Are drop-out rates in therapy the new “elephant in the room”? No, it’s probably worse; the elephant has been standing there for decades. Drop-out rates in therapies such as Cognitive Behavioural Therapy (CBT), despite being very common, are barely talked about. A meta-analysis of 115 studies found that one in four patients terminates CBT before reaching remission. (This number doesn’t even include those who don’t show up to their first session). Amongst a range of disorders treated with CBT, people with depression are the likeliest to drop out (36.4%).
Why are therapy drop-outs bad? In a worst-case scenario, patients stop seeking for help. But dragging oneself from therapist to therapist is strenuous as well and in the case of group therapy may disrupt other patients’ progress too. Besides increased bureaucracy, patients must start from the top in forming a meaningful connection with their clinicians. This meaningful connection, often referred to as Therapeutic Alliance, is argued to be one of the strongest predictors of the patient’s recovery. Although, some patient-clinician’s constellations ought to fail and drop-outs may be advisable at times, it appears unlikely that a “Therapeutic Alliance” can be achieved when constantly jumping from one therapist to the next. Furthermore, needing to start from the top over and over again requires time, thus may needlessly exhaust the already underfunded NHS mental health services. If all of this is true why isn’t the issue publicised more?
According to Dr Tony Rousmaniere some of the blame may lie in clinicians. The clinical psychologist and author of the book Mastering the Inner Skills of Psychotherapy, states in an article on psychotherapy.net that clinicians are generally very discreet about their drop-out rates. “It’s as if you’re asking what sexually transmitted diseases (STDs) they may have. It’s not polite.” Differentiating himself from such secrecy, he wants to highlight the role of therapist factors and how clinicians should incorporate feedback to disincentivise patients dropping out of therapy due clinicians’ flaws.
Alternatively, drop-outs are commonly explained in terms of client factors. Patients needing to terminate therapy as a result of moving towns, financial limitations or time restrictions due to other commitments. Such factors are like ‘bad traffic’ typically framed as outside of anyone’s control, hence negating an obligation for responsibility. And without responsibility there is no one blame, ergo the matter stays silent. Of course, responsibility can’t be evaded every time. Sometimes, individuals may terminate therapy for personal reasons such as diminishing hope of remission. Consequently, they are likely to receive an enormous backlash from friends & family, who might insist on the continuation of the therapy. However, out of respect for confidentiality such critique happens behind closed curtains and is unlikely to reach the public.
Well, if the dilemma of drop-out rates hasn’t even been able to reach the public, it appears unlikely that we are moving closer to solving the matter. This sad truth is in line with the findings from the meta-analysis showing that drop-out rates of around 26% have been constant between 1980-2014.
How can we move forward? Obvious starting points lie within the ‘explored territory’ such as reducing therapist factors? Rousmaniere’s analogy to STDs may illustrate part of the solution. Talking about STDs used to be and, in many settings, still is very much taboo. But as the subject has become less stigmatised, people today feel more open to talk about it and confront such problems via treatment. Similarly, therapists need to become more open about their drop-out rates and seek a constructive discussion with other professionals as well as their clients.
For client factors, we need to take back control of things that seem out of our range. In terms of financial limitations, the government could help by extending funding for the NHS. This is tricky as such a solution is part of a bigger problem: Overcrowded waiting lists. In order to address the latter problem, the NHS has introduced several Apps and online services offering self-guided therapy. But these forms of therapy are considered to have the highest drop-out rates (34.2%), hence they further perpetuate the original problem. Geographical limitations may be equally unsettling. Like the problems arising from maintaining romantic ‘long-distance relationships’, clients may struggle if not be incapable to stick with the same therapist after moving towns. Trying to bridge this distance with video calls or weekly 2-hour drives is naturally not ideal. And finding a new local therapist, who acts as a person ‘on the ground’, is of immense importance. However, we cannot dismiss the decision to simply replace our therapist as something light-hearted. We pledge the value of commitment in our personal relationships with family, friends & partners. But we alienate the relationship with our therapists as something ‘technical’, where it’s about ‘missing an appointment’ not ‘giving up on a relationship’. The question shouldn’t just be: How to deal with your old therapist after moving towns, but reconsider whether moving towns is the right decision if it the opportunity cost is giving up the relationship with your therapist.
Of course, many client factors for drop-outs aren’t the result of external technicalities like financial or geographical limitations but are more personal. Especially in the early stages, patients may feel that they are making zero progress. People may think that treatment in mental health is the same as for physical health. When people have a cough, they go to the pharmacy to get the appropriate medicine. But with therapy it’s not about being given the solutions but finding them with the support of the therapist. If patients are not aware of this, it is no wonder that so many prematurely drop-out.
But maybe it’s something else. Maybe it’s neither about the therapist nor the client but about the interaction between the two. Rousmaniere’s article starts with the words “You understand me thirty percent of the time.” We have heard something along those lines a dozen times in our own arguments and the phenomenon is definitely not less common in therapy. How can patients be better understood by their therapists? One solution to that question may be exemplified by Randolph Nesse’s new book Good Reasons for Bad Feelings. As an advocate of “Evolutionary Medicine”, he illustrates how components of mental disorders like Anxiety, PTSD or Depression have or have had clear evolutionary purposes. Instead of categorising his patients as anomalies of a healthy human being, he empathises with the reasons for their suffering. Also, one could follow the lead of the Mental Health Foundation by adopting more co-productive research approaches. Therapies designed by people who have experienced mental illness may shift the therapy’s focus away from an over-scientific protocol to a more empathetic activity. Not only should the therapist listen to the patient but maybe the science behind therapy should start listening too.
Drop-out rates in therapy have been swept under the carpet or taken for granted far too long. Although solutions may vary, the discussion has to start now.
Akseli Ilmanen is a psychology and sociology student at the University of Bath. You can contact him here: Akseli.Ilmanen@gmail.com
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