Whatever yours may look like, an empty chair is often the most obvious result of an unplanned ending in therapy. Concerned by the level of dropout among my private practice clients a couple of years ago, I set about trying to change it. Two years on, I’m marking my homework. So how have I done?
Ever since I started to become interested in the topic of outcomes in therapy, I’ve been as interested in looking at how clients end therapy as whether it can be shown to make a demonstrable impact in their lives.
Why? Quite simply, without a proper ending, all too often it’s impossible to know what difference therapy has made. Unless you’re in the habit of using sessional measures of outcome, you can only speculate when you’re faced with an empty chair where your client should have been. Did the client get what they needed and forget to tell you? Or, more likely, did the client not get what they needed and wasn’t able to tell you?
More and more, I see the issue of whether clients’ endings are planned or unplanned as being a far better proxy for their experiences of therapy than almost any other indicator.
Back in May 2018 I based a blog upon an exploration of the proportion of clients in my practice in the years 2016 and 2017 who achieved either planned or unplanned endings. I found some good news and some less good news, which I’ll summarise briefly below. I also made a number of resolutions to try and reduce the level of unplanned endings in one particular area of my practice.
Two years on, it feels high time to revisit this area and see whether I’ve stuck to my resolutions, and whether they’ve made a difference to my unplanned ending rates.
Definitions in brief
Within this and the previous blog I use the term dropout as shorthand for an unplanned ending of therapy. As I explain in the previous blog I use the definitions adopted by the CORE System, which breaks planned and unplanned endings down into four distinct categories each:
Planned from outset
Agreed during therapy
Agreed at the end of therapy
Other planned ending
Due to loss of contact
Due to crisis
Client did not wish to continue
Other unplanned ending
More detailed definitions of each are contained within the CORE System Manual which is available from CORE IMS: http://www.coreims.co.uk/
The picture from 2016 – 2017
As outlined in my previous blog, clients come to me via two main referral routes: Employee Assistance Programmes (EAPs), or privately via the BACP therapist directory, recommendation, or my private practice website.
The data presented below shows (for 2016 and 2017) the total number of initial referrals, the number of referrals that went on to become clients (Therapy agreed), and of those clients whose cases were closed at the time of analysis, the proportions that were recorded as planned or unplanned endings.
These were the observations I noted in my earlier blog:
My drop out rate has improved over the two years (from 30% in 2016 to 21% in 2017), but I shouldn’t be too relaxed about this for reasons I explain below.
The number of clients referred by EAPs has risen as a proportion of my overall caseload, from 37% in 2016, to 62% in 2017. This has had a direct bearing on the reduction in my overall dropout rate for 2017.
Clients that are referred to me by EAPs are significantly more likely to reach a planned ending than those from elsewhere.
While the numbers are small, clients that came through non-EAP routes had more unplanned than planned endings.
There was clearly a very significant difference between the ending profiles of my EAP and private clients, with significantly more than 50% of private clients dropping out in each of the two years. Before this exploration I might have had a vague sense that dropout rates for these clients was higher, but the degree of difference came as something of a shock to me.
Based on previous experience at the Royal College of Nursing (RCN) I was confident that I could make a positive impact on those numbers. This experience, together with research I’d undertaken for a blog written the previous year on the topic of dropout in therapy, offered me a range of possible options.
On the basis of these and other reflections I made four resolutions to try and reduce the level of dropout in my private practice clients:
More carefully assess, and if necessary work to strengthen, clients’ levels of motivation for change at the start.
Ensure that the client and I have sufficient clarity over the goals of therapy, and how we will work towards them, as well as keeping progress under regular review.
Make more explicit expectations over session attendance and the process of termination in early contracting.
Clarify and if necessary adjust clients’ expectations over how soon they should expect to experience a sense of progress (one study I’ve profiled previously demonstrated that addressing unrealistic expectations about treatment length significantly reduced dropout).
At the RCN, my service had managed to halve its rate of unplanned endings over a period of two years. How did things play out in my private practice in the two years that followed this first analysis?
The picture from 2018 – 2019
Below are the findings from analysis of my client data for the years 2018 and 2019.
With the caveat that the number of clients overall remains relatively small, two clear themes are evident:
The proportions of EAP clients that reach a planned ending to their therapy has remained relatively consistent. Over the four years the planned ending rate has been between 90 – 95%. Ideally I’d like it to be zero, but at the end of the day I’m a realist. The factors affecting dropout aren’t entirely within my control.
While the number of private practice clients has remained similar over the four years, the proportion of clients reaching a planned end to their therapy has risen significantly, from well under half in 2016, to 85% in 2018 and 100% in 2019.
I’ll settle for 100% in 2019, secure in the knowledge that that rate can only reduce.
What has made the difference?
Can I, hand on heart, say that I have attended faithfully to each of the resolutions I made more than two years ago with each and every client? No, I can’t. Can I point to any one of them and say, “it was this one that made the difference”? No, I can’t.
What I can tell you, however, is that, in general, I’ve been rather more conscious than before of holding these things in mind as I practice. Much like the Hawthorne Effect, in which individuals modify their behaviour in response to their awareness of being observed, I’ve been much more aware of their presence. It feels as if things have changed as much by simply paying greater attention than anything very specific.
I am, though, very much more aware of paying attention to the goals of therapy: first in the process of establishing initial goals together with the client, and subsequently in keeping those goals under regular review to avoid any tendency toward therapeutic ‘drift’.
My favourite strategy remains no 4 above: addressing clients’ expectations over how soon they should expect to experience a sense of progress. This was a deceptively simple strategy that tested the impact of providing information to clients about the number of sessions normally required to achieve improvement.
Clients in the study were randomly allocated to one of two conditions. One received treatment as usual. The second (the education group) were provided with information about the typical trajectory of improvement in therapy and the number of sessions likely to be required to achieve improvement. Those in the education group found to stay in treatment significantly longer and were more than three and a half times more likely to complete therapy.
Sometimes, the simplest strategies are the best.
Related posts on the subject of drop-out
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