Dropping out of psychotherapy

Surveys show that nearly half of people who begin psychotherapy quit against their therapist's recommendation. An article in the Harvard Medical School Psychiatry Department's journal, the Harvard Review of Psychiatry, discusses why this happens so often and suggests some ways to prevent it.

The authors note some reasons patients drop out: they are unwilling to open up about themselves; they cannot agree with the therapist about what the problem is; they just don't get along with or feel confidence in the therapist; they believe they are not improving quickly enough; they have unrealistic expectations. What can be done about it? To find answers, the authors reviewed 35 years of scientific literature. They base their recommendations on the several dozen research studies and clinical descriptions they found.

Before starting therapy, it may help to screen patients for a good match to the therapist and the therapy. There's some evidence that screening questionnaires can help to distinguish patients who will complete therapy from those who won't. Patients at high risk for dropping out might be offered a different treatment, or specific preparation for treatment. Some patients also need to be educated about the process. They can be given an explanation of the rationale, the roles and obligations of patient and therapist, expected difficulties and realistic hopes.

When the treatment is brief or has a fixed end point, dropout rates tend to be lower — in some studies, as much as 50% lower. Knowing when it will end may provide a sense of purpose that prevents patients from becoming discouraged. Therapist and patient should agree in advance on what needs to be accomplished and how it is to be accomplished. Negotiation is especially important in group therapy because otherwise, patients referred to groups may think that the unique features of their own situation are being ignored.

Many studies have shown that the critical feature of all successful psychotherapy is a strong working relationship between the patient and the therapist. There is no formula for achieving it, although warmth, empathy, respect, and interest are always important. The therapist must create an atmosphere in which a patient can safely discuss uncomfortable feelings, doubts, and questions about the therapy and the therapist.

Sometimes the problem is that the patient is not yet sufficiently willing or ready to change. Motivational enhancement aims to promote confidence in the ability to change and create a climate in which commitment to change becomes possible. It is already common in the treatment of alcoholism, drug addiction, and eating disorders.

Case management is sometimes necessary to solve problems that make psychotherapy difficult, such as lack of adequate housing or employment or a disastrous family situation. One study found that case management for severely depressed patients in group therapy reduced the rate of quitting by 50%. Reminding patients of their appointments is routine for many health care professionals but sometimes avoided by psychotherapists. The authors suggest that encouraging consistent attendance is more important.

The authors note that there has been far too little research on this subject as of mid-2005 — only 15 studies since 1970, and only 4 since 1985 — possibly because many psychotherapists take a casual attitude toward the problem. They point out that no single strategy will work for all patients and in all situations, and they recommend that clinicians try several approaches. But only more research will make it possible to compare ways of preventing dropouts and to suggest more specific recommendations.

October 2005 Update