, the workloads and counselling impact of counsellors in private practice have been seldom researched despite them comprising a substantial proportion of practitioners. Aim This study sought to establish a profile of one self-employed counsellor's caseload over several years, assess the impact of counselling using the Outcome Rating Scale (ORS) and provide an example of collaborative, practice-based research (PBR). Method A retrospective client review of client records included demographic information and ORS scores. Analyses identified the nature of any clinical change and its association with client demographics. Results The average age of 720 clients was 41.5 years; 44% were male; and 71% were Pākehā versus 23% Māori. The average number of sessions was 2.4. For the 274 clients with first- and last-session ORS scores, repeated ANOVAs revealed significant changes in ORS scores over time, irrespective of client characteristics and no significant interactions between any of the variables and gains over time. The effect size (0.9) was ‘large’, and Reliable Change Index indicators were comparable to overseas studies using adult subjects in public health settings. Discussion The counsellor's caseload profile was similar to an earlier one and the gain in clients’ ORS scores was comparable to those in several other countries and not associated with clients’ demographic data. There are several reasons for counsellors to collaborate with others in analyses of their practice. This research provides a useful example of such collaboration.
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Two studies examined parents' pre-treatment expectancies for their child's psychotherapy among children (N = 405, ages 2–15) referred for oppositional, aggressive, and antisocial behavior. Study I focused on the development of a measure to assess expectancies. The results indicated that the measure was internally consistent. Moreover, socioeconomic disadvantage and ethnic minority status, severity of child dysfunction, child age, and parental stress and depression were significant predictors of lower parent expectancies for child therapy. Study II examined the relation of parent expectancies and participation in therapy. The results indicated that parent expectancies predicted subsequent barriers to treatment participation, treatment attendance, and premature termination from therapy. Overall, these findings have implications for the study of expectancies for therapy, for identifying families at risk for premature termination from treatment, and for the development of interventions designed to increase parent participation in child therapy.
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Participants were 12 counseling center psychologist and thir 257 college-student clients. Immediately after intake, clients indicated whether or not they would make an additional appointment, their reasons for not making another appointment, and the estimated number of sessions they would attend. Counselors rated clients' attractiveness and disturbance and estimated the number of sessions they would have with each client. Clients who did not make a second appointment were generally satisfied with the help they received in one session. Client estimates were more predictive than counselor estimates of actual number of sessions. Relative to less attractive and disturbed clients, more attractive and disturbed clients made and kept post-intake appointments.
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Controversy about the effectiveness of psychotherapy has a long history. In 1952, British experimental psychologist, Hans Eysenck, casued a furor when he proclaimed that the application of psychotherapy was no more beneficial than the abscence of treatment. In his report, Eysenck (1952( summarized the results of 24 reports of psychoanalytic and eclectic psychotherapies with more than 7,000 neurotic clients reated in naturalistic settings compared with two control groups. Eysenck found that the more intensive the therapy, the worse the results. In fact, Eysenck's date suggested that clients in psychoanalytic treatments had significantly worse cure rates tha nclients who received no treatment.
Clinicians are often concerned when clients decide to terminate therapy without consulting with them. Earlier understandings have included resistance to treatment, lack of motivation, and cultural and economic factors. Often the assumption is that the treatment failed. This study used clients' perspectives to understand self-termination by exploring clients' predictions of therapy length, decisions related to termination, and changes in expectations across sessions. Four major themes for termination were identified. All participants reported satisfaction with treatment and identified improvements that occurred as a result of their therapy. Clinicians are urged to include client expectations of therapy length when developing treatment plans, and to recognize that clients frequently make informed decisions to end therapy when they have received the help they needed.
Substantial numbers of mental health clients do not return following their initial therapy visits or drop out of treatment prematurely. Two general classes of strategies designed to reduce premature attrition and enhance treatment participation are reviewed. Research on psychotherapy preparatory techniques (role induction, vicarious therapy pretraining, and experiential pretraining) indicates that these educational techniques are effective in reducing early treatment attrition and may be especially effective with populations at high risk for dropout (e.g., lower socioeconomic groups, chronically mentally ill clients, and institutionalized juvenile delinquents). Motivational interviewing, a technique originally developed for clients with alcohol problems, is designed to reduce client ambivalence toward therapy and change and enhance commitment to and motivation for treatment. Research in the alcohol field suggests that a session of pretreatment motivational interviewing enhances treatment outcome. Both motivational interviewing and psychotherapy preparatory techniques are relatively brief and easy to incorporate into existing mental health care.