Why patients quit therapy (and what the evidence says)

A patient begins to work, advances, and from one day to the next stops coming. He does not warn, does not respond to the message of reprogramming, does not return. Early abandonment of treatment is one of the most frequent and most frustrating experiences of clinical practice, and also one of the least talked about, because it is easy to live it as a personal failure.

The evidence helps to put it in perspective: abandonment is common, it has identifiable predictors and, in part, it is preventable. Not everything depends on you, but some things do, and they are precisely what research points out.

TL;DR

• About 1 in 5 patients leaves psychotherapy prematurely (average rate of 19.7% according to the largest meta-analysis).
• Abandonment is more common in young patients, in some cadres (personality and eating behavior disorders) and when the therapist is in training.
• The theoretical orientation and format (individual or group) no showed significant differences.
• There are strategies supported to reduce it: align expectations, monitor progress, and take care of the alliance.

What the evidence says

The reference study is the meta-analysis of Swift and Greenberg (2012), published in the Journal of Consulting and Clinical Psychology. It is enormous: 669 studies and 83.834 patients.

The central data: the weighted average dropout rate was 19.7% (IC 95%: 18,7% to 20,7%). That is, about one in five patients leaves treatment early.

That number, moreover, is good news relative. A previous review of two decades ago had estimated a rate close to 47%. Abandonment fell, probably due to changes in the way you work and understand adherence, but it remains a large-scale phenomenon.

What Abandonment Predicts

The meta-analysis identified several moderators, factors associated with increased risk of abandonment:

• Patient age: younger patients leave more.
• Diagnosis: personality and eating behavior disorders were associated with higher rates.
• Therapist's experience: treatments conducted by trained professionals showed more abandonment than those of more experienced clinicians.
• Context and definition: the scope of attention and even how "abandoning" is defined in each study influence the figures.

And just as important, which not predicted abandonment:

• The theoretical orientation of the treatment.
• The individual or group format,.
• Several demographic variables of the patient.

What does it mean in your clinical practice

Abandonment is never entirely eliminated, but several strategies with empirical support help reduce it. The most consistent:

• Align expectations from the beginning. Much of early abandonment comes from a mismatch between what the patient expected and what he finds: how long it will last, how the process is, what is expected of him, when changes tend to appear. Discussing it explicitly in the first sessions prevents avoidable desertions. The first interview is the key moment for that.
• Work the alliance actively. Abandonment is often the final symptom of a damaged alliance that was never named. Detecting and repairing the ruptures of the bond is one of the most direct ways to retain patients.
• Monitor progress. systematic follow-up of results reduces abandonment precisely because it detects patients who are unhooking in time, when there is still room to intervene.
• Take care of the first contacts and absences. A warm reprogramming message after an absence, a reminder that doesn't feel bureaucratic, a space to talk about the doubt of continuing: the details of the link around the session also support the treatment.

Killings and limitations

• Not all abandonment is clinical failure. Some patients leave because they achieved what they were looking for, others because framing was not adequate, others for external reasons that have nothing to do with treatment. "Abandonment" is a broad category that mixes very different situations.
• Definition of abandonment varies. Studies do not agree on what counts as desertion (do not complete a number of sessions, go against the therapist's criteria, stop attending without notice), which introduces noise in any comparison.
• Predictors are averages. That young patients abandon more at the population level does not say anything about a particular young patient. They are signs to be attentive, not labels to prejudge.
• To reduce abandonment is not to retain at all costs. The goal is that those who would benefit from following will not go away for avoidable reasons, not convince someone to sustain a treatment that does not serve them.

In summary

Premature abandonment affects about one in five patients, and although it is never completely eliminated, it has known predictors and prevention strategies with support. The constant that goes through all the evidence is that what it retains is not the technique or the school, but the management of expectations, the care of the alliance and the ability to detect the patient who is unhooking in time.

In order to detect in time, it is necessary to see the patterns: who is missing, who is not reprogramming, how each treatment evolves. When the agenda management and the history of each patient are ordered and in sight, those signals stop passing unnoticed. In Brauni we seek that follow-up is part of the workflow, so that no empty chair is a surprise.

References

• Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547-559. doi.org/10.1037/a0028226
• Swift, J. K., Greenberg, R. P., Whipple, J. L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology: Research and Practice, 43(4), 379-387. doi.org/10.1037/a0028291