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Practice Recommendations for Reducing Premature Termination in Therapy

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DOI: 10.1037/a0028291

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 Professional Psychology: Research and Practice © 2012 American Psychological Association
2012, Vol. 43, No. 4, 379 –387 0735-7028/12/$12.00 DOI: 10.1037/a0028291

Practice Recommendations for Reducing Premature Termination in Therapy

Joshua K. Swift Roger P. Greenberg

University of Alaska Anchorage State University of New York, Upstate Medical University

Jason L. Whipple Nina Kominiak

University of Alaska Fairbanks University of Alaska Anchorage

Premature termination from therapy is a significant problem frequently encountered by practicing

clinicians of all types. In fact, a recent meta-analytic review (J. K. Swift & R. P. Greenberg, 2012,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Psychology. doi:10.1037/a0028226) of 669 studies found that approximately 20% of all clients drop out
of treatment prematurely, with higher rates among some types of clients and in some settings. Although
this dropout rate is lower than previously estimated, a significant number of clients are still prematurely
terminating, and thus further research toward a solution is warranted. Here we present a conceptualization
of premature termination based on perceived and anticipated costs and benefits and review 6 practice
strategies for reducing premature termination in therapy. These strategies include providing education
about duration and patterns of change, providing role induction, incorporating client preferences,
strengthening early hope, fostering the therapeutic alliance, and assessing and discussing treatment
progress.

Keywords: attrition, drop out, practice recommendations, premature termination

Ms. D presented to the clinic for help in making a decision about
whether or not she should seek a divorce from her physically
abusive husband. Over the course of the first few sessions the
therapist provided empathy and support as Ms. D processed her
This article was published Online First April 30, 2012.
JOSHUA K. SWIFT received his PhD in clinical psychology from Oklahoma
State University. He is an assistant professor in psychology at the Depart-
ment of Psychology, University of Alaska Anchorage. His research inter-
ests include psychotherapy process and outcome with a specific focus on
examining the client’s role in treatment and premature termination.
ROGER P. GREENBERG received his PhD in clinical psychology from Syr-
acuse University. He is a distinguished professor and Head of the Psychol-
ogy Division at the Department of Psychiatry and Behavioral Sciences,
State University of New York (SUNY), Upstate Medical University. He
has authored or coauthored more than 160 publications (including 7 books)
focused on psychotherapy process and outcome, comparative effectiveness
of different forms of treatment, and issues in psychopathology and person-
ality.
JASON L. WHIPPLE received his PhD in clinical psychology from Brigham
Young University. He is an associate professor of psychology at the
Department of Psychology, University of Alaska Fairbanks. His interests
include psychotherapy process and outcome, patient-focused research,
psychopharmacology, and clinical supervision.
NINA KOMINIAK is pursuing her BS in psychology at the Department of
Psychology, University of Alaska Anchorage. Her research interests in-
clude psychotherapy process, especially in the field of military psychology
treating clients suffering from posttraumatic stress disorder and traumatic
brain injuries.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Joshua
K. Swift, Department of Psychology, University of Alaska Anchorage,
3211 Providence Drive, SSB214, Anchorage, AK 99508. E-mail:
joshua.keith.swift@gmail.com
379
feelings and thoughts on both sides of the issue. By session five the
therapist believed a strong therapeutic relationship had been built
and sessions were right on track. However, Ms. D failed to show
up for her next scheduled appointment and she made no further
contact with the clinic—Ms. D had prematurely terminated from
therapy. Given that practicing clinicians of all types have had or
will have clients like Ms. D, who unilaterally discontinue therapy,
it is important that we gain a better understanding of this negative
therapy event and identify ways to reduce its occurrence.
Premature termination occurs when a client has discontinued
therapy unilaterally, without meeting the goals or completing the
tasks that were originally proposed for treatment (Garfield, 1994;
Hatchett & Park, 2003; Swift, Callahan, & Levine, 2009). Prema-
ture termination is often referred to by various labels in the
literature (e.g., attrition, drop out, early withdrawal, and unilateral
termination) and is measured through a number of different meth-
ods (e.g., duration-based, failure to complete, missed appointment,
and therapist judgment). While there has been much debate about
which label or operationalization is most appropriate (Hatchett &
Park, 2003; Swift et al., 2009), implicit in all of them are the ideas
that the client has not completed a full course of treatment, that the
client has unilaterally decided to stop attending sessions without
the therapist’s agreement and/or without discussing the decision
with the therapist, and that a significant amount of relief from the
client’s original problems has not been met.
Whatever the operationalization, premature termination is a
significant problem in therapy and even the best interventions and
the most skilled therapists cannot be effective if a client drops out
of treatment. Studies have found that when a client discontinues
treatment prematurely, he or she is more likely to report a greater
dissatisfaction with treatment (Björk, Bjorck, Clinton, Sohlberg, &
 380 SWIFT, GREENBERG, WHIPPLE, AND KOMINIAK
Norring, 2009; Knox et al., 2011) and show a more negative
therapy outcome (Cahill et al., 2003; Klein, Stone, Hicks, &
Pritchard, 2003; Lampropoulos, 2010). However, clients are not
the only ones who are negatively impacted by premature termina-
tion in therapy. Given that continued symptoms and impairment
are more likely in premature terminators, the burden experienced
by their associates (family, friends, employers, etc.) because of the
mental illness also remains. Additionally, the negative effects of
premature termination can carry over to therapists, who frequently
experience a sense of failure or rejection when one of their clients
drops out (Klein et al., 2003; Piselli, Halgin, & MacEwan, 2011).
Furthermore, when clients discontinue by failing to show for a
scheduled appointment, providers and agencies are faced with a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
loss of revenue and an underutilization of time.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Unfortunately, premature termination is not uncommon in psy-
chotherapy. Previous reviews of the literature have suggested that
anywhere from 30% to 60% of all clients drop out of treatment
(Baekeland & Lundwall, 1975; Garfield, 1994; Wierzbicki &
Pekarik, 1993). However, a recent review of the literature by Swift
and Greenberg (2012) indicates that this negative therapy event
may not be occurring as frequently as previously thought. In their
meta-analysis, Swift and Greenberg (2012) aggregated dropout
data from 669 studies representing 83,834 clients. These studies
were found through a wide-ranging search of the psychotherapy
literature, and included studies that reported a dropout rate for
adult clients who initiated a psychological or psychosocial inter-
vention. Their review did not include child or adolescent clients,
drug or alcohol clients, clients who were seeking services for a
health concern, interventions that were self-help or technology-
based, or couples or family-based interventions. Across studies, a
weighted average dropout rate of 19.7%, 95% confidence intervals
(CIs) [18.7, 20.7] was found. Although the findings from this
meta-analysis indicate a lower rate of dropouts compared with
what has been reported by previous reviews, one out of every five
clients are still discontinuing treatment prematurely. It is thus
important that researchers and practitioners seek to better under-
stand premature termination from therapy and identify strategies to
reduce its occurrence.
Why Some Clients Prematurely Terminate
Clients’ reasons for terminating therapy prematurely vary
widely. While one client may discontinue treatment early because
she feels like the therapist acted in a way that betrayed her trust,
another client might terminate services because he is not noticing
improvements as quickly as he expected. In a previous review of
early withdrawal from mental health treatments, Barrett et al.
(2008) categorized the variables that influence premature termina-
tion into six broad areas, including client characteristics (e.g., age,
ethnicity, income), enabling factors and barriers (e.g., cost of
services, level of social support), factors related to need (e.g.,
diagnosis, distress level, psychological mindedness), environmen-
tal factors (e.g., accessibility, treatment options, setting), percep-
tions of mental health problems (e.g., stigma), and perceptions of
and assumptions about treatment (e.g., satisfaction level, expecta-
tions for treatment length). Although Barrett et al.’s (2008) cate-
gories provide a useful framework for the variables that are related
to premature termination in therapy, we feel it is important to make
a distinction between predictor variables and the actual reasons
why clients choose to drop out of treatment.
Predictors of premature termination include the client, provider,
treatment, and setting variables that are associated with higher
rates of drop out. In their meta-analyses, Swift and Greenberg
(2012) examined the relationship between dropout rates and a
number of these predictor variables. They found increased dropout
rates in clients with personality or eating disorder diagnoses com-
pared with other diagnoses such as anxiety, trauma, depression, or
severe mental illness. Rates were also higher with younger clients.
However, dropouts did not differ from completers in terms of
ethnicity or employment status and findings regarding gender,
marital status, and education level were inconsistent. Swift and
Greenberg (2012) further found that premature termination rates
did not differ by theoretical orientation (e.g., cognitive–
behavioral, psychodynamic) or by treatment format (individual or
group); however, rates were higher in treatments that did not have
a set duration, for trainees and younger therapists, and in
university-based clinic settings. Although there is value in recog-
nizing what variables predict premature termination (these vari-
ables help pinpoint clients or situations when clinicians should
focus more on using the dropout reducing strategies), these vari-
ables do not, by themselves, indicate why a client chooses to drop
out, and thus they provide little insight into what techniques may
be of aid in reducing premature termination in therapy.
In contrast, understanding clients’ reasons for premature termi-
nation is important for conceptualizing the strategies that are
aimed to reduce its occurrence. As mentioned previously, clients’
reasons for terminating therapy prematurely vary widely, and the
exact motives likely differ from one client to the next. A number
of studies have attempted to document the various reasons that are
sometimes given (Hunsley, Aubry, Verstervelt, & Vito, 1999;
Knox et al., 2011; Pekarik, 1992; Westmacott, Hunsley, Best,
Rumstein-McKean, & Schindler, 2010). One way to broadly con-
ceptualize clients’ reasons for prematurely terminating therapy is
to compare the client’s perception and anticipation of costs for
continued attendance with their perception and anticipation of
benefits. Attending and engaging in psychotherapy can be a dif-
ficult task for many clients. In addition to the burdens associated
with therapy fees and the need to balance treatment with other
demands (work, family, etc.), it can be very trying for clients to
self-disclose and process the painful and sometimes embarrassing
topics that are often the focus of therapeutic work. In order to be
willing to continue to engage in therapy, the client must either
perceive or anticipate benefits that outweigh these costs. The
benefits could include anything from feeling supported by an
empathic therapist to believing that therapy will lead to change.
Aim of the Current Review
In this article we review six specific practice strategies for
preventing clients from dropping out of therapy prematurely.
These strategies are grounded in a conceptualization of dropouts
based on perceived and anticipated costs and benefits. In other
words, these strategies are designed to help clients perceive and
anticipate benefits from attending therapy that outweigh the costs
that may be present. Given that premature termination is most
likely to occur early on in therapy (Garfield, 1994) and that most
clinicians are eclectic in their treatment orientations (Jensen, Ber-
 REDUCING PREMATURE TERMINATION
gin, & Greaves, 1990; Norcross, Hedges, & Castle, 2002), the
majority of the strategies we review focus on actions therapists
providing treatment from various orientations can take during the
initial therapy sessions. They include providing education about
duration and patterns of change, providing role induction, incor-
porating client preferences, strengthening early hope, fostering the
therapeutic alliance, and assessing and discussing treatment prog-
ress. In addition to presenting the research that supports the use of
these strategies, at the end of each we have included brief deiden-
tified case examples to help illustrate how the strategy would be
used in actual practice. It should be noted here that the strategies
that we have identified are based on our qualitative review of the
dropout literature that coincided with our quantitative meta-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
analytic review of premature termination (Swift & Greenberg,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
2012). Where the aim of the Swift and Greenberg (2012) study was
to document the current rate of premature termination in adult
psychotherapy and test a set of specific moderators and correlates,
the purpose of this review is to identify strategies designed to
reduce premature termination in therapy. Although our review of
the literature in both situations was broad, we did not examine the
psychotherapy literature pertaining to child and adolescent clients,
drug or alcohol clients, psychological services for health concerns,
interventions that were self-help or technology-based, or couples
and family-based treatments. The strategies that we discuss in this
review are thus limited in those respects.
Practice Strategies
Providing Education About Duration and
Patterns of Change
Most clients start therapy with a specific set of expectations or
beliefs for what the intervention will be like. Client expectations
can include beliefs about what types of things will happen in
therapy (see discussion of role induction below) as well as beliefs
about how long treatment will last and how soon one can expect
recovery. Unfortunately, clients frequently have unrealistic expec-
tations regarding the duration of treatment and the timing of
progress. A number of studies conducted by Pekarik and col-
leagues (Mueller & Pekarik, 2000; Pekarik, 1991; Pekarik &
Wierzbicki, 1986) have found that the majority of clients expect to
attend five sessions or less. These expectations are particularly low
when compared with the higher duration expectations of therapists
(Mueller & Pekarik, 2000) and the actual time it takes for recov-
ery, as illustrated by the dose-effect literature (Hansen, Lambert, &
Forman, 2002). In one study assessing both duration and outcome
expectations, Swift and Callahan (2008) found that their partici-
pants expected 25% of therapy clients to have recovered by the end
of two sessions, 44% by four sessions, and 62% by eight sessions.
These unrealistically high expectations for duration and recovery
have been found to be one of the best predictors of actual duration
(Mueller & Pekarik, 2000; Pekarik, 1991; Pekarik & Wierzbicki,
1986; Scamardo, Bobele, & Biever, 2004) as well as treatment
drop out (Aubuchon-Endsley & Callahan, 2009; Callahan,
Aubuchon-Endsley, Borja, & Swift, 2009; Garfield, 1994). Clients
who expect a quick change may be disappointed when it does not
occur. In terms of the costs/benefits conceptualization of drop out,
when expectations for speed of change are not met, the perceived
381
and anticipated benefits for attending therapy are diminished, and
thus the client is at an increased risk for dropping out.
Given that unrealistic duration and outcome expectations have
been linked to premature termination in therapy, one might hy-
pothesize that attempts to help clients develop more realistic
expectations may lead to avoiding of the disappointment and
decreased hope that accompanies unmet expectations and thus
result in fewer clients dropping out. In one test of this hypothesis,
Reis and Brown (2006) allowed some clients to discuss their
duration expectations with a therapist. In these discussions the
therapists were told to encourage expectations for a greater number
of sessions if the clients’ initial estimates were deemed to be
unrealistically low. Reis and Brown (2006) found no differences in
dropout rates between those who did and those who did not engage
in such a discussion. Their results should be interpreted cautiously
though, given that the benchmark for realistic expectations in their
study was three or more sessions; however, recovery in three
sessions is still unrealistic for most clients. In another more recent
test of addressing duration and outcome expectations, Swift and
Callahan (2011) randomized 63 clients into duration education and
control groups. Those in the duration education group were told
that an extensive body of research indicates that it takes approxi-
mately 13 to 18 sessions for 50% of clients to recover. This
education was based off findings from the dose-effect literature
(Hansen et al., 2002). Perhaps not surprisingly, those who received
the education on average expected to attend approximately 15
sessions, while those in the control group only expected six ses-
sions. More importantly, those in the education group attended an
average of almost 11 sessions, while those in the control group
only attended about six sessions. Additionally, therapists who were
blind to the experimental conditions rated only nine of the 29
clients who received the education as premature terminators and
24 of the 31 clients in the control group as such.
Based on the findings from Swift and Callahan (2011), we
would recommend that practicing clinicians help their clients
develop realistic duration and recovery expectations prior to the
start of therapy. Swift and Callahan’s (2011) education was based
on the dose-effect literature, but clinicians working with a more
severely disturbed population or working from an orientation that
espouses longer treatment durations may want to alter the educa-
tion they provide to better fit their clients. Swift and Callahan’s
education was brief and provided to clients in paper format.
However, there is no reason to believe that this education would be
less effective if it occurred through some other means (e.g., face-
to-face discussion, online, video presentation). We do believe that
one important aspect to the education provided by Swift and
Callahan (2011) was that it was presented to the clients as
research-based, which may have increased its perceived credibil-
ity.
In addition to providing clients with some duration education,
we would recommend that clinicians also discuss potential courses
of change with their clients. While we are unaware of any studies
that have empirically examined the benefits of this type of discus-
sion, the suggestion to include this type of education is not new
(Orne & Wender, 1968). Education about potential courses of
change should include a discussion of both positive and negative
courses. One way to present positive patterns of change to clients
is through the psychotherapy phase model, which suggests clients
typically report early improvements in their general sense of
 382 SWIFT, GREENBERG, WHIPPLE, AND KOMINIAK
well-being during the first few sessions, followed by later reduc-
tions of symptoms and increased functioning (Howard, Lueger,
Maling, & Martinovich, 1993). Without this knowledge, some
clients could potentially mistake early gains in well-being as
recovery and thus see little need or benefits from continued atten-
dance. These clients are at risk of prematurely terminating prior to
addressing all of the problems (symptoms and life functioning) or
making a lasting change. Additionally, there may be times when
clients show some temporary deterioration in therapy because of
addressing difficult issues. At these times the perceived cost of
treatment may be high because of having to discuss difficult issues
and the perceived benefit may be low because of an experience of
deterioration. Without being forewarned of this possibility, clients
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
may misinterpret this temporary deterioration as a sign that therapy
This document is copyrighted by the American Psychological Association or one of its allied publishers.
is not working, and drop out as a result. Providing education about
these potential patterns of change along with education about
realistic therapy durations may prevent a number of clients from
prematurely terminating from treatment.
Case example. Mr. R started therapy because of depression
and suicidal thoughts that he was experiencing after his girlfriend
of two years broke up with him. This was his first time seeking out
any form of mental health treatment. Although he was experienc-
ing a significant amount of distress and symptoms, in the first
session he indicated that he was just expecting a couple of ses-
sions. The therapist gently informed Mr. R that although every
client is different and although some changes may occur during the
first two sessions, the typical client needs approximately 15 ses-
sions or so before he or she will experience a notable improve-
ment. Mr. R remained in therapy for a full course of treatment,
experiencing a remission of his depressive symptoms and clini-
cally significant change at termination based on an outcome mea-
sure.
Providing Role Induction
There is also evidence that unmet role expectations predict
premature termination in psychotherapy (Aubuchon-Endsley &
Callahan, 2009; Callahan et al., 2009; Constantino, Glass, Arnkoff,
Ametrano, & Smith, 2011; Garfield, 1994; Greenberg, Constan-
tino, & Bruce, 2006; Reis & Brown, 1999). Role expectations refer
to client and therapist behaviors that the client believes will be
present in treatment. Although some clients start therapy with
more accurate ideas about what behaviors are likely to occur, other
clients start with a number of beliefs that will not be met. Unre-
alistic beliefs about therapy may be based on stereotypes and
inaccurate portrayals of therapy in the media; however, role ex-
pectations can also go unmet when a client’s role expectations are
appropriate, but just do not match the behaviors of his or her
particular therapist. Framed in the cost/benefit conceptualization of
premature termination, clients who are naı̈ve to therapy may start
not knowing what behaviors or roles are most appropriate on their
part and could thus feel lost or like they are doing things wrong.
For other clients who do have specific role expectations that go
unmet, they may anticipate fewer benefits from treatment, thinking
that the treatment is supposed to look differently if it is going to be
effective.
Role induction, referring to the process of providing clients with
some education about appropriate therapy behaviors prior to the
start of treatment, has been studied as a method to help clients
develop more accurate role expectations. A number of studies have
investigated whether pretherapy role induction aimed at instilling
more accurate role expectations can lead to reduced rates of
dropout. For example, Reis and Brown (2006) randomly assigned
125 outpatient clients to start their intake session by either watch-
ing a 12-min psychotherapy orientation video or a 17-min control
video. Using the Termination Status Questionnaire, Reis and
Brown (2006) found that therapists’ ratings of dropout were sig-
nificantly lower for those clients who watched the role induction
video. Studies testing role induction techniques are abundant in the
dropout literature, and similar to Reis and Brown’s (2006) inves-
tigation, most of these studies have demonstrated positive results.
In one unpublished meta-analysis that included 28 studies, Monks
(1996) found that role induction led to both increased attendance
(d ⫽ .32) and decreased dropout rates (d ⫽ .23). Other reviews
have similarly concluded that the inclusion of some form of
pretreatment education that addresses therapy roles results in fewer
clients dropping out of treatment (Barrett et al., 2008; Garfield,
1994; Ogrodniczuk, Joyce, & Piper, 2005; Walitzer, Dermen, &
Connors, 1999).
Given the positive findings from these reviews, it is recom-
mended that practicing clinicians provide some type of role induc-
tion to their clients prior to starting the intervention. In setting forth
an early model for this type of pretreatment socialization, Orne and
Wender (1968) suggested that it include education about the “jobs”
of both the client and the therapist, such as who is expected to do
most of the talking and who will be responsible for structuring or
directing sessions. This type of induction should also include a
discussion of the rationale for the approach that will be used (Ilardi
& Craighead, 1994). Role induction can be provided through a
number of different formats or mediums. While many studies have
tested the effectiveness of brief educational videos (Reis & Brown,
2006; Strassle, Borckardt, Handler, & Nash, 2011), others have
provided this type of induction verbally (France & Dugo, 1985;
Garrison, 1978) or in written format (Garrison, 1978). Addition-
ally, instead of directly educating clients about appropriate roles
and behaviors for therapy, some have found positive results by
having clients watch examples of model therapy sessions (Fouad et
al., 2007; France & Dugo, 1985).
Case example. Mr. O was referred to therapy after an alcohol
infraction on campus. He had never been in therapy before and in
the first session expressed a great deal of skepticism about treat-
ment; he expressed worries about having to lie on a couch and
discuss his dreams. In this session the therapist took extra care to,
among other things, describe his model of therapeutic work, ex-
plaining that there would be no couches or dreams involved.
Rather they would sit and explore some of the motivations for the
client’s alcohol use and work toward whatever alcohol use goals
the client wanted. The therapist also informed the client that
sessions did not have to focus entirely on his alcohol use and the
client could choose to direct the sessions to other topics if he felt
they were more important. By the end of this session Mr. O
seemed excited about therapy and he remained consistent in his
attendance for a full course of treatment.
Incorporating Client Preferences
Just as most clients begin treatment with certain expectations
regarding the therapy encounter, many begin treatment with par-
 REDUCING PREMATURE TERMINATION
ticular preferences for therapy. Client preferences include wants or
desires concerning the type of treatment that is to be used, the type
of therapist one would like to work with, and the roles and
behaviors that are to take place in therapy (e.g., therapist to take an
advice-giving role, homework to be assigned). The accommoda-
tion of these types of preferences has been found to result in an
increased willingness of clients to engage in therapy and lower
rates of premature termination. In a recent meta-analysis including
18 studies, Swift, Callahan, and Vollmer (2011) investigated
whether clients who received their preferred therapy conditions
were more or less likely to drop out compared with clients who
either had no choice or received a nonpreferred condition. Swift et
al. (2011) found a significant dropout effect, odds ratio [OR] ⫽
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
0.59, 95% CIs [0.44, 0.78], indicating that clients who had their
This document is copyrighted by the American Psychological Association or one of its allied publishers.
preferences accommodated were almost half as likely to drop out
of treatment prematurely compared with clients whose preferences
were not taken into account. Accommodating client preferences
has the potential to alter both perceived costs and perceived
benefits; by allowing the clients to have a choice in therapy, they
get to engage in a treatment that may be more enjoyable and
pleasing to them rather than one that they may have some aversion
to.
Given the findings from the Swift et al. (2011) preference
meta-analysis and other recent studies (Greenberg & Goldman,
2009; Mohlman, 2011), practicing clinicians may be able to pre-
vent a number of their clients from dropping out of treatment by
incorporating their clients’ preferences into the treatment decision-
making process. Therapists sometimes make their own subjective
treatment decisions after they have gathered information about the
client’s presenting problems and history. Although therapists may
have training and experience in treating particular problems, cli-
ents are experts in their own lives and best know what approaches
they are willing to engage in (even if a treatment has been proven
to work 100% of the time, it will be of little use if the client is not
willing to try it). However, accommodating client preferences does
not mean the therapist should automatically use the client’s pre-
ferred methods. Often clients are unaware of what treatment op-
tions are available or best suited for their particular problems.
Instead, therapists should consider sharing their knowledge about
the particular disorder and the nature of different approaches to the
treatment of those problems with clients. Clients can then share
their preferences regarding those treatment options with the ther-
apist and work collaboratively toward a decision about which
approach might be best.
Case example. A young trainee was working with Ms. P on
her symptoms of generalized anxiety from a manualized-based,
cognitive– behavioral approach. After five sessions little progress
had been made. When her therapist discussed concerns with her
about the lack of treatment progress, Ms. P shared that the treat-
ment approach made sense to her and she saw how it could be
helpful for someone with her symptoms; however, she had a strong
desire for a less directive approach. With supervision, the trainee
worked on adapting his style to match Ms. P’s preferences and a
steady decrease in her symptoms soon followed.
Strengthening Early Hope
Expectations for change have also been suggested to be a key
contributor to success in therapy, explaining as much as 15% of the
383
variance in therapy outcomes (Greenberg, 2012; Norcross & Lam-
bert, 2011). Although it is important that clients do not hold
unrealistic expectations (i.e., recovery after only one or two ses-
sions), it is also important that they have a general hope that
therapy can help them get better. This principle speaks directly to
anticipated benefits; without a hope or belief that therapy will
work, motivation to continue with treatment will be lost and
premature termination will likely follow.
In describing the importance of hope in therapy, Frank and
Frank (1991) proposed that “it is aroused by cues in the immediate
situation . . . and is strengthened by progress toward the goal” (p.
133). This statement suggests that therapists can arouse client hope
by presenting an initial treatment situation in which the client
believes positive change will follow. In order to arouse these
hopes, therapists should focus on how they present themselves and
the interventions, and how they talk about their clients. In terms of
the intervention, treatments are seen as more credible when clients
believe in the causal explanation of the problems and the descrip-
tion of how the specific therapy approach will help in overcoming
those problems (Devilly & Borkovec, 2000; Greenberg et al.,
2006; Horvath, 1990; Ilardi & Craighead, 1994; Kazdin & Krouse,
1983). Constantino et al. (2011) suggest that not only should
therapists describe a logical treatment rationale, but they also
should express confidence that the treatment will work for the
client. In offering this view, therapists can share with their clients’
findings from research studies supporting the efficacy of the in-
tervention. In addition to having hope in the treatment, it is also
important that clients have faith in their therapists. The perceived
credibility of the therapist has been found to influence client
satisfaction with treatment and treatment outcomes (Hoyt, 1996).
Strong (1968) originally proposed that therapists can be perceived
as more credible when they are perceived as being expert (influ-
enced by reputational cues and psychological knowledge), attrac-
tive (influenced by similarity in background and opinions), and
trustworthy (influenced by therapist genuineness, warmth, and
empathy). There is some evidence that culture also influences
perceived credibility, but this may be because of perceived simi-
larity in background and opinions rather than a racial match (Zane,
Hall, Sue, Young, & Nunez, 2004). Finally, it has been suggested
(Constantino et al., 2011) that therapists increase client hope by
expressing confidence in their clients and their ability to have a
successful therapy outcome. Therapists’ efforts to strengthen cli-
ents’ initial levels of hope by presenting themselves and treatments
in a credible way and by expressing confidence in clients could
lead to lower rates of premature termination.
Frank and Frank’s (1991) statement also suggests that therapists
can strengthen the client’s hope by helping facilitate early progress
in therapy. A number of suggestions could be made to help
therapists in doing so. First, therapists should routinely give atten-
tion to pacing in their work with clients. At the start of therapy,
therapists may want to focus more on strategies to help the client
move through the Phase Model (Howard et al., 1993) stage of
remoralization. Howard et al. (1993) and others (Lambert & Ogles,
2004) have suggested that remoralization can best be facilitated by
developing a therapeutic alliance with the client built on principles
such as acceptance, empathic understanding, genuineness, trust,
and warmth. After the client experiences improvements in his or
her sense of well-being, he or she then may be ready to address
specific symptoms and areas of impairment. By moving too fast
 384 SWIFT, GREENBERG, WHIPPLE, AND KOMINIAK
into actions, techniques, or painful experiences and emotions,
clients are at risk of becoming overwhelmed (increased perceived
cost) and are thus are more susceptible to dropping out. It can also
be recommended that therapists and clients begin their work by
focusing on some of the goals that seem more amenable to change.
After the initial goals have been met and the level of hope has been
strengthened, clients may be more prepared, and thus more willing
to remain in treatment, for some of the slower progress, potential
setbacks, and painful emotions that might be expected with some
of the more complex and deep-seeded problem areas.
Case example. Ms. O, a graduate student, sought therapy
because she was having difficulty making progress on her thesis
proposal. Weeks earlier her thesis committee had asked her to
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
revise certain portions of her project and propose it to them again
This document is copyrighted by the American Psychological Association or one of its allied publishers.
in a couple months’ time. She took the committee’s constructive
feedback as a major failure and as a result began experiencing
panic attacks whenever she attempted to work on the revisions.
Ms. O was an international student and in the first session she
reported that her family had never discussed mental health issues
before. She worried that the panic attacks were a sign she was
“going crazy.” During the first session the therapist attempted to
normalize her symptoms framed in the context of her experience
and the pressure she places on herself to do well in school. The
therapist also commended her for the step she took to seek out
treatment, discussed a treatment plan, and expressed confidence
that by working together, they would be able to help her get
past the panic attacks. Ms. O came back to the second session
stating that she was no longer experiencing panic attacks and she
had been able to get back to her thesis work. With therapy she was
then able to focus on the expectations she places on herself for
academic success.
Fostering the Therapeutic Alliance
In order to prevent clients from dropping out of therapy prema-
turely, clinicians can also work to foster the therapeutic alliance.
Although there is not yet a universally agreed upon definition of
the therapeutic alliance (Horvath, Del Re, Fluckiger, & Symonds,
2011), Bordin’s (1979) pan theoretical construct of the working
alliance is perhaps the most widely accepted. According to Bordin
(1979), the working alliance is composed of agreement on the
goals and tasks for therapy and the bond that exists between
the therapist and client. Taken together, these three components of
the therapeutic alliance, as well as other similar definitions of the
construct, have been found to be significantly related to treatment
outcomes (Horvath et al., 2011).
Given the robust relationship that exists between the therapeutic
alliance and treatment outcomes (Horvath et al., 2011), one might
also predict that the therapeutic alliance could play a role in
treatment dropout. When the therapeutic alliance is strong, the
perceived benefits of collaboratively working with an accepting
and empathic individual can help outweigh any of the costs that
come up in therapy. Recently, Sharf, Primavera, and Diener (2010)
conducted a meta-analysis that examined the relationship between
the premature termination and the therapeutic alliance in adult
individual psychotherapy. Across studies (k ⫽ 11), a significant
relationship between dropout and the strength of the alliance was
found (d ⫽ .55), with weaker ratings of alliance being associated
with an increased likelihood of dropping out. Sharf et al. (2010)
further found that the alliance was more strongly related to dropout
in studies with clients who had a lower level of education, in
treatments that were of a longer duration, and in inpatient settings.
Given Sharf et al.’s (2010) findings that a relationship between
therapeutic alliance and premature termination exists, it follows
that efforts to foster the therapeutic alliance can lead to greater
perceived benefits and thus fewer clients dropping out. Efforts to
foster the therapeutic alliance can occur both early on in therapy
when the risk of premature termination is high, and as therapy
progresses. Early efforts should focus on making sure there is an
agreement on the goals and tasks before jumping to treatment
interventions. This agreement can often be obtained by encourag-
ing clients to share their opinions, preferences, and reflections
about possible approaches to treatment as well as seeking feedback
from the client about the level of collaboration (Tryon & Wino-
grad, 2011). This suggestion matches the previously mentioned
dropout reducing strategies of accommodating client treatment
preferences and expectations as well as appropriately pacing treat-
ment. Early and consistent efforts should also be made to develop
a strong bond with clients by providing an empathic and safe
environment. Clients who feel this type of connection with their
therapists and who believe that they are working together in
treatment will have a harder time discontinuing treatment prema-
turely. Additionally, as mentioned in a previous strategy, this type
of bond will help the client move through the phase of remoral-
ization, thus strengthening clients’ hopes for the possibility of
change.
Therapists should be aware that the strength of the alliance can
fluctuate over the course of therapy, and clients may be at a higher
risk of dropping out when they perceive a rupture or breakdown in
the alliance (Knox et al., 2011). The perceived loss of a collabor-
ative supporting relationship may result in the relationship itself
being perceived as a cost in therapy, which may be very difficult
for many clients to endure. At times when there has been an
alliance rupture, Safran, Muran, and Eubanks-Carter (2011) sug-
gest that therapists seek to understand and empathize with clients’
negative feelings about the relationship, and then quickly seek
ways to explore and resolve those conflicts.
Case example. Ms. U had a history of starting and prema-
turely stopping treatment with a number of previous therapists,
complaining about the relationship with each. Knowing this, her
therapist worked hard to develop a bond with Ms. U by being
genuine, supportive, expressing an empathic caring, and quickly
processing her feelings when she had felt like he hadn’t understood
her. After a little over 20 sessions Ms. U stated that she finally felt
like she could trust her therapist and she proceeded to share about
being sexually abused as a child, something she said she had never
felt comfortable sharing with any other person.
Assessing and Discussing Treatment Progress
Our last recommendation for decreasing premature termination in
therapy is for clinicians to routinely monitor treatment outcomes. The
current trend for clinicians to monitor their clients’ outcomes is
strongly tied to the concept of patient-focused research (Howard,
Moras, Brill, Martinovich, & Lutz, 1996). According to Howard et al.
(1996), patient-focused research includes (a) routine tracking of client
outcomes on an objective measure, (b) a comparison of the client’s
course of change to what would be expected in order for the client to
 REDUCING PREMATURE TERMINATION
recover, and (c) feedback to the therapist as to whether or not the
client’s progress matches the expected or hoped for trajectory. Clients
whose progress deviates in a negative direction from the hoped for
path are at an increased risk of dropping out of therapy or terminating
with a negative outcome (Lambert, Hansen, & Finch, 2001). These
are clients who are experiencing, and thus likely also anticipating, no
noticeable benefits in terms of symptoms and distress from their
engaging in treatment. Using outcome measures, clinicians can iden-
tify which clients are not progressing or deteriorating before the client
drops out. The clinician can then make changes to the course of
treatment as appropriate. A number of different outcome monitoring
and feedback systems exist, with three of the most popular being
Lambert and colleagues’ Outcome Questionnaire-45.2 system (OQ-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
45.2; Lambert et al., 2004); Barkham and colleagues’ Clinical Out-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
comes in Routine Evaluation system (Barkham et al., 2001); and
Miller, Duncan, and colleagues’ Partners for Change Outcome Man-
agement System (PCOMS; Miller, Duncan, Sorrell, & Brown, 2005).
Recently, Lambert and Shimokawa (2011) reviewed the litera-
ture on studies that have examined the influence of therapist
feedback systems, including studies that used the OQ-45.2 and
studies using the PCOMS. Across studies of both systems, Lam-
bert and Shimokawa (2011) found significant effects favoring
those clients whose therapists received regular feedback regarding
their progress. Specifically, when feedback was provided, clients
showed significantly higher average posttreatment outcome scores,
were significantly more likely to make a reliable improvement
while in therapy, and were significantly less likely to end therapy
with a negative treatment outcome. Unfortunately, Lambert and
Shimokawa’s (2011) review only examined the influence feedback
has on therapy outcomes and did not directly examine whether the
feedback systems led to fewer clients dropping out of treatment
prematurely. However, their finding that fewer clients end therapy
in a deteriorated state when feedback is used implies fewer clients
drop out according to the reliable improvement definition of pre-
mature termination (Hatchett & Park, 2003; Swift et al., 2009).
Although using an objective outcome measure is one useful way
for therapists to gain feedback from their clients about progress,
gaining feedback by directly talking to clients may be beneficial as
well. A number of studies have found that premature terminators
express a greater dissatisfaction with treatment (Björk et al., 2009;
Knox et al., 2011). Regularly checking in with clients about how
they feel treatment is going (i.e., their perceived benefits and costs
associated with engaging in treatment) may allow therapists to
recognize client dissatisfaction and make changes as appropriate
before the client stops attending. This suggestion fits well with
previous suggestions to foster alliance and repair alliance ruptures,
and together would also lead to fewer clients dropping out.
Case example. Ms. T had sought out treatment after having
a hard time adjusting to a number of recent stressors, including
having a baby and deciding to go back to school. During the
first couple of sessions her clinician collaboratively worked
with her to develop a treatment plan. As sessions continued,
Ms. T’s therapist noticed that her scores on the OQ-45.2 were
showing a slight deterioration. At the start of session six the
therapist shared this fact with Ms. T and asked what she thought
about how therapy had been progressing so far. Ms. T indicated
that since developing the original treatment plan she had
changed what she wanted to work on in therapy and she was not
sure how to bring this up with the therapist. The therapist and
385
Ms. T then discussed her new treatment goals and consistent
improvements were observed thereafter.
Conclusions
According to the most recent general review of premature
termination in therapy, almost 20% of all clients fail to complete
treatment (Swift & Greenberg, 2012). Although this number is not
as high as previously thought (Wierzbicki & Pekarik, 1993),
premature termination is still a significant problem with deleteri-
ous impacts on the clients who drop out, their associates, and the
providers and agencies that work with them. It is thus important
that practicing clinicians make a concerted effort to prevent pre-
mature termination from occurring with their clients. In this article
we reviewed six methods for reducing premature termination in
therapy that focus on reducing the perceived and anticipated costs
and increasing the perceived and anticipated benefits that are
experienced by clients. Addressing client preferences and expec-
tations (duration, outcome, and role expectations), as well as
building early hope for change are strategies that therapists can
engage in during the first few sessions with each client. Although
preferences, expectations, and hope can change as treatment pro-
gresses and the therapist may need to focus on these at any time
during therapy, the biggest impact of these strategies depends on
the therapist’s initial actions. On the other hand, fostering the
therapeutic alliance and assessing and discussing treatment prog-
ress and satisfaction are strategies that should be used throughout
the course of therapy.
Although there is research supporting the use of each of these
strategies individually, we believe that they can also be used in
combination by therapists to further prevent premature termination
in clients. Taken together, these strategies should help clients to
perceive and anticipate benefits from therapy that outweigh costs
associated with therapy attendance and engagement. Clinicians
should work to implement these strategies in a way that fits their
own theoretical orientation. For example, the education that a
therapist would provide to a client about the length of therapy and
the appropriate roles and behaviors for therapy would largely
depend on the theoretical model of the therapist. Additionally,
therapists should work to tailor the use of these strategies to the
needs of the individual client. As one case in point, some clients
display strong hopes that therapy will produce change prior to even
starting therapy, while others are more reserved concerning their
optimism for treatment success. In working with clients with lower
expectations for change, therapists will want to place more em-
phasis on strategies to strengthen hope by helping the client make
early changes and fostering the therapeutic alliance. In addition, a
client’s cultural background may play a large role in a number of
the strategies and therapists should adopt a style that is suitable to
each client’s characteristics, values, and beliefs. For example,
clients of some cultural backgrounds may desire a therapist who
takes more of a consultant role (Atkinson, Kim, & Caldwell,
1998), and they could be turned off from therapy if the therapist
uses too much warmth and empathic support. Use of the strategies
mentioned here in a way that presents the most perceived benefit
and the least perceived cost to the individual client will likely
result in the greatest reductions in rates of premature termination.
While there is a growing body of evidence supporting the use of
these strategies to reduce premature termination in therapy, it is likely
 386 SWIFT, GREENBERG, WHIPPLE, AND KOMINIAK
that some clients will still prematurely terminate from treatment. In
such situations therapists are encouraged to review the case with the
intent to identify the perceived costs that led the individual client to
discontinue treatment prematurely as well as potential ways the strat-
egies could have been used differently to increase the perceived or
anticipated benefit. Consultation may be useful in this process. Fur-
ther research on these strategies is also needed to assist in reducing the
number of clients who discontinue treatment prematurely. While
some of these methods have been studied more extensively (e.g., role
induction), others need further validation (e.g., discussing client sat-
isfaction, duration education, repairing alliance ruptures). Specifi-
cally, research focusing on testing these strategies in the situations
where dropout is more likely (i.e., with younger clients, those with
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
personality or eating disorder diagnoses, trainee clinicians, university-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
based clinic settings) would be of particular value.
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Received December 15, 2011
Revision received March 7, 2012
Accepted March 19, 2012 䡲