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Are psychotherapies with more dropouts less effective_
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http://www.tandfonline.com/action/journalInformation?journalCode=tpsr20
Psychotherapy Research
ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20
Are psychotherapies with more dropouts less
effective?
Catherine M. Reich & Jeffrey S. Berman
To cite this article: Catherine M. Reich & Jeffrey S. Berman (2018): Are psychotherapies with
more dropouts less effective?, Psychotherapy Research, DOI: 10.1080/10503307.2018.1534018
To link to this article: https://doi.org/10.1080/10503307.2018.1534018
View supplementary material
Published online: 22 Oct 2018.
Submit your article to this journal
Article views: 9
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EMPIRICAL PAPER
Are psychotherapies with more dropouts less effective?
CATHERINE M. REICH
1
& JEFFREY S. BERMAN
2
1
Department of Psychology, University of Minnesota Duluth, Duluth, MN, USA &
2
Department of Psychology, University of
Memphis, Memphis, TN, USA
(Received 10 June 2017; revised 26 September 2018; accepted 1 October 2018)
Abstract
Psychotherapy dropout is often regarded as an indicator of treatment failure; however, evidence of a relationship between
dropout and outcome has not been well established. The current research consisted of three meta-analytic studies, the
results of which found (a) individuals who dropped out began treatment more distressed than those who completed
therapy, (b) individuals who dropped out of therapy were more distressed at posttreatment than individuals who
completed therapy, and (c) treatments with higher rates of dropout were also less effective for the treatment completers.
Dropout may particularly signal poor outcomes for shorter treatments. The continued ambiguity in the meaning of
dropout is discussed as well as the promising potential for future research in the area of dropout as it relates to outcome.
Keywords: dropout; premature termination; psychotherapy outcome; treatment outcome
Clinical and methodological significance of this article: The findings from this meta-analytic review suggest that
treatments with greater numbers of dropouts appear to be less effective and individuals who drop out of therapy report
greater distress than completers. Dropout may particularly signal poor outcomes for shorter treatments. As such, these
findings may impact how researchers and clinicians choose to regard, track, and address drop out in its various forms.
The potential ambiguity of judging treatment effectiveness based on whether clients leave treatment early is explored.
Approximately 20% of the clients who begin psy-
chotherapy discontinue services prior to completion
of the treatment (Swift & Greenberg, 2012). It is
unknown, however, whether individuals who drop
out of therapy are more or less distressed than indi-
viduals who complete treatment. Although this type
of therapy termination could be viewed as a sign of
treatment failure, the meaning of this behavior is
ambiguous as clients may choose to drop out of
therapy for other reasons such as barriers outside of
therapy or even improvement of symptoms. It
remains unclear whether the decision to end services
early should be regarded as an indicator of treatment
effectiveness. The current research presents three
separate meta-analyses to related to these questions.
Defining Psychotherapy Dropout
Researchers have used a variety of labels and definitions
to refer to the early discontinuation of treatment (see
Swift, Callahan, & Levine, 2009). For the purposes of
this paper, dropout is the unilateral decision on the
part of the client to discontinue treatment after the
first session but at some point before psychological ser-
vices are considered complete. Notably, dropout is
conceptually separate from treatment acceptability,
which refers to client preferences for different treat-
ment rationales and the associated impact of the prefer-
ences on treatment refusal before treatment has started
(e.g., Walter, Guyatt, Montori, Cook, & Prasad, 2006).
Reasons for Psychotherapy Dropout
In a few cases writers have described dropout expli -
citly as treatment failure or as an indicator of poor
clinic performance (e.g., Hunt & Andrews, 1992;
Samstag, Batchelder, Muran, Safran, & Winston,
1998). More often, dropout is implicitly regarded as
a negative outcome, reflected in efforts to retain indi-
viduals “at risk” of dropping out, assessing treatments
© 2018 Society for Psychotherapy Research
Correspondence concerning this article should be addressed to Catherine M. Reich, Department of Psychology, University of Minnesota
Duluth, 1207 Ordean Court 320 Bohannon Hall, Duluth, MN 55812, USA. Email: [email protected]; [email protected]
Psychotherapy Research, 2018
https://doi.org/10.1080/10503307.2018.1534018
under the assumption that individuals who drop out
did not improve, or assuming that dropping out is
synonymous with a poor outcome. Though some
clients certainly do drop out due to dissatisfaction,
researchers and clinicians have long acknowledged
the complex and disparate motivations for ending
therapy (e.g., Brown, Andreason, Melling, Imel, &
Simon, 2015; Pekarik, 1983b, 1992; Simon, Imel,
Ludman, & Steinfeld, 2012). For example, in a
study conducted at a community mental health
center, 26% of dropouts reported discontinuing
treatment because they disliked the services and
35% reported logistical constraints (e.g., transpor-
tation difficulties); however, the largest portion of
clients (39%) reported no longer needing services
(Pekarik, 1983b). In addition, the clients who
reported no longer needing services and those report-
ing logistical constraints showed improvement on
self-reported distress since initiating therapy
(Pekarik, 1983b).
Although several quantitative reviews have investi-
gated dropout from psychotherapy (e.g., Baekeland
& Lundwall, 1975; Cuijpers, van Straten, Andersson,
& van Oppen, 2008; Garfield, 1994; Mohr, Vella,
Hart, Heckman, & Simon, 2008; Olver, Stockdale,
& Wormith, 2011; Phillips, 1985; Swift & Greenberg,
2012; Wierzbicki & Pekarik, 1993), these reviews
have focused on reporting rates or predictors of
dropout and have not addressed differe nt reasons
for terminating and or the importance of dropout
for psychotherapy outcome.
Psychotherapy Outcome and Dropout
Given the ambiguous meaning of psych otherapy
dropping out, an examination of the relative out-
comes of completers versus noncompleters is
needed. Few primary studies have focused on this
question and those that do often rely on the subjective
opinions of the clients, lack a comparison to comple-
ters, or are limited in generalizability because of a
highly specific population or setting. Nonetheless,
some studies report more psychological symptoms
among dropouts relative to completers (Bryant
et al., 2007), less symptom relief (Cahill et al.,
2003; Klein, Stone, Hicks, & Pritchard, 2003), and
lower ratings of satisfaction (Brown et al., 2015;
Simon et al., 2012). Other studies have concluded
the reverse, with dropouts reporting perceptions of
improvement relative to the start of treatment (e.g.,
Lampropoulos, 2010; Silverman & Beech, 1979),
fewer symptoms relative to completers (Hansen,
Hoogduin, Schaap, & de Haan, 1992), improvement
following drop out (DiPietro, Valoroso, Fichele,
Bruno, & Sorge, 2002; Manthei, 1995), no evidence
of relapse (Borrelli et al., 2002), and satisfaction with
the services they received (Brown et al., 2015; Silver-
man & Beech, 1979; Simon et al., 2012). Still others
have failed to detect differences between dropouts
and completers when using client-rated outcomes
(Kolb,
Beutler, Davis, Crago, & Shanfield, 1985).
One reason for the discrepancies in these findings
might be that on average the clients across these
studies dropped out for different reasons and differ-
ent types of dropout are uniquely related to
outcome. Another explanation for these discrepant
findings might reflect the timing of the dropout. For
example, there is some evidence that clients who
drop out early in treatment cite situational constraints
and discomfort with services as their reason for termi-
nating (Hynan, 1990) and report poorer outcomes at
follow-up (Pekarik, 1983a), whereas individuals who
drop out later in therapy tend to cite improvement
(Hynan, 1990; Pekarik, 1983a). Given the inconsist-
ent findings regarding outcome and dropout in
primary studies, a meta-analysis would be particu-
larly helpful.
The Current Research
In examining the relevance of dropout for psy-
chotherapy outcome, three related questions were
considered and addressed in three separate analyses:
1. Dropouts and completers at pretreat-
ment. One might first wonder whether
clients who drop out begin their treatment
with more or less severe symptom distress.
As such, studies reporting the level of pretreat-
ment symptom distress for treatment drop-
outs and completers were used for the first
set of analyses.
2. Dropouts and completers at posttreat-
ment. Regardless of whether or not clients
who drop out of therapy begin more dis-
tressed, one might wonder how dropouts
fare compared to treatment completers with
regard to outcome. If dropouts experience
worse outcomes than completers, this would
favor a conceptualization of dropout as a
signal of dissatisfaction. To assess this possi-
bility, studies comparing outcomes for drop-
outs and completers posttreatment were
examined with the second set of analyses.
3. Dropout and outcome. Ideally, an analysis
would examine comparative treatment
studies for the relationship between relative
dropout rates with the relative outcomes for
all participants in those treatments. Unfortu-
nately, the outcomes for dropouts are often
unknown. In the absence of such data, the
2 C. M. Reich and J. S. Berman
current study examined the available data
(i.e., completer outcomes) to test whether an
association between dropout rate and
outcome might be present. Is dropout an indi-
cator of treatment effectiveness for those who
complete the therapy? In other words, when
comparing two treatments, is the rate of
dropout from one treatment relative to
another predictive of the relative effectiveness
of those treatments for the completers? If
dropout is a sign of treatment failure, then
one would predict that higher rates of
dropout herald a less effective treatment. If
dropout is, as many have suggested, a more
complex phenomenon, then one would
expect for the relationship between dropout
and outcome to vary in its strength or direc-
tion depending on the type of dropout. For
example, higher rates of dropout due to dis-
content with the treatment might be expected
to be more highly related to treatment ineffec-
tiveness than dropout due to logistical con-
straints. Furthermore, dropout due to
improvement might be expected to be associ-
ated with better outcomes. Therefore, the
third set of analyses examined comparative
treatment trials in which the rates and
reasons given for dropout as well as the thera-
peutic outcomes of these treatments were
reported for each treatment group.
It may also be possible that dropout is only relevant
for treatment outcome under certain conditions.
Therefore, analyses also examined whether the rel-
evance of dropout for treatment outcome varied as
a function of treatment, therapist, client, and study
factors.
Overall Method
Studies
Search methods. The 669 articles of the most
recent meta-analysis of dropout rates (Swift & Green-
berg, 2012) were first screened for eligible articles.
Studies published after the Swift and Greenberg
(2012) meta-analysis search were identified through
PsycINFO and PsycARTICLES using the terms
dropout, attrition, or termination combined with
either psychotherapy or treatment from the period
of 2010 to 2017. Finally, issues of psychotherapy
journals were hand searched including the American
Journal of Psychiatry, Behavior Therapy, Behaviour
Research and Therapy, British Journal of Psychiatry,
Journal of the American Medical Association Psychiatry,
Journal of Clinical Psychology, Journal of Consulting and
Clinical Psychology, Psychotherapy, and Psychotherapy
Research also from the period of 2010 to 2017. To
be selected, the published articles had to be available
in English.
Selection criteria. A full explanation of exclusion
criteria can be found in Figure 1. Notably, studies
with treatments that took place in inpatient units or
in prison as well as studies of individuals with psycho-
tic, child, or family/couple populations were excluded
because in each case there may be external pressures
beyond the individual’s preference guiding the
decision to continue treatment.
Procedure
Coding. All screening and coding followed
PRISMA guidelines for meta-analyses and was con-
ducted by the first author. Ten percent of the
studies were randomly selected and rated by a
second coder. The reliability between the first and
second coder was excellent for both effect size data
(ICC = .91) as well as all variables pertaining to
dropout and timing such as treatment length (ICC
= .92). Dropout rates were computed as proportions
of the total dropped over the total sample at the start
of the treatment. These proportions were corrected
for abnormal distribution using the arcsine trans-
formation for all analyses (Keppel & Wickens,
2004, Chapter 7, p. 155).
Cohen’s(1977) d was calculated as a measure of
effect size to indicate the strength of the difference
being assessed (Borenstein, Hedges, Higgins, &
Rothstein, 2009 ). When no information was provided
in an article except that the comparison was “not stat-
istically significant,” the effect size was assumed to be
zero. This method could be randomly biased as some
studies may have had a nonsignificant but slightly
positive or slightly negative finding. Excluding such
cases could also bias the findings toward inclusion
of studies that reported significant findings. There-
fore, the results below are reported both including
and excluding effect sizes assumed to be zero when
the results were meaningfully different. In all cases,
Hedges’ g (Hedges & Olkin,
1985,
p. 81) was used
to correct for sampling bias.
Additional variables were coded as available for
descriptive purposes and to explore potential moder-
ating effects. Moderators were selected based on
those variables noted to moderate dropout rates in
the Swift and Greenberg (2012 ) meta-analysis as
well as availability of data in articles. Additionally,
two variables related to dropout were coded: the
study definition of dropout and the average number
of sessions before drop out occurred. When the
Psychotherapy Research 3
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