Opting out

More often termed “dropping out” or, mainly by researchers, “attrition”. Used to refer to clients terminating therapy before a planned ending. I use the term “opting out” as I believe “dropping out” puts a rather disrespectful framework on this as 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, wise or not, to opt out of therapy. “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).

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.

Equally clearly, opting out can take many forms. The simplest aspect is when in how long a planned therapy it happens which is clearly a function of how many sessions have already happened and how many were planned and 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 o perhaps even a planned penultimate session are different from earlier opting out though that again partly relates to how many sessions were planned.

Then there is how termination happens. The most common form probably is simple termination of contact: 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 that session early pre-empting much or any discussion), attending and negotiating that it does seem appropriate to terminate then, attending and negotiating a farewell session or sessions but still terminating earlier than originally planned. Then there is not attending but communicating and explaining the decision.

Another issue, if there is some communication, is the reason 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 or general) is making things worse; life events and external issues making continuation difficult or impossible (financial issues including paying when therapy is private or insurance funded but insurance no longer paying).

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.

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 #

Acting out
Dropping out
Early termination
Survival analysis

Chapters #

Mainly addressed, but 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.

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