The perennial question. Do clients drop out because they got what they needed and forgot to tell us, or because they didn’t get what they wanted and couldn’t tell us? Either way, drop out is (arguably) largely preventable. We need to start taking it personally and examining what’s behind it. Here’s what one (IAPT) service found when it investigated the phenomenon.
There seem to be two main stories I hear about client dropout. The first is that clients improve and stop coming as a result, a phenomenon known as progress withdrawal. The second is that clients aren’t getting what they need but don’t feel able to tell us. What I seem to hear less of is a determination to find out which of these is truer, and what we should do as a result.
The longer I’ve been doing therapy, the less accepting I’ve become of the position that dropout is somehow a fact of therapeutic life we have to learn to live with. Increasingly, I’m taking dropout personally. If clients have improved then I want to know before they disappear. And if they haven’t improved, well…..the same applies.
Talking Change Psychological Therapy Service (Solent NHS Trust)
Brace yourselves because I’m going to say something complementary about IAPT. Or rather, one IAPT service.
I’ve been highlighting the disturbing levels of attrition across IAPT for so long I’m surprised I haven’t received a personal letter from Jacob Rees-Mogg telling me to stop carping. As recently as our last blog I highlighted that fewer IAPT clients than ever before are completing therapy. So, imagine my surprise and delight to discover a recently published paper profiling the attempt of one IAPT service to better understand and profile its drop outs.
The researchers at Talking Change Psychological Therapy Service set out three key aims for the study:
To explore what can cause discontinuation of therapy
To obtain the experience of people who have received treatment and dropped out from Talking Change Psychological Therapy services
To explore whether people recovered as part of the treatment withdrawal and what may have helped towards that recovery
Talking Change Psychological Therapy Service
Clients
2,318 patients who dropped out of treatment between Nov 15 – Jan 19
818 engaged with follow up drop out calls
205 patients recovered pre drop out calls
365 found to have recovered post drop out calls
According to the paper, follow up of clients that drop out, by the service’s research and audit team, is part of standard service procedures. Between November 2015 – January 2019 a total of 2,318 clients were recorded as having dropped out of treatment.
Prior to follow up by the research and audit team, 205 (9%) were recorded as having recovered. We can presume from this that these were clients that had two or more sessions with accompanying measures.
Participating patients were telephoned after dropping out over a 2-month period post-discharge. Of the 2,318, a total of 818 (35%) engaged with follow up calls. In order to gauge their experiences of using the service, as well as their reasons for discontinuing, they were asked the following interview questions:
How are you feeling?
How have you been coping since your therapy stopped?
Can you tell us your experiences with therapy and the service? What were the reasons therapy stopped?
As part of service evaluation, do you mind if I ask questions about your mood and anxiety symptoms?
As part of the process, these former clients also completed GAD-7 and PHQ-9 measures. Their responses to the questions and measure items enabled the researchers to determine the key reasons behind their disengaging, as well as their current symptom levels at the point of interview.
What led clients to unilaterally disengage?
The researchers used thematic analysis of participants’ responses to identify the main reasons for clients’ disengagement from the service. Five main themes were identified: ‘Felt better’, ‘Issues with group settings’, ‘Therapeutic alliance breakdown’, ‘Miscommunication’ and ‘Impracticalities’.
Some clients felt better for reasons that included having benefitted from a strong therapeutic alliance with the therapist, learning and application of specific tools and techniques from their therapy, and a sense of cohesion and support from being part of a therapeutic group.
Less positively, other clients experienced a range of problems including the perceived unsuitability of group interventions, lack of treatment choice, treatments that were felt to be unsatisfactory, breakdowns in communication over appointments and a range of practical difficulties that made regular attendance problematic.
Sadly, the percentages of clients whose responses fell into each of the five main themes is not given in the paper. As a result, therefore, we don’t know, for example, what proportion of clients disengaged from the service because they were feeling better.
What proportion of clients that disengaged were recovered?
Part of the interview process involved asking clients to complete GAD-7 and PHQ-9 measures. Analysis of their responses revealed that 365 had moved to recovery. Although not stated explicitly, it seems safe to presume that these were clients whose measures prior to drop out showed them to have been above one or both of the GAD and PHQ cut-offs, and below the cut-offs for both at the time of follow up.
Prior to the drop out calls, 205 or 9% of the 2,318 clients that disengaged were found to be recovered. Drop out calls identified a further 365 who moved to recovery after drop out calls. If I’m interpreting this correctly, this means that 45% of clients who dropped out and engaged in subsequent follow up had moved to recovery.
Adding together clients who were found to have recovered before and after follow-up gives a total of 570, which is 24% of the total number of clients (2,318) that dropped out.
How can we understand these data?
From the qualitative analysis it is clear that some clients that dropped out did feel better: they experienced sufficient benefit not to need to continue. From the quantitative analysis it is clear that 9% of clients (205) that dropped out were shown to have recovered. A further 365 were identified as recovered as a result of follow up, bringing the total recovered to 570, or 24% of total dropouts.
Could the real proportion of those dropping out as a result of feeling better be higher than 24%? It is feasible, though it’s difficult to know. Only one in three clients engaged with follow-up calls, and my guess is that those that did engage were those that had more positive experiences of the service. All my experience tells me that therapy clients who aren’t getting what they need are more likely to fade away quietly rather than complain.
It’s laudable that this service has made the efforts it has to understand the reasons behind its pattern of dropout, and to quantify what proportion of clients that drop out have done so having improved. Given that a whole research and audit team is routinely involved in following up dropouts, however, I can’t help feeling that a lot of resource is used establishing, effectively, why the horse has bolted.
Where do we need to get to?
As I’ve blogged about recently, I’ve had some success over the past couple of years in reducing my levels of client dropout. The day I’ll be happy, however, will come when I have eliminated it altogether. I don’t want to be gazing at the stable door wondering why the horse has bolted. I’d rather be certain that my clients are getting enough of what they need from the process that I’m not suddenly going to be faced with an empty chair.
I’ve said it before, but I’ll say it again, that what I’m focusing on presently is to:
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).
I think we need to be our own researchers in this process and find as many ways as we can to ask of our clients “So, how are we doing?”. If we focus on some of the simple things, and do them really, really well, then maybe we can stop dropout being the inevitable collateral damage of doing therapy.
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Just like you we thrive on feedback. Please leave your thoughts on what you’ve read in the comments section below.
Great blog as always Barry. My feeling is that most clients drop out when the therapy is drifting and they aren’t getting what they need. Most clients see therapists as ‘experts’ (no matter how humanistic we are) so it can be hard to say they aren’t getting their therapeutic needs met (unless asked). Most therapists are also nice people (I have met some who aren’t !- but that’s rare) so my guess is that many clients also feel bad about saying “this isn’t working for me”. I have found the solution is very much as you suggest, checking in how the therapies going, are we talking about the right area’s ?, is it helpful ? If so how is it helpful?.
Another aspect I think is very important is being flexible to clients changing circumstances where possible. As Erving Yalom says ‘Boundaries need to be established and respected, but when the situation requires it, we must be willing to be flexible, creative, and individualised with the therapy we offer’ (The Gift of Therapy 2002) To give an example I recently changed three clients session times because their work situations had all changed (2 had got jobs, the others job location changed). If I hadn’t done so, my guess is all three would have been unable to continue, all continued therapy and are progressing well. All that required was me working slightly later one evening of a work day (I took an extra hour off in the morning) I could have said ‘no these are the times I work’ while strong boundaries are very important, sometimes ‘boundaries’ can also end up being barriers’.
Thanks for your comments Graeme. I completely agree with your thoughts on clients reluctance to challenge us. There’s a power imbalance that we need to be mindful of at work, whether we like it or not.
Yalom has it exactly right. Boundaries for the sake of boundaries serve no purpose. Many of my clients work shifts and regular appointments are nigh on impossible. I’m really pleased you’re willing and able to flex. We need more responsiveness of this kind!
Cheers, Barry