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Premature Termination: When clients leave early

Just as I didn’t blog for several months with no discussion or mention of my upcoming absence, many times clients will terminate therapy with no mention of their intentions. Research shows that the average number of therapy sessions varies from one to four sessions. One session! Meaning as a therapist, you have a short time period to make a sufficient impact.

Premature termination happens quite often with rates hovering around 47%. Meaning more than half of clients will terminate before they see significant progress. A harrowing statistic but one that emphasizes the importance of therapists actively engaging clients in an effort to increase treatment retention. One of the best articles I found on the subject was published in the 2005 Harvard Review of Psychiatry.

Premature termination is “a client’s (patient’s) decision to end therapy, contrary to both the therapist’s current recommendation and the initial agreement between client (patient) and therapist.” I would like to include a lack of significant progress by the time of termination in that definition. I typically think of significant progress as a significant drop in Beck Depression Inventory or Outcome questionnaire, etc. While “significant progress” may be included in the initial agreement between client and therapist, a client’s definition of significant progress may be different than the initial plan.

Discussing premature termination is important because ultimately it hurts everyone involved in the therapeutic process. First of all, the client is impacted as they ultimately didn’t experience successful treatment and may likely feel even more discouraged than when entering therapy. This is particularly true with clients experiencing disorders such as anxiety and PTSD in which avoidance is the essence of their presenting problem. When these clients prematurely terminate, they may experience a temporary reduction in symptoms because they are no longer discussing upsetting issues. However, their symptoms come back very quickly and often much worse than before.

Second, from my experience as a therapist, one of the most frustrating events is when clients terminate early. Although it takes much more effort and time for longer term clients, I always feel that clients just showing up to therapy speaks volumes about their engagement and sometimes my abilities as a therapist. When clients leave treatment early, it often makes the therapist question their skill and ability as a clinician. This is particularly true with new therapists. That lack of early career success may lead to a lack of confidence and impact a therapist’s ability to successfully work with other clients.

What may be other impacts of premature termination? How can clients continue to engage in therapy despite the difficult nature of therapy? Next post will continue to discuss this topic and ways that therapists can help increase therapy retention.


 

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8 comments


  1. Sometimes there could be reasons the client terminates early that may be difficult to discuss with the clinician such as finances if managed healthcare is not an option or a limited option. Lack of availability on the therapist's part, lack of expertise, and/or just a gut instinct could all be reasons people terminate therapy early.


  2. After 2.5 years of psychodynamically oriented therapy, during which I have experienced very little improvement in my anxiety symptoms, I am considering changing therapists.

    One major reason I may leave is because my therapist maintains a very distant, detached and cold demeanor. It's something I can't seem to work past, and when I bring up the topic directly with him, he simply attributes it all to projection from the past and nothing changes.

    I believe that if I worked with a therapist who incorporates a bit of humanity, warmth and hope into the work I'd be much better off.

    I'd be curious to hear your thoughts on this.


  3. I have been a therapist for over 4 years in many different settings. I have experienced clients terminating early from therapy often and I have often questioned my skills and approach when they do. However, I have to keep reminding myself that clients terminate for a lot of reasons; most commonly because therapy is work! Nice to know that other therapists struggle with the same issue.


  4. Clients open their hearts in a clinical setting to a virtual stranger. They need to feel personally cared about in order to continue that incredibly personal act in front of a person who is watching a clock and taking their money. If a therapist doesn't make a client feel personally cared about, the abrupt termination may be one big FY.


  5. Another reason for a sudden termination is transference. Clients are embarrassed to reveal it, yet it consumes them. Therapists should inform clients of the phenomenon of transference and ask them to let them know if they experience symptoms of it. Instead, there is a bizarre lack of communication about it from therapists. Clients suffer in silence and eventually terminate to put themselves out of their misery.


  6. I just terminated with a newish LPC Intern I am working with (she is my case worker). I called her from the psych hospital after a meltdown to apologize for missing an appointment. She was angry..YES ANGRY. Here I am in a mental hospital..and SHE is the angry one. Normally, she misses appointments, is one hour late, etc. This is the only time I missed. I was never late. The doctor at the hospital wanted me t have weekly counseling..When I told her this,,she hesitated a long long time and I had to drag out of her that she would do it. It was obvious that she did not want to offer the counseling my psychiatrist said that I needed. She finally told me "just come to the office as soon as you get released on the 25th from the hospital..Well..I did what she said and guess what? As usual, she wasn't there..she had called in sick. I threw my hands in the air and left a message with the receptionist to tell my case worker "cancel counseling, cancel group; permanently." I feel I was more than justified.


  7. Hi Renee,
    So sorry to hear that. Sounds like she wasn't able to meet you in the middle. If you still feel like therapy would be helpful, I do hope that you seek out another therapist. It may be worth looking for a psychologist. I know they sometimes can be hard to find and insurance doesn't always cover them, but often the higher level of training and deeper commitment to psychotherapy can make them more responsive, more able to meet your needs. I wish you well in your search.


  8. If you have enjoyed a young psychologist's blog please visit my new website DearHoopers.com. My wife Kate and I have started an advice column and we would love for you to visit.

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