Psychotherapy

Volume 36/Summer 1999/Number 2

REDUCING PSYCHOTHERAPY DROPOUTS: MAXIMIZING

PERSPECTIVE CONVERGENCE IN THE
PSYCHOTHERAPY DYAD
BRENDALI F. REIS

LILLIAN G. BROWN

University of Pennsylvania
School of Medicine

California School of Professional

Psychology, Fresno

Premature termination of psychotherapy is

a pervasive problem30 to 60% of
psychotherapy clients drop out of treatment
before its completion. This review
summarizes 3 decades of research on the
topic. Client, therapist, and administrative
variables have been extensively
investigated. Because of a variety of
methodological problems, this literature is
highly contradictory, and results are
difficult to reconcile, with only
socioeconomic status (SES) and ethnicity
emerging as consistent predictors of
dropout. Research looking at interactive
and multidimensional factors such as
working alliance, satisfaction, patient
likability, and expectations has proven
more useful than research on client,
therapist, and administrative variables.
Findings suggest that dropouts might be
minimized if differences between
therapists' and patients' perspectives on
the therapeutic enterprise are

This article is based in part on a dissertation by the first

author submitted to the California School of Professional
Psychology-Fresno, in partial fulfillment of the requirements
for the degree of doctor of philosophy. Major portions of this
work were made possible by funding from scholarship No.
200085/93-0 CNPq, Brasilia, Brazil. The authors wish to
thank Merle Canfield and Shelley Stokes for their help and
discussions that contributed to this review.
Correspondence regarding this article should be addressed
to Lillian G. Brown, Ph.D., S130 East Clinton Way, Fresno,
CA 93727-2014. E-mail: LHARRIS@MAIL.CSPP.EDU

acknowledged and recognized as

legitimate targets for intervention.
Introduction
In relation to psychotherapy, the terms dropout, premature terminator, defector, and unilateral terminator (UT) are all used to refer to a
patient or client who terminates treatment before
the clinician believes the client is ready. In this
review we have privileged the term UT for the
sake of brevity and because the term dropout implies an incompleteness that may or may not be
accurate. This will be elaborated when we discuss
the heterogeneity of the dropout population. We
argue that while many UTs are satisfied customers, of those who are not, many leave because
their perspectives differ from those of their therapists. These UTs might remain in treatment longer
if they were better prepared for the therapy experience and accorded the opportunity to participate
in treatment planning.
From some theoretical perspectives (e.g., Pekarik, 1983a), UT is considered a major obstacle
to the effective delivery of mental health services.
Although research has demonstrated that UTs do
not constitute a homogeneous group (as will be
discussed later), and despite the fact that some
approaches (e.g., solution-focused and humanistic) may not view UT as problematic, dropping
out has been related to poor outcomes (Heilbrun,
1982; Lyons & Woods, 1991; May, 1984). A
meta-analysis of studies conducted over 30 years
involving 2,400 patients indicated that the issue
of an optimal amount of therapy is intrinsically
linked to diagnosis and outcome criteria; nevertheless, eight visits was the point by which 50%
of patients showed measurable improvement
(Howard, Kopta, Krause, & Oriinsky, 1986).
Poor outcomes have been reported especially for

123

B. F. Reis & L. G. Brown

UTs who drop out early. Follow-up studies have
shown that patients attending only one or two
sessions tend to become worse or to improve less
or to be more symptomatic (depending on the
measure) than those attending three or more sessions (Pekarik, 1983a, 1992). Another problem
with UTs is that financial and human resources
are not used to their full advantage when attrition
rates are high. The unscheduled down time of the
"no-show" hour can render premature termination
demoralizing for therapists, who may believe they
have failed or were rejected by the patient. This
may in turn impair clinicians' self-confidence and
effectiveness (Pekarik, 1985a; Sledge, Moras,
Hartley, & Levine, 1990). Moreover, it is the
UT, not the remainder, who seems to be the typical chronic patient (Baekeland & Lundwall,
1975). UTs tend to overutilize services, in some
cases contacting mental health facilities at twice
the rate of patients classified as appropriate terminators (Carpenter, Del Gaudio, & Morrow,
1979). Thus, UTs are expensive in terms of time
and money, display poor treatment outcomes, and
demoralize therapists who may respond with impaired self-confidence and reduced efficacy. For
these reasons we undertook this review, with the
intent of identifying UT predictors amenable to
change by clinicians.
The Definition Problem
The variety of operational definitions is a major
factor confusing the UT concept (Beck et al.,
1987; Fiester, Mahrer, Giambra, & Ormiston,
1974; Garfield, 1994). In the majority of studies,
failure to attend a specified number of sessions is
the criterion for classifying a patient as a dropout
(Baekeland & Lundwall, 1975; Pekarik, 1985b).
Unfortunately, researchers use different cutoffs
(Pekarik, 1985b), with the consequence that patients considered dropouts in one study are viewed
as continuers in others (Garfield, 1994). Even if
all researchers adopted the same number of sessions as the criterion for dropout, results would
still be inconsistent, as duration is not necessarily
related to dropout status. Many studies supposedly exploring dropout status are really investigating "early termination . . . a phenomenon . . .
less useful and imprecise since it is composed of
early dropouts and early appropriate terminations" (Pekarik, 1985b, p. 87).
Thus UTs, simply defined by an arbitrary number of sessions, constitute a very heterogeneous
group. Early UTs differ from late UTs, not only

124

in terms of outcomes, but also in terms of termination antecedents; and UTs, completers, and continuers often show no outcome differences at all.
This phenomenon tends not to be recognized by
therapists, who are prone to see all UTs as treatment failures. UTs who reported "no need for
(further) services" (39%) and "environmental
constraints" (35%) as reasons for terminating
scored less symptomatically on the Brief Symptom Inventory (Derogatis & Spencer, 1982) than
did patients citing "dislike of services" (26%) in
a 3-month follow-up study (Pekarik, 1983b, p.
909). In a similarly designed 4-month follow-up,
those reporting improvement displayed outcomes
comparable to completers and better than continuers. Notwithstanding, therapist ratings of problem
improvement were higher for continuers and completers (Pekarik, 1992), suggesting that therapist
judgment of improvement is strongly related to
duration of treatment. Therapists expect improvement to require lengthy treatment.
In addition, the use of the median number of
sessions (5) in an outpatient community mental
health center (CMHC) misclassified 40% of clinically defined appropriate terminators as dropouts.
The use of the mean number of sessions (12) also
yielded unsatisfactory results, as 71% of clinically defined appropriate terminators were misclassified as dropouts (Morrow, Del Gaudio, &
Carpenter, 1977). Regardless of the duration criterion used, therapists display a negative attitude
toward brief stays and toward UTs (Buddeberg,
1987) and seem to fail to recognize that UTs
are not necessarily treatment failures. This bias,
conveyed by many of the results described above,
has been demonstrated in numerous other studies
(Ellingson, 1990; Papach-Goodsitt, 1986; Schwartz,
1991).
Despite therapists' tendency to overlook potentially positive outcomes, their clinical judgment
is still more useful than number of sessions or
any other criterion for defining the highly heterogeneous population of UTs. Analyses revealed
that UTs differed from completers on 11 of 18
client and therapist variables when the criterion
was therapist judgment, whereas no differences
at all emerged between the two groups when a
duration criterion was used (Pekarik, 1985b). Because of the reliability problems inherent in therapist judgment, failure to keep the last appointment
scheduled has been used occasionally as an alternative. This method, however, can misclassify
(as dropouts) both appropriate terminators who

Psychotherapy Dropouts
would be discharged by the therapist within a few
sessions and symptomatic patients (as appropriate
terminators) when they refuse to schedule another
session and declare treatment finished (Pekarik,
1985b).
Scope and Severity of the Problem
Regardless of definition, UT rates across different ages, client groups, settings, diagnoses, and
treatment modalities range from 30 to 60%
(Baekeland & Lund wall, 1975). Studies variously
find the mean or median number of sessions ranging from 3 to 13 and clustering around 6 (Ciarlo,
1979; Garfield, 1994; National Institute of Mental
Health, 1981).
In an outpatient psychiatric clinic of a large
health maintenance organization, approximately
30% of the clients attend only one session, despite
the fact that their prepaid plan entitles them to
more sessions (Rosenbaum, Hoyt, & Talmon,
1989). Similarly, at the Columbia Medical Plan,
a prepaid group practice that serves more than
20,000 enrollees, the mean number of visits per
episode is 4.9, and the rate of single-visit episodes
is 38% (Kessler, Steinwachs, & Hankin, 1980).
Although this might be viewed positively by administrators in terms of cost containment, UTs
actually raise costs considerably because they
tend to be chronic utilizers, with poor outcomes
that frequently require expensive, intensive treatment (e.g., emergency room visits).
What the foregoing data make evident is that
most patients attend only a few therapy sessions.
Garfield (1994) provided an eloquent illustration
of this state of affairs by describing a study whose
population included only well-educated persons
who made the choice to enter long-term therapy
in a private practice setting and "decided to commit a sizable amount of time and money in their
treatment" (DuBrin & Zastowny, 1988, p. 393).
Notwithstanding, 13% failed to return after intake
and 28% terminated unilaterally by the eighth
session, for an overall UT rate of 41%.
Because 20 to 57% of patients do not return
after the first visit and 37 to 45% attend only one
or two sessions (Ciarlo, 1979; Hester & Rudestam, 1975; Pekarik, 1983a), the early phase of
psychotherapy seems crucial for continuation, as
UT rates level out after that (Baekeland & Lundwall, 1975; Pollack, Mordecai, & Gumpert,
1992). In a study where new intake procedures
reduced UT rates from 54 to 19% in a CMHC,
the authors reported that UT rates dropped sig-

nificantly when patients attended three or more

sessions (Salta & Buick, 1989). Patients appear
to decide whether to return at the end of the intake
interview (Anderson, Hogg, & Magoon, 1987),
a finding supported in a study that compared preand post-first session expectations of premature
terminators and continuers. Although the two
groups' pre-session expectations did not differ,
significant differences in post-session expectations emerged. UTs were less likely to consider
counseling helpful and showed less positive attitudes about returning (Gunzburger, Henggeler,
& Watson, 1985).
UT Predictors
Administrative variables. Tune spent on a waiting list before and after intake is one of the variables studied hi the UT literature. One review
concluded that delay in assigning patients to therapists is associated with dropping out (Baekeland
& Lund wall, 1975); some studies reveal no relationship, however (Anderson et al., 1987;
Freund, Russell, & Schweitzer, 1991). Although
transfer from one clinician to another has been
associated with UT (Tantam & Klerman, 1979),
another study showed that returning after intake
to a different counselor was related to lower UT
rates than continuing with the same intake therapist (Krauskopf, Baumgardner, & Mandracchia,
1981). Similarly, length of intake interview was
positively related to continuation hi one study
(Tryon, 1989a) and to UT hi another (Rodolfa,
Rapaport, & Lee, 1983). In a university counseling center sample, number of days from intake
interview to first session did not differentiate returners and nonreturners, although number of
days between intake and receipt of a letter or
telephone call to set up the first appointment did
(Rodolfa et al., 1983). Telephone reminders of
appointments have been specifically tested and
reported to reduce UT rates from 32 to 11% in a
CMHC (Turner & Vemon, 1976).
These inconsistent findings reflect recurrent
methodological problems related to sampling,
lack of cross-validation, differential case assignment, and especially definition of UT. In exploring predictors of UT, attempted replications frequently fail, and differences between UTs and
completers, when they emerge, are generally
small (Beck et al., 1987; Garfield, 1986; Wierzbicki & Pekarik, 1993).
Client variables. Patient age has variously been
found to be related (in 31.4% of studies) and

125

B. F. Reis & L. G. Brown

unrelated (in 68.6%) to UT (Baekeland & Lundwall, 1975). Aside from methodological differences, conflicting results are attributable to other
patient characteristics that contribute more to the
variance of UT than age. This was evident in a
study that investigated several client, therapist,
and administrative variables in relation to counseling duration among 469 college studies. Results revealed that the six variables studied contributed only 23% of the total variance. Although
there was a tendency for duration to lengthen with
age, this variable accounted for less than 4% of
the variance (Jenkins, Fuqua, & Blum, 1986).
Client gender and marital status are equally
inconsistent predictors. Gender predicted UT in
44% of 29 investigations, while it bore no significant relationship in the remaining studies. Social stability (occupational, residential, marital),
in the same fashion, was associated with continuation in only half of the studies assessing its predictive value (Baekeland & Lundwall, 1975).
In addition to gender, age, and social stability,
several other client variables have produced conflicting and inconclusive results. Diagnosis,
symptom level, presenting problem, and previous
experience with therapy have variously been associated with continuation in some studies and with
UT in others (Baekeland & Lundwall, 1975; Garfield, 1994).
Referral source and alcohol or drug abuse seem
to bear some relationship to UT. In his report of a
drastic reduction of UT rates in a large psychiatric
service when the clinic changed its orientation from
long-term psychodynamic psychotherapy to a shortterm approach, Straker (1968) identified type of
referral as the strongest predictor of UT prior to the
reform. Self-referrals unilaterally terminated less
often than did involuntary clients. This finding was
replicated in a psychodynamically oriented outpatient clinic, where system referrals, as opposed to
self-referrals, distinguished UTs from continuers
(Richmond, 1992). Analyses of the files of 175
patients at a CMHC indicated mat of numerous
demographic and clinical variables, unemployment,
and alcohol and substance abuse were the only predictors of appointment noncompliance (Dubinsky,
1986). Distinct utilization patterns for substance
abusers were found in another CMHC sample of
144 patients. These patients missed more appointments, stayed in treatment for shorter periods of
time, and displaced higher UT rates than did patients without substance abuse problems (Ford,
Snowden, & Walser, 1991).

126

Finally, researchers have also analyzed the

effects of personality characteristics. Both counseling readiness and psychological mindedness
predicted continuation (Cartwright, Lloyd, &
Wicklund, 1980; Heilbrun, 1982), and nonpsychological mindedness has been associated with
UT (McCallum, Piper, & Joyce, 1992). A review
of the literature revealed the latter to be associated
with UT in 92% of the studies analyzed (Baekeland & Lundwall, 1975). Other traits, such as
high novelty-seeking and impulsiveness (Wingerson et al., 1993), low frustration tolerance (Frayn,
1992), poor motivation, and poor introspection abilities have been associated with UT (Baekeland &
Lundwall, 1975). In addition, UK more defensive
the patient is, the greater die likelihood of UT (Galliger, 1953; Taulbee, 1958; Zplik & Hollon, I960),
although one study found this relationship significant only for females (Heilbrun, 1982).
Clients who are involuntary referrals, substance abusers, or diagnosed with personality
characteristics associated with UT are rarely avid
consumers of psychotherapy. When in treatment,
they are likely to be considered resistant, as they
tend to experience therapy as unnecessary and
intrusive. When a therapist fails to acknowledge
die client's perspective, a vicious cycle materializes wherein die therapist's attempts to treat are
met with increasing disengagement or withdrawal. Successful treatment requires some degree of perspective convergence, and if die patient's condition precludes movement toward the
therapist's position, it is incumbent upon the therapist to assess her or his flexibility to acknowledge and validate die patient's perspective.
Therapist variables. Research exploring therapists' characteristics, primarily addressing gender
and level of experience, permits no firm conclusions. Results variously indicate mat male therapists face higher attrition rates than do females
(Betz & Shullman, 1979), that female therapists
tend to lose more patients (Epperson, 1981), and
that therapist gender bears no effect whatsoever
on UT (Jenkins et al., 1986; Krauskopf et al.,
1981;Rodolfaetal., 1983). Several findings suggest the potentially interactive nature of therapist
gender on termination status. Variables such as
dominance and autonomy in therapist and client,
respectively, mediated relationships between gender and UT (Baekeland & Lundwall, 1975).
Generally, studies reveal an inverse relationship between therapist experience level and UT
(Baekeland & Lundwall, 1975; Rodolfa et al.,

Psychotherapy Dropouts
1983; Tyson & Reder, 1979), but the literature
is far from conclusive. While a retrospective
study of 595 patient files at a rural CMHC indicated fewer UTs for more experienced psychotherapists (Scogin, Belon, & Malone, 1986), two
university-based investigations yielded no significant effects (Jenkins et al., 1986; Krauskopf
et al., 1981). In a meta-analysis of 125 studies
of UT no significant effect sizes were reported
for any of the therapist variables investigated,
including experience (Wierzbicki & Pekarik,
1993).
Interpersonal dyadic variables. Apparently,
there are factors interacting with therapist level
of experience. For example, while experience
level did not differentiate return rates after intake
of 539 college students, agreement between the
parties on the definition of the problem as educational, vocational, or personal did. When there
was agreement, 83.6% returned versus 72.9%
when there was no agreement, a difference that
was highly significant (Krauskopf et al., 1981).
A study of 533 clients and 34 clinicians at a university counseling center supported these findings
and shed further light on potential second-order
factors mitigating the effect of experience level
on UT (Epperson, Bushway, & Warman, 1983).
This investigation revealed a main effect of counselor recognition of client's definition of problem
on termination status as well as an intriguing interaction between problem recognition and counselor experience. When problem recognition was
present, trainees experienced more UT than did
the more experienced counselors (27% vs. 17%).
When problem recognition was absent, however,
higher UT rates occurred for experienced counselors (59% vs. 32%). Problem recognition is paramount for experienced therapists. For less experienced therapists, however, lack of problem
recognition (perspective divergence) does not
produce comparably high UT rates. Perhaps when
inexperienced therapists fail to acknowledge the
patient's perspective, therapist-client similarity
plays a compensatory role and helps avoid some
UTs. Inexperienced trainees working with clients
whose perspectives they do not share may concentrate on developing rapport and may benefit by
similarity to their clients (in age and trainee or
novice status), while experienced counselors who
"move more rapidly with clients" (Epperson et
al., 1983, p. 314) may alienate clients whose
perspectives differ, resulting in greater attrition
for the latter.

Patient-therapist similarity may explain other

conflicting results regarding therapist experience
and UT. While therapist experience was associated with UT in a rural CMHC (Scogin et al.,
1986), the relationship did not appear in university clinics (Jenkins et al., 1986; Krauskopf et
al., 1981). Arguably, both in terms of age and
SES, therapists in university clinics may be more
similar to their patients than CMHC therapists are
to theirs.
The significant relationship between patienttherapist congruence (agreement) on the nature
of the problem and UT rates (Epperson et al.,
1983; Krauskopf et al., 1981) has been replicated
by a cross-validated study in which some variables were modified. These included the nature,
structure, and brevity of the counseling program,
age and education of clients, and experience of
therapists. Therapists were significantly more accurate (according to clients' descriptions) in identifying clients' problems when working with completers than when working with UTs (Pekarik,
1988). Similarly, in a study of 33 therapy dyads
at a university counseling center, when therapist's
and patient's attributions of the cause of the problem were congruent, the incidence of UT was
significantly lower (Tracey, 1988).
The degree to which patient and therapist follow each other harmoniously and the perceived
relevance of their communications have also been
used to compare UTs and continuers. Results
have shown that UT dyads display lower levels
of topic determination (topic initiations followed
by the other participant) than continuing ones
(Tracey, 1986). Content analyses (aimed at defining similar, congruent, or comparable views of
the patient's presenting problem, need for therapy, etc.) of the first interview of 32 UTs and 32
continuers revealed that clinicians were significantly more incongruent with UTs than with continuers. In addition, clinician interventions were
more irrelevant to the expectations of UTs than
to those of continuers (Duehn & Proctor, 1977).
Clearly, the recurrent theme arising from these
investigations is that when perspective divergence
occurs in the therapy dyad, UT rates increase.
Perspective Divergence and UT
Socioeconomic Status. One of the variables
most consistently associated with UT is SES. Regardless of the sample stratification method used
(e.g., diagnosis, ethnicity, etc.), numerous investigations have verified the greater likelihood of

127

B. F. Reis & L. G. Brown

low-SES patients to terminate unilaterally (e.g.,
Hillis, Alexander, & Eagles, 1993). Their findings have been reflected in reviews of studies
conducted primarily in psychoanalytically oriented clinics (Baekeland & Lundwall, 1975) as
well as in more recent reviews and meta-analyses
summarizing findings from studies carried out in
settings with several different theoretical orientations (Garfield, 1986; Wierzbicki & Pekarik,
1993). In 1977, Garfield contended that "social
class is probably the most useful predictor of continuation of psychotherapy" (p. 485).
This phenomenon has historically been attributed to SES-related educational disadvantages resulting in reduced psychological mindedness and
verbal skills as well as limited ability to abstract
and fantasize (Baum & Felzer, 1964; Brill & Storrow, 1960), fundamental requirements of many
therapeutic approaches. Furthermore, these patients tend not to "anticipate taking an active role
in [their] own treatment and [are] not likely to
see talking as curative" (Heitler, 1976, p. 342;
Hoehn-Saric et al., 1964). Quite predictably,
their relative lack of sophistication with, and information about psychological treatments, in conjunction with distinct values and lifestyles,
clashes with therapists' assumptions and expectations, especially those stemming from more traditional, expressive orientations (Heitler, 1976).
Stated differently, low-SES clients and their therapists tend to have markedly divergent perspectives.
To the extent that psychotherapy departs from a
medical format, low-SES patients' advice-seeking
and preferences for brief, symptom-oriented
cures result in unrealistic (divergent), unmet expectations (Hoehn-Saric et al., 1964; Hollingshead & Redlich, 1958; Overall & Aronson,
1963). In his 1994 review of the literature on
client variables related to UT, Garfield reported a
"frequent but not invariant" relationship between
SES and length of stay (p. 199). This author pondered that underlying mis relationship may be
other factors, such as the interaction between lowSES patients' expectations and attributes and
middle-class therapists' own values and attitudes.
This is consistent with Acosta's (1979) argument that one of the reasons for the underutilization of mental health services by low-SES clientele is that the mental health system is .biased in
favor of higher SES patients. According to
Acosta, therapists feel disinterested in or frustrated by working with low-income patients and

128

make treatment decisions that are not compatible

with these clients' expectations. Wierzbicki and
Pekarik's (1993) meta-analysis indicated that univariate relationships between SES and UT disappear when multivariate analyses are performed
using both social class and expectations, in this
case, duration expectations. In other words,
rather than viewing the SES phenomenon as a
function of deficits in the client, it makes more
sense to view it as an interpersonal phenomenon.
Client and therapist both approach the therapeutic
enterprise with a whole host of expectations
which, if not met, are likely to result in a less
than optimal experience at high risk for UT.
Ethnicity. Although race and ethnicity tend to
correlate with SES, results from this area are a
little less clear than are those regarding SES. Despite some mixed results (Garfield, 1994) and
studies where no relationship emerges (Sledge et
al., 1990; Stabler & Eisenman, 1987), ethnicity
has generally been a strong predictor of UT. Racial status emerged as the only variable, apart
from education and income, to produce significant effect sizes on UT in a meta-analysis conducted by Wierzbicki and Pekarik (1993). An
investigation of 17 CMHCs revealed that African
Americans not only attended significantly fewer
sessions than did Whites, but also terminated therapy after the intake session with greater frequency
(Sue, McKinney, & Allen, 1976). African
Americans are more likely to terminate unilaterally and to attend fewer sessions than are Whites
(Greenspan & Kulish, 1985; Rosenthal & Frank,
1958; Yamamoto, James, & Palley, 1968). UT
rates for non-White clients (50% for African
Americans, Native Americans, and Asian Americans and 42% for Chicanes) are significantly
higher than the 30% UT rate for Whites (Sue,
1977).
Second-order factors appear to influence the
relationship between ethnicity and UT. An interesting study at a CMHC verified that although
different patterns of utilization, diagnosis, and
type of personnel seen characterized minority clients when compared to majority clients, none of
these variables correlated significantly with UT
rates. After partialling out SES (the only significant correlate), all minority groups except Chicanos were more likely to terminate unilaterally
than Anglos. The author suggested that the higher
UT rates among minorities may be a function of
a therapist's inability to respond to the divergent
expectations and needs of ethnic minority clients

Psychotherapy Dropouts
(Sue, 1977). This suggestion is supported by data
indicating that therapists high in ethnocentrism
are more likely to lose their patients than are less
ethnocentric clinicians (Baekeland & Lundwall,
1975). In corroboration, "negative attitude
toward therapist" and "no benefit from therapy"
were the main reasons provided by low income,
ethnically diverse patients for their unilateral termination of psychotherapy (Acosta, 1980, p.
439).
Even though racial status, income, and education are strongly related to UT, their mean effect
size was only of moderate magnitude, ranging
from .23 to .37 in Wierzbicki and Pekarik's
(1993, p. 193) meta-analysis. These authors concluded that "more complex variables, such as client's intentions and expectations and clienttherapist interactions" may be more useful
because they are "far more powerfully related to
dropout than simple client and therapist variables"
(p. 194).
Minimizing Perspective Divergence
Matching studies have evaluated the effects of
maximizing similarity (or convergence) and minimizing divergence within the therapeutic dyad.
The rationale is that outcomes will improve and
there will be fewer UTs when clients are offered
types of treatment and are seen by the type of
therapist best suited to (compatible with, not divergent from) their specific needs. Nine of the 14
studies reviewed by Luborsky, Chandler, Auerbach, Cohen, and Bachrach (1971) showed a positive relationship between outcome and similarity
of patient and therapist. Although this line of
research has been considered promising (Luborsky et al., 1980), systematic studies are still rare.
Some studies have attempted to identify optimal
matches between specific patient characteristics
(e.g., diagnosis) and types of treatments (Piper,
Azim, McCallum, & Joyce, 1990; Stotsky et al.,
1991). Greater attention, however, has been dedicated to potentially optimal combinations of patients and therapists in terms of sociodemographic
variables, particularly ethnicity.
Sociodemographic variables. Culture-compatible
approaches have proved effective in increasing
service utilization of CMHC patients (e.g., Flaskerud, 1986). UT predictors were examined in
1,746 Asian clients in several CMHCs. Results
revealed that client-therapist language and ethnic
matches significantly increased the number of sessions attended. No other variable produced sig-

nificant effects (Flaskerud & Liu, 1991). In spite

of a possible confounding of level of functioning at
admission (a greater number of higher functioning
patients assigned to the matched condition), bom
gender and ethnic matches were significantly associated with reduced UT and increased treatment
duration in another CMHC investigation. This study
found that gender and ethnic matches were more
important for Asian American women than for
Asian American men, White American women, or
White American men (Fujino, Okazaki, &
Young, 1994).
Despite a few negative findings (e.g., O'Sullivan, Peterson, Cox, & Kirkeby, 1989) and the
relatively small number of studies addressing the
effects of matching, evidence in favor of ethnic
matches has led some reviewers to contend that
continuing in therapy appears to be "consistently
and negatively affected when the therapist and the
client come from different backgrounds [italics
ours]" (Beutler, Machado, & Neufeldt, 1994, p.
234). More specifically, UT rates tend to increase
among ethnic minority patients seen by White
therapists.
We believe that different backgrounds are only
detrimental to the therapeutic relationship to the
extent that they engender perspective divergence.
Studies such as Beutler et al.'s (1994) and Fujino
et al.'s (1994) raise an even more interesting possibility. It is conceivable that the greater the distance from the majority, or the degree of oppression, the greater the relevance and deleterious
effects of perspective divergence on treatment. If
two White males disagree, it is only a disagreement; whereas if a White male and Asian female
disagree, the disagreement is more likely to be
considered by the therapist part of the problem
to be resolved. Further, the Asian female may
experience the divergence as a message of devaluation and a reason for shame.
Working alliance. The most relevant point suggested by matching research is the unequivocal
importance of the quality of the human interaction
in the therapeutic encounter. It constitutes the
most decisive component of clients' decisions regarding continuation. Thus, "the crucial predictive factors [for termination status] may not
be sufficiently apparent until the patient and the
therapist have had a chance to interact" (Luborsky
et al., 1980, p. 480). Research addressing interactional factors, such as likability of patients and
therapists, therapists' ability to understand clients, perceived helpfulness and dedication of

129

B. F. Reis & L. G. Brown

therapists, and quality of the therapeutic relationship, supports this contention. Of particular relevance are findings from investigations of the
working alliance, patient and therapist satisfaction, and congruence of expectations.
Construed as a multidimensional phenomenon,
the working alliance involves the affective bond
between patient and therapist, the patient's capacity to work purposefully in therapy, and patienttherapist agreement on the goals and tasks of the
treatment (Gaston, 1990). The helping alliances
of "established therapeutic dyads" (those with at
least two sessions) were compared in a study of
individual therapy in which patients later terminated either unilaterally or in agreement with the
therapist (Tryon & Kane, 1990, p. 234). The
quality of the helping alliances of UTs was poorer
man that of appropriate terminators. Interestingly, counselors' ratings did not differentiate terminators; it was the patient's perception of the
quality of the alliance, not the therapist's, that
predicted UT (Tryon & Kane, 1990).
Intake interviewers with high attrition are described by their clients as more passive and less
understanding. Furthermore, UTs experience a
weaker alliance, like their intake clinicians less,
and feel less well-liked and less respected by them
(Mohl, Martinez, Ticknor, Huang, & Cordell,
1991). A series of studies by Tryon (1986,1989a,
1989b, 1990) revealed that "high engaging" therapists (determined by the percentage of clients
returning to them for more than one session) conduct longer interviews and are rated by their clients as more understanding. Further, counselor
desire to see the client, client-rated "counselor
identification of concerns for which the client did
not seek help initially," and counselor "teaching
clients about their problems" (Tryon, 1990, p.
249) were all associated with return for a second
interview. While these may initially seem contradictory to results indicating that convergent perspectives reduce UT, upon reflection they are
quite consistent. What therapists appear to be doing in Tryon's study is elaborating on what clients
have saidnot contradicting or in any way invalidating it.
A factor analysis of variables differentiating
UTs from continuers in a CMHC after the first
session yielded four factors for the continuers.
Two of these seem to tap the same order of interpersonal phenomena described above. "Collaborative Involvement," consisting predominantly of

130

process variables, referred to "a sense of collaboration and mutual involvement" between the parties and the establishment of a relationship. The
second factor, "Patient Satisfaction with Intimate
Therapist," included "a serious patient working
with a therapist described as being close" and the
fulfillment of the patient's expectations of finding
out what was wrong (Fiester & Rudestam, 1975,
p. 534).
Satisfaction. Dissatisfaction with services or
therapists is frequently mentioned by UTs as their
reason for quitting (Acosta, 1980; DuBrin & Zastowny, 1988; Gill, Singh, & Shanna, 1990; Pekarik, 1983b, 1992). UTs' levels of satisfaction
with therapy or therapist tend to be significantly
lower than are continuers' or completers'
(McNeill, May, & Lee, 1987; Papach-Goodsitt,
1986; Zisook, Hammond, Jaffe, & Gammon,
1978).
Expectations. Satisfaction has been repeatedly
associated with confirmed expectations toward
treatment (Goin, Yamamoto, & Silverman, 1965;
Sabourin, Gendreau, & Frenette, 1987; Silverman & Beech, 1979). Unconfirmed expectations have consistently emerged in review of factors bearing a systematic relationship with UT
(Garfield, 1994; Mennicke, Lent, & Burgoyne,
1988). They were associated with UT in 100%
of the studies reviewed by Baekeland and Lundwall (1975).
The expectations of 15 UTs who terminated on
or before the fourth session were compared to
those of 30 continuers at a university clinic. While
therapist empathy levels, warmth, genuineness,
and level of activity did not differentiate the two
groups, UTs were less likely than continuers to
report that the first session fulfilled their expectations (Gunzburger et al., 1985). Consistent results
were provided by studies targeting specific subsets of the general outpatient clinical population.
Reasons for withdrawing from treatment of 15
obsessive-compulsive UTs were compared to
those of 15 age- and diagnosis-matched successful completers. Besides being less symptomatic,
more critical of the therapist, and experiencing
less anxiety in carrying out homework assignments, UTs reported more incongruent treatment
expectations than did completers (Hansen, Hoogduin, Schaap, & Haan, 1992). Expectations were
significantly related to continuing in a sample of
147 depressed women, of whom 34 were classified UT and 9 did not even attend the first session

Psychotherapy Dropouts
(refusers). Completers endorsed expectations
congruent with the treatment rationale significantly more often than did UTs or refusers
(Rabin, Kaslow, & Rehm, 1985). Similarly,
lower SES patients indicated before their first interview how active, passive, or supportive they
anticipated the therapist would be and the extent
to which they anticipated that their intake clinician would focus on organic or emotional problems. Responses were compared to their perceptions of the first interview on the same
dimensions, provided immediately after the intake. Discrepancies between pre-intake expectations and post-intake perceptions were significantly greater in the nonreturn group than in the
return group (Overall & Aronson, 1963).
Client likability. Perspective divergence comprises a process variable that seems to work recursively. Just as divergence interferes with a patient's perseverance and willingness to continue
in therapy, it affects a therapist's ability to relate
to the patient optimally. In perspective-divergent
treatment dyads, patients are less likely to be attractive for therapists, and this decreases the likelihood of a successful encounter. Therapists are
less likely to feel congenial toward clients who
do not want or do not understand what they (therapists) have to offer. Similarly, clients are unlikely
to feel congenial toward therapists when they feel
embarrassed or ashamed because of lack of familiarity with the rules of the therapy enterprise.
The positive role played by patients' likability has
been reported both for outcomes (e.g., Staples,
Sloane, & Whipple, 1976) and for termination
status (Lothstein, 1978).
Client attractiveness is one of the components
of the concept of engagement in therapy developed by Tryon(1989a, 1990,1992). Her research
revealed that, besides promoting patient return
for a second session, an interview is engaging
when (a) both patient and therapist describe it as
deep and valuable, (b) patients are educated about
their problems and behaviors by therapist, (c) duration is longer, and (d) clients are rated as attractive by their therapists. Data also indicated that
likable clients elicited a "warmer, friendlier reaction from the therapist" (Tryon, 1992, p. 311)
and agreed with therapists about concerns and
desired course of action. Therapists of likable
patients indicated a greater understanding of the
patients' feelings, saw them as more motivated,
and were more confident that the client would

work out his or her problems than therapists of

less likable patients (Tryon, 1992).
To the extent that low-SES patients tend to
present high levels of incongruent expectations of
treatment vis-a-vis their therapists' and behave in
ways that are challenging to therapists, their levels of satisfaction with treatment, likability, and
ability to form a productive alliance are at risk.
This brews perspective divergence. In our view,
this explains the overwhelmingly "frequent but
not invariant" (Garfield, 1994, p. 199) relationship between SES and length of stay aforementioned.
Pretreatment preparation. The role played by
divergent perspectives in expectations of therapy
has been demonstrated not only by investigations
that assess their direct impact on treatment continuation but also by experiments that manipulate
client expectations in order to obtain a better fit
between patients' attitudes and the realities of the
therapeutic process. Such manipulations employ
a variety of different procedures, including interviews, films, audiotapes, videotapes, and brochures. Essentially, they teach prospective clients
about the general characteristics of psychotherapy,
describe and explain expected patient and therapist
behaviors, and describe certain phenomena mat
may occur (e.g., negative feelings toward therapist)
with suggestions about dealing with them.
Prepared patients exhibit decreased approvalseeking expectations (Talbot, 1981), are more attractive to their therapists, display increased
motivation to begin treatment and increased expectations of improvement, and report a better
understanding of the therapy process and their
role in it than nonprepared patients (Strupp &
Bloxom, 1973). These patients also develop attitudes conducive to involvement in the therapy
process, including increased willingness to selfdisclose, to discuss problems, and to be assertive
and direct with the therapist. Furthermore, they
appear accepting of the concept that talking about
problems is helpful (Acosta, Yamamoto, Evans,
& Skilbeck, 1983).
When compared to controls, pretrained clients
display more desirable in-therapy behavior
(Hoehn-Saric et al., 1964; Strupp & Bloxom,
1973), such as higher levels of self-exploration
and more dependable, self-initiated collaborative
efforts of self-exploration; greater readiness in
initiating communications in group therapy;
higher frequency and duration of communica-

131

B. F. Reis & L. G. Brown

tions; and higher frequency of self-initiated communications (Heitler, 1973). In addition, these
patients compared to nonprepared clients are evaluated as significantly more attractive by their therapists, receive higher ratings of involvement, are
seen as closer to therapists' ideals of model patients (Heitler, 1973), and are described as better
or more preferred patients by therapists (Larsen,
Nguyen, Green, & Attkisson, 1983).
Prepared clients develop better therapeutic relationships as described by their therapists (Lawe,
Home, & Taylor, 1983) and receive more favorable therapist ratings of ease in establishing and
maintaining the therapeutic relationship than unprepared clients (Hoehn-Saric et al., 1964). Finally, these patients see their therapists as more
interested, respectful, and accepting (Lambert &
Lambert, 1984); they report greater satisfaction
(Strupp & Bloxom, 1973); and they develop more
accurate (convergent with therapist's) expectations for therapy (Lambert & Lambert, 1984)
when compared to controls.
In view of the positive effects of preparation
techniques on the process of therapy, it is not
surprising that these strategies also affect treatment continuation. Several studies have indicated
that, compared to controls, prepared patients
complete therapy in higher numbers, display
higher attendance rates, and are less likely to miss
appointments or terminate unilaterally (Berry,
1990; Hoehn-Saric et al., 1964; Lambert & Lambert, 1984; Larsen etal., 1983; Lawe etal., 1983;
Talbot, 1981; Warren & Rice, 1972). Although
some studies have not found significant differences on some of the target variables (e.g., Zwick
& Attkisson, 1984, 1985), many investigators
have expressed their astonishment that formal
pretreatment preparation is rather rare (Cheng,
1991; Gomes-Schwartz, 1978; Hansen et al.,
1992; Klein & Carroll, 1986; Ravndal & Vaglum, 1992).
Summary and Conclusions
Therapy UTs pose a pervasive problem challenging professionals involved with the delivery
of mental health services for all types of patients
in all types of settings30 to 60% terminate
treatment unilaterally. Research historically approached this problem in terms of administrative,
client, and therapist variables. The strongest antidote to UT administratively appears to be appointment reminders.

132

Due to methodological problems such as small

and nonequivalent samples, uncontrolled differential case assignment, lack of cross-validations,
and especially, inconsistent definitions of UT
across studies, the literature on client and therapist variables is highly inconsistent, results are
difficult to reconcile, and conclusions are virtually
impossible to reach. Nevertheless, SES and ethnicity have consistently been found to predict UT.
While neither is amenable to change, treatment
will benefit from acknowledging these patienttherapist differences and the perspective divergence they create.
Exploration of aspects such as patient-therapist
congruence in their views of the problem, the
degree to which the parties are able harmoniously
to follow each other, and the perceived relevance
of their communications have demonstrated the
role played by interpersonal variables in UT.
Studies investigating the effects of matching patients and therapists by SES and ethnic backgrounds have suggested that the multiple factors
accounting for UT are more interactive than
static, more interpersonal than intrapsychic.
Hence, research efforts have increasingly addressed strength of the working alliance, client
satisfaction, and congruence between patients'
and therapists' expectations of the therapy process
and of each others' behavior. Divergent expectations, the establishment of a weak working alliance, and patient dissatisfaction increase the
chance of UT. Pretherapy preparation procedures
that provide clients with information and address
their expectations have reduced UT rates.
We hope this review of the UT literature will
remind practicing clinicians that patients are
likely to remain and participate productively in a
process they know about. The primary lesson to
be learned from the UT literature is that in order
to reduce UT rates, clinicians need to acknowledge the divergent perspectives that so frequently
estrange them from their clients, dooming to failure the enterprise that brings them together for a
given period of time. This is not to suggest that
one's professional judgment need be suspended,
nor that clients should dictate their treatment
plans. Clearly, ethicolegal guidelines cannot be
abandoned. Nevertheless, merely by acknowledging divergent perspectives and expectations,
clinicians can mindfully decide whether to address them directly. This decision is partly determined by theoretical orientation and partly by

Psychotherapy Dropouts
personal style. Whether it be SES, ethnicity, language, or issues related to the therapeutic enterprise (e.g., the etiology of or solution for problems) that differentiate them from their patients,
therapists must acknowledge perspective divergence and take to heart the idea that therapy is a
collaborative endeavor. Openness to modifying
their perspectives, as they expect patients to modify theirs, will enhance treatment and reduce UT.
In summary, though we cannot change many
of the factors involved with UT (e.g., ethnicity,
gender, SES), research suggests clinicians can
significantly reduce UT by implementing some
practical strategies. Although many psychotherapists have traditionally resisted appointment reminders, perhaps because no-shows and cancellations were grist for the interpretive mill, for
therapists whose orientation does not preclude appointment reminders, this seems an effective way
to reduce UTs. More importantly, putting into
practice some form of pretreatment preparation
procedures, and implementing a treatment negotiation process in the initial phase of treatment are
all likely to enhance engagement and prevent UT.
Underlying these practices, particularly the latter
two, is a genuine willingness on the part of the
therapist to view the client as a partner with
unique and legitimate perspectives on the treatment process.
Just as therapists expect clients to come in with
problems, they should expect them to bring different perspectives. Just as clinicians' training and
experience provide them with expertise about
treatment, clients' unique experiences provide
them expertise about their lives. UT is minimized
when perspective divergence is expected, recognized, acknowledged, and incorporated into the
process.
While many UTs leave having achieved their
goals, it is important to keep in mind that many
fail to return precisely because they did not get
what they wanted. When patient and therapist
differ about treatment dimensions, it is part of the
clinician's job to elicit and address the difference,
accept the client's perspective as understandable,
and then adapt the treatment plan so that the client
will engage in the process. Ultimately, the therapist may succeed in closing the perspective gap
so that the patient can accept the utility of the
clinician's perspective. This job requires the attitude and ability to bracket one's own perspective
and work around the patient's views. The ultimate

aim is to create a treatment culture maximally

suitable for patient and therapist to work together.
References
ACOSTA, F. X. (1979). Barriers between mental health services and Mexican Americans: An examination of a paradox. American Journal of Community Psychology, 7, 503520.
ACOSTA, F. X. (1980). Self-described reasons for premature
termination of psychotherapy by Mexican-American,
Black-American, and Anglo-American patients. Psychological Reports, 47, 435-443.
ACOSTA, F. X., YAMAMOTO, J., EVANS, L. A., & SKILBECK,
W. M. (1983). Preparing low-income Hispanic, Black, and
White patients for psychotherapy. Evaluation of a new orientation program. Journal of Clinical Psychology, 39,
872-877.
ANDERSON, T. R., HOGG, J. A., & MAGOON, T. M. (1987).
Length of time on a waiting list and attrition after intake.
Journal of Counseling Psychology, 34,93-95.
BAEKELAND, F., & LUNDWALL, L. (1975). Dropping out of
treatment: A critical review. Psychological Bulletin, 82,
738-783.
BAUM, O. E., & FELZER, S. B. (1964). Activity in initial
interviews with lower-class patients. Archives of General
Psychiatry, 10, 345-353.
BECK, N. C., LAMBERTI, I., GAMACHE, M., LAKE, E. A.,
FRAPS, C. L., MCREYNOLDS, W. T., REAVEN, N., NEISLER,
G. H., & DUNN, J. (1987). Situational factors and behavioral self-predictions in the identification of clients at high
risk to drop out of psychotherapy. Journal of Clinical Psychology, 43, 511-520.
BERRY, P. A. (1990). Efforts to determine termination in
psychotherapy. Dissertation Abstracts International, 51,
10B. (University Microfilms No. AAD91-06004)
BETZ, N. E., & SHULLMAN, S. L. (1979). Factors related to
client return rate following intake. Journal of Counseling
Psychology, 26, 542-545.
BEUTLER, L. E., MACHADO, P. P. P., & NEUFELDT, S. A.
(1994). Therapist variables. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior
change (4th ed., pp. 229-269). New York: John Wiley.
BRILL, N. Q., & STORROW, H. A. (1960). Social class and
psychiatric treatment. Archives of General Psychiatry, 3,
340-344.
BUDDEBERG, C. (1987). Does termination of psychotherapy
mean therapeutic failure? Praxis der Psychotherapie und
Psychosomatik, 32, 221-228.
CARPENTER, P. J., DEL GAUDIO, A. C., & MORROW, G. R.
(1979). Dropouts and terminators from a community mental
health center Their use of other psychiatric services. Psychiatric Quarterly, 51, 271-279.
CARTWRIGHT, R., LLOYD, S., & WICKLUND, J. (1980). Identifying early dropouts from psychotherapy. Psychotherapy:
Theory, Research, and Practice, 17, 263-267.
CHENG, L. Y. (1991). Sino-therapy: Is it necessary? Is it
possible? Bulletin of the Hong Kong Psychological Society,
26-27, 71-80.
CIARLO, J. A. (1979). Annual evaluation report for 1975 of
the Northwest Denver Mental Health Center. In C. Windle
(Ed.), Reporting program evaluations: Two sample community mental health center annual reports (pp. 17-85).

133

B. F. Reis & L. G. Brown

Rockville, MD: U.S. Department of Health, Education,
& Welfare.
DEROOATIS, L. R., & SPENCER, P. M. (1982). The brief symptom inventory: Administration, scoring and procedures
manual-1. (Available from L. R. Derogatis, Psychology
Department, Hahnemann University, Philadelphia, PA,
19102)
DUBINSKY, M. (1986). Predictors of appointment noncompliance in community mental health patients. Community
Mental Health Journal, 22, 142-146.
DuBRTN, J. R., & ZASTOWNY, T. R. (1988). Predicting early
attrition from psychotherapy: An analysis of a large private
practice cohort. Psychotherapy, 25, 393-408.
DUEHN, W. D., & PROCTOR, E. K. (1977). Initial clinical
interaction and premature discontinuance in treatment.
American Journal of Psychiatry, 47, 284-290.
ELUNGSON, A. G. (1990). Early premature termination from
a university counseling center A qualitative research study
(dropouts, terminator). Dissertation Abstracts International, 51, 05B. (University Microfilms No. AAD9028269)
EPPERSON, D. L. (1981). Counselor gender and early premature terminations from counseling: A replication and extension. Journal of Counseling Psychology, 28, 349-356.
EPPERSON, D. L., BUSHWAY, D. J., & WARMAN,R. E. (1983).
Client self-terminations after one counseling session: Effects of problem recognition, counselor gender, and counselor experience. Journal of Counseling Psychology, 30,
307-315.
FIBSTER, A. R., MAHRER, A. R., GIAMBRA, L. J., & ORMISTON, D. W. (1974). Shaping a clinic population: The dropout problem reconsidered. Community Mental Health Journal, 10, 173-179.
FIBSTER, A. R., & RUDEST AM, K. E. (1975). A multivariate
analysis of the early dropout process. Journal of Consulting
and Clinical Psychology, 43, 528-535.
FLASKERUD, J. H. (1986). The effects of culture-compatible
intervention on the utilization of mental health services
by minority clients. Community Mental Health Journal,
22, 127-141.
FLASKERUD, I. H., & Liu, P. Y. (1991). Effects of an Asian
client-therapist language, ethnicity and gender match on
utilization and outcome of therapy. Community Mental
Health Journal, 27, 31-42.
FORD, L., SNOWDEN, L. R., & WALSER, E. J. (1991). Outpatient mental health and the dual-diagnosis patient: Utilization of services and community adjustment. Evaluation and
Program Planning, 14, 291-298.
FRAYN, D. H. (1992). Assessment factors associated with
premature psychotherapy termination. American Journal of
Psychotherapy, 46, 250-261.
FREUND, R. D., RUSSELL, T. T., & SCHWEITZER, S. (1991).
Influence of length of delay between intake session and
initial counseling session on client perceptions of counselors and counseling outcomes. Journal of Counseling Psychology, 38, 3-8.
FUJINO, D. C., OKAZAKI, S., & YOUNG, K. (1994). AsianAmerican women in the mental health system: An examination of ethnic and gender match between therapist and client. Journal of Community Psychology, 22, 164-176.
GALUOER, J. J. (1953). The problem of escaping clients in
noudirective counseling. In W. Snyder (Ed.), Group report
of a program of research in psychotherapy (pp. 21-39).
State College, PA: Pennsylvania State College School of
Education.

134

GARFIELD, S. L. (1977). A note on the confounding of personality and social class characteristics in research on premature termination. Journal of Consulting and Clinical Psychology, 45, 483-485.
GARFIELD, S. L. (1986). Research on client variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp.
213-256). New York: John Wiley.
GARFIELD, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp.
190-228). New York: John Wiley.
GASTON, L. (1990). The concept of the alliance and its role
in psychotherapy: Theoretical and empirical considerations.
Psychotherapy, 27, 143-153.
GILL, H. P., Swan, G., & SHARMA, K. C. (1990). Study of
dropout from a psychiatric clinic of a general hospital.
Indian Journal of Psychiatry, 32, 152-158.
COIN, M., YAMAMOTO, J., & SILVERMAN, J. (1965). Therapy
congruent with class-linked expectations. Archives of General Psychiatry, 13, 133-137.
GOMES-SCHWARTZ, B. (1978). Effective ingredients in psychotherapy: Prediction of outcome from process variables. Journal of Consulting and Clinical Psychology, 46, 1023-1035.
GREENSPAN, M., & KULISH, N. M. (1985). Factors in premature termination in long term psychotherapy. Psychotherapy, 22, 75-82.
GUNZBUROER, D. W, HENGGELER, S. W, & WATSON, S. M.

(1985). Factors related to premature termination of counseling relationships. Journal of College Student Personnel,
26, 456-466.
HANSEN, A. N., HOOGDUTN, C. A., SCHAAN, C., & HAAN,
E-DE. (1992). Do drop-outs differ from successfully treated
obsessive-compulsives? Behaviour Research and Therapy,
30, 547-550.
HEILBRUN, A. B. (1982). Cognitive factors in early counseling
termination: Social insight and level of defensiveness. Journal of Counseling Psychology, 29, 29-38.
HEITLER, J. B. (1973). Preparation of lower-class patients for
expressive group psychotherapy. Journal of Consulting and
Clinical Psychology, 41, 251-260.
HEITLER, J. B. (1976). Preparatory techniques in initiating
expressive psychotherapy with lower-class, unsophisticated
patients. Psychological Bulletin, 83, 339-352.
HILUS, G., ALEXANDER, D. A., & EAGLES, J. M. (1993).
Premature termination of psychiatric contact. International
Journal of Social Psychiatry, 39, 100-107.
HOEHN-SARIC, R., FRANK, J. D., IMBER, S. D., NASH,
E. H., STONEN, A. R., &BATTLE, C. C. (1964). Systematic
preparation of patients for psychotherapyI. Effects on
therapy behavior and outcome. Journal of Psychiatric Research, 2, 267-281.
HOLUNGSHEAD, B., & REDLICH, F. C. (1958). Social class

and mental illness. New York: John Wiley.

HOWARD, K. I., KOPTA, S. M., KRAUSE, M. S., &ORUNSKY,
D. E. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41, 159-164.
JENKINS, S. J., FUQUA, D. R., & BLUM, C. R. (1986). Factors
related to duration of counseling in a university counseling
center. Psychological Reports, 58, 467-472.
KESSLER, L. G., STEINWACHS, D. M., & HANKIN, J. R.
(1980). Episodes of psychiatric utilization. Medical Care,
18, 1219-1227.
KLEIN, R. H., & CARROLL, R. A. (1986). Patient characteristics and attendance patterns in outpatient group psychother-

Psychotherapy Dropouts
apy. International Journal of Group Psychotherapy, 36,
115-132.
KRAUSKOPF, C. I., BAUMOARDNER, A., & MANDRACCHIA, S.
(1981). Return rate following intake revisited. Journal of
Counseling Psychology, 28, 519-521.
LAMBERT, R. G., & LAMBERT, M. I. (1984). The effects of
a role preparation for psychotherapy on immigrant clients
seeking mental health service in Hawaii. Journal of Community Psychology, 12, 263-275.
LARSEN,D.L., NGUYEN,T.D.,GREEN, R. S., & ATTKISSON,
C. C. (1983). Enhancing the utilization of outpatient mental
health services. Community Mental Health Journal, 19,
305-320.
LAWE, C. F., HORNE, A. M., &TAYLOR, S. V. (1983). Effects
of pretraining procedures for clients in counseling. Psychological Reports, 53, 327-334.
LOTHSTEIN, L. M. (1978). The group psychotherapy phenomenon revisited. American Journal of Psychiatry, 135, 14921495.
LUBORSKY, L., CHANDLER, M., AUERBACH, A. H., COHEN,
I., & BACHRACH, H. M. (1971). Factors influencing the
outcome of psychotherapy: A review of quantitative research. Psychological Bulletin, 75, 145-185.
LUBORSKY, L., MINTZ, I., AUERBACH, A., CRITS-CHRISTOPH,
P., BACHRACH, H., TODD, T., JOHNSON, M., COHEN, M.,
& O'BRIEN, C. P. (1980). Predicting the outcome of psychotherapy: Findings of the Peon psychotherapy project.
Archives of General Psychiatry, 37, 471-481.
LYONS, L. C., & WOODS, P. J. (1991). The efficacy of
rational-emotive therapy: A quantitative review of the outcome research. Clinical Psychology Review, 11, 357-369.
MAY, I. M. (1984). Number of sessions and psychotherapy
outcome: Impact on community mental health center services. Dissertation Abstracts International, 45,05B. (University Microfilms No. AAD84-17240)
McCALLUM, M., PIPER, W. E., & JOYCE, A. S. (1992). Dropping out from short-term group therapy. Psychotherapy,
29, 206-215.
McNEiLL, B. W., MAY, R. J., & LEE, V. E. (1987). Perceptions of counselor source characteristics by premature and
successful terminators. Journal of Counseling Psychology,
34, 86-89.
MENNKKE, S. A., LENT, R. W., &BURGOYNE, K. L. (1988).
Premature termination from university counseling centers:
A review. Journal of Counseling and Development, 66,
458-465.
MOHL, P. C., MARTINEZ, D., TICKNOR, C., HUANG, M., &
CORDBLL, L. (1991). Early dropouts from psychotherapy. The
Journal of Nervous and Mental Disease, 179, 478-481.
MORROW, G. R., DEL GAUDIO, A. C., & CARPENTER, P. J.
(1977). The dropout and the terminator A methodological
note on definitions. Journal of Clinical Psychology, 33,
867-869.
National Institute of Mental Health. (1981). Provisional data
on federally funded community mental health centers,
1978-1979. Report prepared by the Survey and Reports
Branch, Division of Biometry and Epidemiology. Washington, DC: U.S. Government Printing Office.
O'SuujvAN, M. J., PETERSON, P. D., Cox, G. B., & KraKEBY, J. (1989). Ethnic populations: Community mental
health services ten years later. American Journal of Community Psychology, 17, 17-30.
OVERALL, B., & ARONSON, H. (1963). Expectations of psychotherapy in patients of lower socioeconomic class. American Journal of Orthopsychiatry, 33, 421-430.

PAPACH-GooDsnr, L. J. (1986). Psychotherapy dropouts view

their treatment: A follow-up study (therapy outcome, premature termination, client self-reported outcome, consumer
satisfaction). Dissertation Abstracts International, 47, 016.
(University Microfilms No. AAD86-05536)
PEKARK, G. (1983a). Follow-up adjustment of outpatient
dropouts. American Journal of Orthopsychiatry, 53, 501511.
PEKARK, G. (1983b). Improvement in clients who have given
different reasons for dropping out of treatment. Journal of
Clinical Psychology, 39, 909-913.
PEKARK, G. (1985a). Coping with dropouts. Professional
Psychology: Research and Practice, 16, 114-123.
PEKARK, G. (1985b). The effects of employing different termination classification criteria in dropout research. Psychotherapy, 22, 87-91.
PEKARK, G. (1988). Relation of counselor identification of
client problem description to continuance in a behavioral
weight loss program. Journal of Counseling Psychology,
35, 66-70.
PEKARK, G. (1992). Relationship of clients' reasons for dropping out of treatment to outcome and satisfaction. Journal
of Clinical Psychology, 48, 91-98.
PIPER, W. E., AZIM, H. F. A., McCALLUM, M., & JOYCE,
A. S. (1990). Patient suitability and outcome in short-term
individual psychotherapy. Journal of Consulting and Clinical Psychology, 58, 475-481.
POLLACK, J., MORDECAI, E., & GUMPERT, P. (1992). Discontinuation from long-term individual psychodynamic psychotherapy. Psychotherapy Research, 2, 224-234.
RABIN, A. S., KASLOW, N. J., &REHM, L. P. (1985). Factors
influencing continuation in a behavioral therapy. Behavior
Research and Therapy, 23, 695-698.
RAVNDAL, E., & VAGLUM, P. (1992). Different intake procedures: The influence on treatment start and treatment response: A quasi-experimental study. Journal of Substance
Abuse Treatment, 9, 53-58.
RICHMOND, R. (1992). Discriminating variables among dropouts from a psychological training clinic. Professional Psychology Research and Practice, 23, 123-130.
RODOLFA, E. R., RAMPORT, R., & LEE, V. E. (1983). Variables
related to premature terminations in a university counseling
service. Journal of Counseling Psychology, 30, 87-90.
ROSENBAUM, R., HOYT, M. F., & TALMON, M. (1989). The
challenge of single-session therapies: Creating pivotal moments. In R. Wells & V. Giantelli (Eds.), The handbook
of brief therapies (pp. 165-189). New York: Plenum.
ROSENTHAL, D., & FRANK, J. D. (1958). The fate of psychiatric clinic outpatients assigned to psychotherapy. Journal of
Nervous and Mental Disease, 127, 330-343.
SABOURIN, S., GENDREAU, P., & FRENETTE, L. (1987). Le
niveau de satisfaction des cas d'abandon dans un Service
universitaire de psychologic. (The satisfaction level of
drop-out cases in a university psychology service). Canadian Journal of Behavioural Science, 19, 314-323.
SALTA, L., & Buioc, W. P. (1989). Impact of organizational
change on the intake, referral, and treatment of outpatients
at a community mental health center. Journal of Mental
Health Administration, 16, 71-79.
SCHWARTZ, D. M. (1991). Early termination from individual
psychotherapy: A follow-up study of the earliest-leaving
patients. Dissertation Abstracts International, 52, 056.
(University Microfilms No. AAD91-29062)
SCOGIN, F., BELON, H., & MALONE, M. (1986). Mental health
services in a rural clinic: A retrospective study of length of

135

B. F. Reis & L. G. Brawn

stay and premature termination in psychotherapy. Journal of
Rural Community Psychology, 7, 35-44.
SILVERMAN, W. H., & BEECH, R. P. (1979). Are dropouts,
dropouts1} Journal of Community Psychology, 7, 236-242.
SLEDGE, W. H., MORAS, K., HARTLEY, D., & LEVTNE, M.
(1990). Effect of time-limited psychotherapy on patient
dropout rates. American Journal of Psychiatry, 147,1341 1347.
STAHLER, G. J., & EISENMAN, R. (1987). Psychotherapy dropouts: Do they have poor psychological adjustment"! Bulletin
of the Psychonomic Society, 25, 198-200.
STAPLES, F. R., SLOANE, R. B., & Wmmjs, K. (1976).
Process and outcome in psychotherapy and behavior therapy. Journal of Consulting and Clinical Psychology, 44,
340-350.
STOTSKY, S. M., GLASS, D. R., SHEA, M. T., POXONIS,
P. A., COLLINS, J. F., ELKJN, I., WATKINS, J. T., IMBER,
S. D.,LEBER, W. R., MOYER, J., &OLTVERI,M. E. (1991).
Patient predictors of response to psychotherapy and pharmacotherapy: Findings in the NIMH treatment of depression collaborative research program. American Journal of
Psychiatry, 148, 997-1008.
STRAKER, M. (1968). Brief psychotherapy in an outpatient
clinic: Evolution and evaluation. American Journal of Psychiatry, 124, 105-112.
STRUFP, H. H., & BLOXOM, A. L. (1973). Preparing lowerclass patients for group psychotherapy: Development and
evaluation of a role-induction film. Journal of Consulting
and Clinical Psychology, 41, 373-384.
SUE, S. (1977). Community mental health services to minority
groups: Some optimism, some pessimism. American Psychologist, 32, 616-624.
SUE, S., McKiNNEY, H. L., & ALLEN, D. B. (1976). Predictors of the duration of therapy for clients in the community mental health system. Community Mental Health Journal, 12, 365-375.
TALBOT, B. E. (1981). Written preparation for psychotherapy
and its effects on patient expectations and premature termination. Dissertation Abstracts International, 43, 08B.
(University Microfilm No. AAD82-15997)
TAMTAM, D., & KLERMAN, G. (1979). Patient transfer from
one clinician to another and dropping out of outpatient
treatment. Social Psychiatry, 14, 107-113.
TAULBEE, E. S. (1958). Relationship between certain personality variables and continuation in psychotherapy. Journal
of Consulting Psychology, 22, 83-89.
TRACEY, T. J. (1986). Interactional correlates of premature
termination. Journal of Consulting and Clinical Psychology, 54, 784-788.
TRACEY, T. J. (1988). Relationship of responsibility attribution congruence to psychotherapy outcome. Journal of Social and Clinical Psychology, 7, 131-146.

136

TRYON, G. S. (1986). Client and counselor characteristics and

engagement in counseling. Journal of Counseling Psychology, 33,411-414.
TRYON, G. S. (1989a). A study of engagement and premature
termination in a university counseling center. Counseling
Psychology Quarterly, 2, 419-429.
TRYON, G. S. (198%). Study of variables related to client
engagement using practicum trainees and experienced clinicians. Psychotherapy, 26, 54-61.
TRYON, G. S. (1990). Session depth and smoothness in relation to the concept of engagement in counseling. Journal
of Counseling Psychology, 37, 248-253.
TRYON, G. S. (1992). Client attractiveness as related to the
concept of engagement in therapy. Counseling Psychology
Quarterly, 5, 307-314.
TRYON, G. S., & KANE, A. S. (1990). The helping alliance
and premature termination. Counseling Psychology Quarterly, 3, 233-238.
TURNER, A. J., & VERNON, J. C. (1976). Prompts to increase
attendance in a community mental health center. Journal
of Applied Behavior Analysis, 9, 173-181.
TYSON, R. L., & REDER, P. (1979). Aspects of the patient
intake process in a psychotherapy clinic. British Journal of
Medical Psychology, 52, 309-320.
WARREN, N. C., & RICE, L. N. (1972). Structuring and stabilizing of psychotherapy for low-prognosis clients. Journal
of Consulting and Clinical Psychology, 39, 173-181.
WIERZBICKI, M., & PEKARK, G. (1993). A meta-analysis of
psychotherapy dropout. Professional Psychology .-Research
and Practice, 24, 190-195.
WINGERSON, D., SULLIVAN, M., DAGER, S., FLICK, S.,
DUNNER, D., & ROY-BYRNE, P. (1993). Personality traits
and early discontinuation from clinical trials in anxious
patients. Journal of Clinical Psychopharmacology, 13,194197.
YAMAMOTO, J., JAMES, Q. C., &PALLEY, N. (1968). Cultural
problems in psychiatric therapy. Archives of General Psychiatry, 19, 45-49.
ZISOOK, S., HAMMOND, R., JAFFE, K. ,& GAMMON, E. (1978).
Outpatient requests, initial sessions, and attrition. International Journal of Psychiatry Medicine, 9, 339-350.
ZOUK, E. S., & HOLLON, T. N. (1960). Factors characteristic
of patients responsive to brief psychotherapy. American
Psychologist, 15, 287.
Zwrac, R., & ATTKISSON, C. C. (1984). The use of reception
checks in client pretherapy orientation research. Journal of
Clinical Psychology, 40, 446-452.
ZWICK, R., & ATTKISSON, C. C. (1985). Effectiveness of a
client pretherapy orientation videotape. Journal of Counseling Psychology, 32, 514-524.