Often termed “dropping out” or, mainly by researchers, “attrition” or increasingly “early termination”. The term is used to refer to clients terminating therapy before a planned or agreed ending. I use the term “opting out” though I concede that “early termination” is neutral and accurate though perhaps it is too neutral.
I dislike “dropping out” because it puts a rather disrespectful framework on this: I can’t think of a situation in which there can be therapy and the client not have capacity to consent to that and hence have capacity to make a decision to opt out of that therapy, whether that is a wise choice or not. “Attrition” is clearly less pejorative but locates things in rather dehumanised, almost accidental frame of reference. To me the one term denigrates clients a bit and the other reduces them to passive cogs (too often how, mostly covertly, therapy research frames clients … and, perhaps increasingly, practitioners too). Though better than “attrition” I do think “early termination” is also minimising the client’s agency.
Details #
Clearly the idea has been around as long as the idea of therapies with planned durations have been around. However, it has grown in usage, if perhaps not in real exploration, with the rise of “outcome research”, “controlled trials” and the general commercialisation, commoditisation and industrialisation of therapy and therapy research. Ironically perhaps, I think it has also grown, over the last 30 or 40 years, with the offering of shorter therapies
Clearly, opting out can take many forms with hugely important qualitative and quantitative research approaches.
Probably the biggest challenge to qualitative research is that clients who have opted out of therapies are very likely to be less likely to opt in to research after the event (though, equally clearly, a probably smaller set may be highly motivated to talk about why they opted out. Of course, setting aside the rather obvious post-termination interview approach, there are rich qualitative research approaches looking at video, audio and transcript material from therapies where the client opted out where informed consent was given for such analyses.
How to define opting out: categories #
The next issue is definition. When therapies were long and open ended opting out is about a disagreement between client and therapist (or client and group, including the therapist/conductor if being group analytic) or in family therapies, where one family member opts out but others continue, it’s disagreement between one family member and the therapist and other members. I have never seen any research on that but I hope it exists. Of course, if one believes in the psychoanalytic unconscious, the issue of agreement gets a bit more complicated. I don’t think enough has been done to explore how a dyad or group see the balance of conscious and unconscious forces in termination decisions, agreed or not.
As therapies moved to fixed lengths the definition is easier though there is still the issue of client and therapist agreeing termination before the planned number of sessions is reached. Although some analytic therapists disagree, most of us also accept that there are times when a therapy terminates before the planned duration and both accept that this perhaps unfortunate, but external forces make it inevitable: serious illness, a move to keep a job or support a suddenly needy relative or very close friend. Collapse of funding is perhaps another common external reason.
Then there is how termination happens. The most abrupt and perhaps commonest form probably that the client doesn’t attend a planned session, makes no communication, doesn’t attend the next planned session (if one is offered) and doesn’t respond to attempts by the practitioner or service to make contact. However, other forms include the client attending and saying that s/he/they won’t attend any more sessions (plus or minus then leaving during that session, pre-empting more discussion). Then there is attending and negotiating that though the therapist may not entirely agree, the client is determined to finish (with or without some termination sessions agreed but still terminating earlier than originally planned. Then there is not attending but communicating and explaining the decision.
Then, if there is some communication, there are the reason or reasons given: feeling enough as been achieved (see “Good Enough Level (GEL)”), feeling therapy generally, or this particular therapy, is too hard for the gains made; feeling therapy (this particular one or any) makes things worse. And, as noted above, life events and external issues may be all or part of the reasons given.
Clearly many of these issues of classifying opting out overlap into clinical judgements and (ideally?) into qualitative and process research. My impression is tat the volume of such work on opting out is small.
Counting sessions #
So how should we treat the numbers of sessions attended when the client opted out? The simplest aspect is when in a planned therapy is how many sessions were attended and how many were planned: an apparently simple issue of two numbers. However, beware the seduction of numbers, it’s arguable that opting out after one session is importantly different from later opting out except perhaps in 2+1 or even 1+1 therapy plans. (If after just one session, was that session a first therapy session having had an earlier assessment, with that therapist or someone else, after how long a wait?) Equally, opting out of a planned final session or perhaps even a planned penultimate session are different from earlier opting out though that again partly relates to how many sessions were planned. Treating the number attended as a fraction of those offered can be oversimplifying things, perhaps importantly.
One final but small issue is whether the original plan included a plan for a follow-up meeting or review. How to classify not attending that?
All these details can be boring to record carefully and sometimes not easy to classify so it’s not surprising that the literature on opting out often has no detail other than perhaps when in the planned sessions it happened. However, our understanding of how therapy works, and sometimes doesn’t or harms, is diminished by not recording, and analysing, more detail about opting out.
Try also #
Chapters #
Mainly addressed, though fairly simply, in chapters 7 and 8.
Online resources #
Not yet. I hope to have shiny apps and Rblog entries exploring some of the quantitative ways to describe opting out.
Dates #
First created 15.viii.23, improved 28.x.26.
