Abstract
What does it mean to ‘drop out’ of therapy? Many definitions of ‘dropout’ have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client’s experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11–17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: ‘dissatisfied’ dropout, ‘got-what-they-needed’ dropout, and ‘troubled’ dropout. ‘Dissatisfied’ dropouts reported stopping therapy because they did not find it helpful. ‘Got-what-they-needed’ dropouts reported stopping therapy because they felt they had benefitted from therapy. ‘Troubled’ dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of ‘dropout’ cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.
Highlights
Dropout from psychological treatment is a significant concern across mental health services, including services for children and young people
A further aim was to test whether this refined categorization of dropout was better at predicting clinical outcomes than the generic ‘dropout’ definition, in adolescents who received therapy for depression
While we could speculate these adolescents were justifying their decision to end therapy by saying they didn’t need to keep going, this study found a trend toward them having better outcomes compared with ‘dissatisfied’ dropouts and completers, supporting their reported perception that they did not need to continue in therapy
Summary
Dropout from psychological treatment is a significant concern across mental health services, including services for children and young people. It is acknowledged that dropout can occur after any number of sessions (Wierzbicki and Pekarik, 1993; de Haan et al, 2015), so a strength of this operational definition is that it does not presuppose a treatment duration required to classify a client as a completer or dropout. Concerns about the reliability of this operational definition have been raised, as it has been acknowledged that therapists may differ in the criteria they use to judge the appropriateness of the ending of treatment (Wierzbicki and Pekarik, 1993). This approach to defining dropout is subjective, dependent on the clinician’s own views and possibly their therapeutic orientation
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