Assessment Factors Associated with Premature Psychotherapy Termination D O U G L A S H . FRAYN, M . D . FRCP(C)* P r e m a t u r e p s y c h o t h e r a p y t e r m i n a t i o n is associated w i t h c e r t a i n specific ego deficits and e n v i r o n m e n t a l c i r c u m s t a n c e s t h a t can he evaluated a t t h e t i m e of i n i t i a l assessment. I n t r o s p e c t i o n , f r u s t r a t i o n t o l e r a n c e , m o t i v a t i o n , p o s i t i v e c o u n tertransference and life c i r c u m s t a n c e f a c t o r s most highly d i s c r i m i n a t e between t h e t e r m i n a t o r s and t h e c o n t i n u i n g therapy group. INTRODUCTION Premature patient termination unfortunately is a relatively frequent occurrence, irrespective of the type of psychotherapy undertaken. Psychotherapy research literature also uses other interchangeable terms for this event, such as patient attrition, forced termination and dropout. For the purpose o f this study, premature termination was defined as meaning any patient unilaterally leaving intensive psychotherapy or psychoanalysis before the agreed-upon minimal treatment period, that is, after less than nine months of beginning therapy. I n a recent large study one-third o f depressive patients accepted for psychotherapy dropped out before the agreed-upon four months. ' Depending upon the type and duration o f the treatment, this unplanned termination figure can vary f r o m one-eighth o f all analytic cases over t w o years w i t h experienced analysts to greater than one-half o f borderline cases i n analysis or psychotherapy over a four-year p e r i o d . I t also should be noted that a significant number o f prospective patients drop out before the formal assessment period is even completed. Such patients are considered assessment dropouts (nonstarters) and, therefore, are not i n cluded as part o f this psychotherapy attrition study. Psychotherapy process and outcome studies have investigated b o t h p a t i e n t and therapist ' factors as well as their interactional variables ' w i t h the consistent finding that patient variables most highly correlate w i t h eventual outcome although individual traits of b o t h parties do contribute. The significant patient variables (e.g., mistrust, hostility, denial, and increas1

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* Psychotherapy Consultant, Clarke Institute of Psychiatry; Training and Supervising Analyst, Toronto Institute of Psychoanalysis; Associate Professor of Psychiatry, University of Toronto. M a i l i n g a d d r e s s : Clarke Institute of Psychiatry, 250 College Street, Toronto, Canada M5T1R8. A M E R I C A N J O U R N A L O FPSYCHOTHERAPY, Vol.X L V I , N o . 2,April 1992

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Assessment Factors Associated w i t h Premature Psychotherapy Termination ing anxiety) contributing to a negative outcome have most frequently been assessed during the initial phase of psychotherapy, using speech units and interaction profiles from tape recordings and research observations. These patient negative alliance factors correlate higher than the positive factors (e.g., motivation for insight) when making outcome predictions. Such characterological traits result i n major interpersonal deficits that reduce the possibilities for meaningful or intimate relationships including the proposed therapy dyad. I t appears that patients who tend to do poorly, bring negative dynamic factors to the treatment situation that persist across hours of psychotherapy rather than just being episodic misunderstandings. These resistance factors and nonfacilitating qualities may be intransigent to the therapist's efforts to alter the impending termination or resolve the stalemate. 11

Although it has been said that patients have less positive attitudes toward inexperienced and/or remote therapists and that more clinic patients eventually drop out earlier or refuse treatment when confronted w i t h such therapists, L u b o r s k y concludes that there is no evidence that the therapist's professional experience or orientation is directly related to the continuing patient's overall psychotherapy outcome. One cannot rely solely on the extent of a therapist's training or even the patient's perceived goodness of the therapist i n order to accurately predict the course of therapy. Clinic patients are also more likely to drop out of supportive psychotherapy when their appointments are delayed or the clinic site changed than when their transient therapists rotate. The decision to terminate is frequently not a mutual one, particularly for patients receiving therapy through public health delivery systems. Discussion and bilateral decisions to terminate are more likely to take place i n private practice settings. 12

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Patient factors previously studied and associated w i t h the likelihood of not completing intensive treatment are: active substance abuse, axis I I diagnosis (dramatic-erratic,borderline or characterologically d i f f i c u l t ) ' , early prolonged silences, primitive defenses, preoedipal conflicts, persistent transference resistance, psychosomatic or somatizing symptomatology and situational crises. The findings of negative reactions to the therapist and the treatment situation have special significance that, i f ignored, can lead to early termination. I n retrospect, frequently these events could have been foreseen at the outset of treatment. Patient selection, therapeutic approach and setting, length of treatment, procedural and goal expectations, therapist experience and attitude are all interactional influences on the potential for patients to terminate therapy prematurely. Dropping out of treatment is usually a complex interaction 1

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between the patient, therapist, and the situational factors. Early recognition by the therapist of significant assessment qualities should lead to a more sophisticated selection of patients and appropriate intervention strategies that can facilitate continuing therapy and may lead to an eventual positive therapeutic outcome. This study focuses on those dynamic patient qualities that can be quantifiably assessed during consultation by relatively senior trainees. One of the significant problems i n making psychotherapy outcome predictions based on psychodynamic factors is the lack of rater reliability, particularly when trying to assess important dynamic qualities such as the libidinal stage, global ego functioning, predominate transference, and degree of therapeutic alliance available. These psychodynamic entities can have significantly different evaluations depending upon the therapists' orientation and training. I t was hoped that through the use of a descriptive questionnaire (which gave each quality a brief quantitative outline) the individual factors would be more understandable and be more consistently rated, particularly when completed by relatively inexperienced therapists. 17

METHOD The total number of patient assessments studied over the seven-year period was 85; 60 percent of these were psychotherapy assessments done by senior psychiatry residents and 40 percent were psychoanalytic assessments done by supervised candidates i n training (psychiatrists or psychologists). B o t h therapists and their supervisors were provided w i t h a descriptive assessment questionnaire that was to be completed and forwarded following the assessment period. As this was a voluntary exercise I asked to be informed about the therapists' assessments, particularly of patients who prematurely terminated even i f all the other assessments were not available. I also suggested that the therapist's supervisor might undertake to rate the reported assessment factors which also would provide a basis for ongoing supervision discussion of the specific psychodynamic assessment variables. For this study the 20 known cases (PT) that terminated prematurely (that is those who unilaterally dropped out of therapy within nine months or less following assessment and acceptance), were compared to 20 randomly choservcases (CT) who continued therapy. There proved to be a total of 40 different therapists i n training (21 female/19 male) who completed these particular assessment questionnaires on their prospective patients. The T.I.P. Assessment Questionnaire consisted of a listing of the patients' biographical and clinical data as well as a series of 16 patient qualities and dynamic factors, all of which had been implicated f r o m previous reports 252

Assessment Factors Associated with Premature Psychotherapy Termination as probable dropout factors. These assessment factors were rated using a 0 to 4 descriptive scale. DESCRIPTION OF T H E SIGNIFICANT ASSESSMENT FACTORS

Scores range from 0 (most impaired) to 4 (least impaired), using T.I.P. Questionnaire ratings. P a s t + v e T r a n s f e r e n c e s : history of typical and consistent attitudes toward parents, teachers, bosses, and former therapists, primarily—splitting / negative or resentful/ ambivalent / benign / positive or grateful. C l i n i c a l F u n c t i o n i n g : the level of patient's present ability to cope and lack of symptomatology—incapacitated / severe / moderate / mild / asymptomatic. A f f e c t A v a i l a b i l i t y : the degree of patient's openness and awareness of feelings — denies affects & memories / secretive / defensive / open / warm. T h e r a p i s t A l l i a n c : the type of the therapist's feelings aroused by working w i t h this patient (or countertransference)—fearful / negative / guarded / interested / positive. I n t r o s p e c t i o n : the degree of psychological-mindedness that includes self-awareness, curiosity, intuition, and capacity for insight—disinterest i n introspection / questionable self-reflection / adequate thoughtfulness / favorable self-awareness / intuition and insight. O b j e c t R e l a t e d n e s s : includes the quality of the patient's social adaptation, friendships and intimacy—disinterested, chaotic or absent ties / exploitative or primarily self-involved / inhibited or commitment problems / able to f o r m close friendships / successful at love and sensitive to others. F r u s t r a t i o n T o l e r a n c e : the degree of ego strength, i.e., adaptive ability, tolerance to anxiety, ability to function under stress—poor reality testing / regressive potential / prominent anxiety / workable tolerance / good frustration capacity and able to sublimate. M o t i v a t i o n : the degree of self-interest/commitment to understand self and sufficient suffering to bring about a desire for change—poor / problematical / wish rather than realistic self-expectation / adequate self-motivation / desire to do whatever is necessary. L i f e C i r c u m s t a n c e s : the degree of support for therapy that present personal (age, finances) and environmental (time, family, work) circumstances can provide at this time — poor / significant difficulties / questionable / adequate / favorable. I m p u l s e C o n t r o l : the ability to delay impulses, postpone immediate gratification and discuss rather than act —antisocial behavior / impulsive 253

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behavior / consistent concern for or episodic loss of control / stable, good behavioral control / flexibility and moderation under stress. Description of the Other Factors Assessed (nonsignificant): C h i l d h o o d A t t a c h m e n t : the degree of parental caring and attachment. P a s t P o s i t i v e T r e a t m e n t : past treatment outcomes, as assessed by patient. S y m p t o m D u r a t i o n : symptom or illness duration. P a t i e n t A l l i a n c e : the degree of immediate positive feeling patient has towards therapy and the therapist, including facilitating transferences (note as rated by the therapist). W o r k A d a p t a t i o n : includes persistence, pursuit of goals, good school/ employment record and attendance. S e x u a l F u n c t i o n i n g : the degree of sensual interest, pleasure, and performance as expressed by the patient. R E S U L T S ( s e e G r a p h 1) O f the 20 cases (PT) who prematurely terminated out of the 85 patients assessed (50 psychotherapy / 35 psychoanalysis), 12 had been i n psychotherGraph 1

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PREMATURE

20; 10-

CH 1. 2. 3. 4. 5. 6. 7. 8. 254

Childhood Attachment Past +ve Treatment Past 4-ve Transference (p .006) Clinical Functioning (p .01) Symptom Duration Affect Availability (p .037) Patient Alliance TherapistAlliance(p.OOl)

9. 10. 11. 12. 13. 14. 15. 16.

Introspection (p .001) Object Relatedness (p .012) Frustration Tolerance (p . 001) Motivation (p .001) Life Circumstances (p .001) Work Adaptation S exual Functioning Impulse Control (p .01)

Assessment Factors Associated with Premature Psychotherapy Termination apy and 8 were psychoanalytic dropouts, that is similar to the overall frequency o f these t w o undertaken treatment modalities. The type o f psychotherapy d i d not indicate differences i n the eventual termination outcome, w i t h approxiamately one-quarter terminating early for both psychotherapy (24%) and psychoanalysis (23%). O f the 20 cases who dropped out during therapy, 10 (50%) d i d so within 9 months. There was a total o f 22 female and 18 male patients rated by 21 female and 19 male therapists who completed the assessment-questionnaire ratings and undertook supervised psychotherapy or psychoanalysis o f the patients. Neither the age nor gender of the patient or therapist was significantly related to premature termination. There was a trend toward lower impairment ratings for the female patients and higher dropout rates among the female patient/female therapist combinations which represented a total o f 40 percent (8/20) o f all the therapy combinations which eventually terminated. The three other patient/ therapist gender combinations were similar (4/20) concerning patient attrition rates. A trend towards higher dropout rates i n those psychoanalytic control patients under 25 years was noted. There was no one diagnostic entity that differentiated between the t w o groups although an axis IT diagnosis w i t h either narcissistic or borderline traits was the most frequent diagnosis i n the dropout group. The dynamic assessment factors that most highly discriminated outcome between the two groups were Introspection, Frustration Tolerance, Motivation, Therapist Alliance, and Life Circumstances items (p < .001). Impulse Control, Past Positive Transferences, and Present Clinical Functioning also significantly discriminate (p < .01) between those who continue therapy and those who terminate early, w i t h Object Relatedness and Affect Availability being less significant (p < .05). (Table I ) . DISCUSSION It has been generally assumed that premature termination signifies a poorer therapeutic outcome than that which can be achieved by continuing therapy, although the differences may not be as significant as once believed. Because o f the time, effort, expense and disruption to b o t h patients and their therapists, it is important t o be able t o identify those patients most likely to terminate prematurely. A n obvious limitation to this prospective survey is the number o f uncompleted or unreturned questionnaires, particularly noted i n the continuing therapy (CT) group. This makes i t impossible to accurately state the percentage o f dropouts that took place within 9 months after beginning therapy. O f the 85 cases accepted for therapy there were 20 known 4

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Table I

ASSESSMENT FACTORS ASSOCIATED W I T H PREMATURE TERMINATION

Assessment Factors

Group

Adjusted Score

1. Childhood Attachment

CT PT CT PT CT PT CT PT CT PT CT PT CT PT CT PT CT CT PT CT PT CT PT CT PT CT PT CT CT PT CT PT

59 56 67 49 56 38 57 49 38 40 57 50 63 52 70 55 64 48 59 46 62 43 70 48 73 56 60 55 62 54 60 48

2. Past +ve Treatment 3. Past +ve Transferences 4. Clinical Functioning 5. Symptom Duration 6. Affect Availability 7. Patient Alliance 8. Therapist Alliance 9. Introspection 10. Object Relatedness 11. Frustration Tolerance 12. Motivation 13. Life Circumstances 14. Work Adaptation 15. Sexual Functioning 16. Impulse Control CT = Continuing Treatment Group, N = 20 PT = Premature Termination Group, N = 20

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Probability n.s. n.s. p .006 p .01 n.s. p .037 n.s. p .001 p .001 p .012 p < .001 p < .001 p .001 n.s. n.s. p < .01

Assessment Factors Associated w i t h Premature Psychotherapy Termination premature terminators (PT), giving an approximate dropout rate of 1 i n 4. One of the advantages of a descriptive assessment questionnaire is that the assessed qualities are itemized and described rather than demanding global ratings concerning complex factors subsumed under the a single heading. This sample of therapists is representative of the more senior psychiatric residents and interested psychoanalytic candidates. The chosen outpatients had no obvious contraindications for intensive psychotherapy and had expressed a verbal commitment to undertake twice weekly expressive psychotherapy or 4-5 times weekly psychoanalysis following the assessment interviews. Those patients who eventually dropped out (PT) generally had higher pathology ratings and showed significantly more ego deficits (graph 1). O u r outcome results show that the factors that are positive predictors of patients continuing therapy (CT) are the ego strengths of introspection, impulse control, and frustration tolerance along w i t h a high degree of early motivation. Surprisingly perhaps, was the degree of importance of positive life circumstances and support for those continuing on i n therapy. That the therapists' alliance (countertransference) turned out to be a more significant predictor than the assessed patients' alliance (transference), probably reflects the therapists' bias. I t has been previously noted that therapists rate the attitude of poorer-outcome patients as being more positive than do the patients when rating themselves. O u r findings are also consistent w i t h the conclusions reached by Gaston and M a r m a r who reported that a higher degree of defensiveness and lower environmental support were associated w i t h decreased patient commitment and capacity to do therapeutic work. This suggests that inadequate therapeutic alliance development is not only a major predictor of poor clinical outcome but also of early dropout. Lower et a l . found that b o t h individual screening analysts and the group committee evaluation rated poor ego strength and social adaptation as the most unfavorable qualities when judging analyzability potential. They also stressed that psychosexual phase pathology ratings were not as reliably related to outcome as ego functioning ratings. Other assessment factors that have been added to the present expanded T.I.P. Assessment Questionnaire include: self-regulation, self-concept, object constancy, substance abuse items, as well as fantasy and dream awareness profiles. These factors are now part of the present psychodynamic assessment/evaluation questionnaire although they were not included at the time of this study. 18

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therapy. This finding is similar to the N . I . M . H . Collaborative Study where 32 percent (77/239) terminated before completing therapy and 44 percent (35/77) of those who dropped out d i d so within the first month of treatment. This suggests that there are at least two distinct groups of premature terminators excluding those who leave during the assessment. The first being the early terminators, where often there is insufficient motivation or the emergence of a powerful disorganizing negative transference and resistance at a time before a significant therapeutic alliance is available. The later terminators, perhaps are a more heterogeneous group, whose dropping out is a manifestation of a variety of other environmental and conflictual dynamic issues rather than their sharing of similar core conflicts. W h e n dropouts are followed-up, these former patients frequently will report that they left because therapy was not helping them or that their therapist d i d not seem interested or understanding of them. Patients' perceptions of their therapy are more reliably related to outcome than either the therapists' or observers' initial impressions. Although patients are the obvious ones doing the leaving, sometimes termination seemed to be an intersubjective reflection of their therapists' ambivalence, as well. Less openly spoken about are patients' erotic fears and envy of their therapists while overt problems such as time limitations and family/work responsibilities are often cited as being more acceptable reasons for not continuing further psychotherapy. Some patients feel that they do not want or need further treatment and are satisfied to leave i n spite of the therapists' pessimism over their seeming improvement or flight into health. I t is known that while therapists value insight as a necessary feature for lasting improvement, patients will rate feeling good about themselves and their improved life situation as more important factors i n their decision. 2

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Because a patient terminates prematurely it should not be assumed that this also represents an unsuccessful outcome. Waldinger and Gunderson's borderline-patient study found that the longer patients stayed i n treatment, the more they improved yet many of these longer-term but rated " successful" cases eventually terminated against the therapist's advice. They agree with Searles' concern that for therapists one of the most stressful aspects of practicing psychotherapy is dealing w i t h feelings of impotence and rage following the premature termination of therapy by their patients. Patient dropout is an unwelcome circumstance for most therapists, and particularly so when initiated by patients. This unexpected event can undermine therapists' confidence i n their ability to sustain loving feelings and to effectively grieve. Frequently the terminating patient is i n a state of negative transference and some w i t h a history of repetitive "impulsive" separations have an 4

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Assessment Factors Associated w i t h Premature Psychotherapy Termination absence of grief or other feelings of loss, particularly i f i n control of the separation. Dysphoric, vengeful feelings are then be left for the therapist to experience. Such patients now have actively reenacted that which they passively and helplessly had experienced i n childhood, i.e., they leave rather than be left. Pretherapy preparation for prospective patients should be considered. By providing written materials, preparatory films and workshops or even trial sessions, there is a supportive as well as an educational interaction that may enhance the patients' motivation and reduce unrealistic expectations. Such training may be helpful not only to the patients but also to the clinicians who will have additional observations i n order to chose the most suitable forms of psychotherapy for their patients. W e have had a positive experience giving prospective psychotherapy patients a pretreatment guide to psychotherapy. This does not replace individual orientation discussion w i t h the therapist but has been useful i n helping to clarify the psychotherapy contract, frame, and procedural issues. I n our opinion such information and knowledge does not stimulate unmanageable transferences but can be a positive influence i n facilitating a working alliance. The psychoanalytic control cases d i d not receive formal preanalytic preparation but generally had more assessment orientation interviews than d i d the psychotherapy patients prior to making their commitment for treatment. 23

This study does not report on the assessments of the patients by the therapists' supervisors that were usually completed at the same time as the assessments done by the therapists. A consistent finding was that the supervisors rated the patients initially as having higher impairment scores than their supervisees. A m o n g the less experienced therapists/supervisees, ratings for the patient's immediate transference and therapist's countertransference items as well as the patient's manifest object relatedness and capacity for self-inquiry, seemed unduly optimistic when compared to their supervisors assessments. I t has been previously reported that agreement among experienced supervisors concerning trait and ability ratings, is highly correlated. ' Further patient ratings done by these same therapists-intraining at 9 or 12 months time usually reflected a higher awareness of patient pathology even when there had been obvious patient improvement. One wonders about the unconscious use of denial, show of optimism and expectant faith that b o t h therapists and patients require i n order to undertake an intensive, intimate, therapeutic relationship particularly without specific time limitations. I t is our impression that after therapy has progressed, these same therapists are not only more understanding of their 5

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patients' pathology and aware of their own countertransference but are also less defensive i n identifying these problematic areas. The emphasis i n this paper on the patient factors is not meant to exonerate poor therapists who because of lack of skill, empathic failure or incompetent interventions can drive away even the most motivated patients. There should be encouragement and opportunity for therapists who wish to take part i n a sensitivity group experience and/or individual therapy particularly concerning countertransference and empathic problems. The supervisors felt that as a rule the therapists that took part i n this project were adequate, interested, and had been successful w i t h other patients. I t is highly unlikely that any one type of therapist can be as equally effective w i t h all types of patients. Further research into patient/therapist matching and therapist support systems is required. Early diagnostic awareness and technical innovation is crucial i n identifying and dealing w i t h the factors leading to potential premature termination of psychotherapy. Further research and follow-up of terminated patients, is necessary to clarify the demographic and clinical variables within the different attrition groups. 24

SUMMARY Characteristics of patients accepted for b o t h intensive psychotherapy and psychoanalysis were rated during their initial assessments. Twenty cases that terminated prematurely (most within the first month) were compared w i t h twenty cases that continued i n therapy. While neither specific diagnosis, type of insight therapy, nor gender of the patient or therapist was a reliable predictor of premature termination, it was found that psychodynamic and environmental assessment factors significandy differed between these two groups. I n those patients who eventually dropped out, specific ego deficits, primarily introspection, frustration tolerance, impulse control, and motivation, were rated as significantly more impaired. The therapists' negative feelings toward their prospective patients and the patients' hostility toward past caretakers and present life circumstances were also associated w i t h premature termination. A c k n o w l e d g m e n t s : I wish to acknowledge the help of the candidates of the Toronto Institute of Psychoanalysis as well as Cathy Spegg, the residents, and psychotherapy supervisors of the Clarke Institute of Psychiatry, for their contributions to this project.

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