Therapist Indicated Premature Termination, but What Did The

UNIVERSITY OF CINCINNATI

______, 20 _____

I,______, hereby submit this as part of the requirements for the degree of:

______in: ______It is entitled: ______

Approved by: ______

PREMATURE TERMINATION: THE PATIENT’S PERSPECTIVE A dissertation submitted to the Division of Research and Advanced Studies of the University of Cincinnati

in partial fulfillment of the requirements for the degree of

DOCTORATE IN PHILOSOPHY (Ph.D.)

In the Department of Psychology Of the College of Arts and Sciences

2001

David J. Reynolds B.S., S.U.N.Y. College at Brockport, 1994 M.A., University of Cincinnati, 1997

Committee Chair: Edward B. Klein, Ph.D. 2

Abstract

PREMATURE TERMINATION: THE PATIENT’S PERSPECTIVE David J. Reynolds

This thesis compares patients who prematurely terminated psychological services to those who completed or continued treatment. It examines between-group differences in demographic and clinical variables, including patients’ opinions about their therapists as well as their responses to open-ended questions regarding hopes, surprises, and the most and least effective aspects of treatment. Premature terminators are defined as patients who stop psychological services before meeting their treatment goals – as judged by their therapist – with or without informing the therapist. Data were collected as part of a larger naturalistic study of the effectiveness of a waiting- list group, which patients could attend after their initial interview but before they were assigned a therapist at a university-affiliated urban mental health center. The data clarify the consistent finding that race, education, and income have a low to moderate relationship with premature termination. Compared to completer/continuers, premature terminators were more likely to be African- American, less educated, and report less income. While premature terminators did not differ from completer/continuers in terms of symptom discomfort, as measured by the OQ-45, they rated as significantly lower their overall benefit from treatment, and the extent to which their therapists were likable, understanding, and gave good advice. Patient ratings of getting good advice and being understood emerged as the best predictors from among other variables that included race- and gender-based matching of patient to therapist, patient ratings of therapist abilities, prior inpatient or outpatient experience, education, occupational status, occupational type, and reported monthly income. Good advice and understanding together predicted 34% of the variance and correctly classified 71% of patients in a bivariate logistic regression. A similar percentage of the two groups reported medication and talking one-on-one as “hoped for” treatments and experienced “talking” as the most effective part of treatment. Few members of either group reported positive or negative surprises with treatment.

For Angela

Acknowledgements

Many thanks to my committee; Edward B. Klein, PhD, Walter N. Stone, MD, and Robert W.

Hatfield, PhD. Your patience and encouragement have been much appreciated over the years. You are the models upon which I shall base my career. Thanks also to the statisticians who provided additional feedback: Jamie DeCoster, PhD, Department of Social Psychology, Free University

Amsterdam; Karen Scheltema, PhD, HealthEast Research and Education, St. Paul, MN; Eric

Gerber, MA, University of Georgia, Athens; Paul McGeoghan, PhD, Information Services, Cardiff

University; and Susan Elgie, PhD, Research Consulting Service, University of Toronto. And a final thanks to Horace Freeland Judson, Center for the History of Recent Science at George Washington

University, for his editorial comments.

Table of Contents

Chapter One: Literature Review……...……………………………………………………….…10

Chapter Two: Method…………………………………………………………..……...….….…..32

Chapter Three: Results……………………………………………………………..……...... …...39

Chapter Four: Discussion……………………………………………………………..……...…..50

Table of Contents

Chapter One: Literature Review……………..…………………….…………………...….…….10

A Definition……………………………………………………………...…………...…….11

Race………..…………………………………………………………………………...…..19

Gender…….………………………………………………………………………………...21

Education………………………………………………………………………………..….22

Income………………………………………………………………………………….…..23

Initial discomfort level………………………………..……………………………….…....24

Therapeutic factors identified by patients……………………………………………..……25

Hopefulness…………………………………………………………………….…..25

Good advice……………………………………………………...…………………26

Likeability...…………………………………………………………………….…..28

Understanding…………………………………………………………………..…..28

Encouragement…………………………………………………………………...... 28

Patient expectations………………………………………………………………………...29

The patient’s perspective…………………………………………….…………………..…30

Chapter Two: Method……………………………..……………………………………………..32

Participants………………………………………………………...………………….……32

Design……………………………………………………………...………………..……...32

Measures…………………………………………………………..………………..……....33

OQ-45……………………………………………………………………………....33

Follow-up Interview………………………………………………………………..34

Setting……………………………………………………………...………………..……...34

Procedure………………………………………………………...………………..………..34

Numerical coding of premature terminators vs completer/continuers……………...36

Chapter Three: Results……………………………….…………………………………………..38

Participant Demographics…………………………………………………………………..38

Forms of treatment entered by participants………………………………………………...38

Comparison of patients who did and did not respond to follow-up interview……………..41

Premature terminators……………………………………………………………………....41

Hypothesis I………………………………………………………………...……………....42

Hypothesis II……………………………………………………………...….………….….44

Hypothesis III……………………………………………………………….……………...47

Chapter Four: Discussion………….……………………………………………………………..50

Communication Barriers…………………………………..………………………………..53

Good Advice and Understanding…………………………………………………………...54

Generalizability…………………………………………………………………...………...55

Limitations……………………………………………………………………………….…55

Likert Ratings………………………………………………………………………55

Consent of Patients with Previous Therapy Experience…………...……………….55

Recommendations…………………………………………………………..……………....56

References………………………………………...………………………………….…………….59

List of Tables & Appendices

Table 1 (Descriptive Statistics for Continuous Variables)……………….…………………..…….39

Table 2 (Descriptive Statistics for Categorical Variables)…………………………..……………..40

Table 3 (Therapeutic Ratings for Premature Terminators and Completer/Continuers)...………….44

Table 4 (Classification of Premature Terminators Versus Completer/Continuers Using Good

Advice and Understanding)……………………………………………………………………...…47

Appendix A: Follow-Up Discussion: Attitudes About Central Clinic…………………………..…70

Appendix B: Patients Hope for Treatment…….………...……………………….……………...…72

Appendix C: Patients’ Surprises with Treatment…………….…………………………………….76

Appendix D: Patients’ Most Useful Aspect of Treatment………..………………………………...78

Appendix E: Patients’ Least Useful Aspect of Treatment..…………………..…………………….81

Chapter One

A Definition

Premature termination from psychotherapy essentially describes a situation in which patients stop treatment before they have resolved their issues or met their goals. This is in contrast to patients who complete therapy by eventually meeting their initial treatment goals. One question that has been raised concerns the criteria according to which patients are deemed to be premature terminators. For some investigators, premature termination occurs when patients fail to attend a particular session, such as the second (Epperson, Bushway, & Warman, 1983). For others, failure to attend treatment with a given frequency has been used to define premature termination. For example, patients who attend fewer than one session per week might be considered premature terminators. Additionally, attendance at fewer than a set number of sessions has qualified as premature termination (Cole, Branch, & Allison, 1962). In the latter formulation, termination has been considered premature if the patient attended fewer than ten sessions (Cartwright, Lloyd, &

Wicklund, 1980). Duration-based assessments have also been used such that premature termination was defined as attending treatment for less than one year, regardless of the frequency or total number of sessions attended (Atwood & Beck, 1985).

Throughout the literature, the predominant definition of premature termination has been by therapist judgment. Patients have been deemed premature terminators when they unilaterally 11

withdrew from treatment at any point because of a lack of interest or willingness, against – or without – therapist consent (Carpenter, Del Gaudio, & Morrow, 1979).

The definition of premature termination used by researchers is important because it, in part, determines the reported rate of drop out. In their large-scale review of published studies, Wierzbicki and Pekarik (1993) found significant differences in premature termination rates that depended on the definition of this phenomenon. Overall, studies that defined premature termination based on patients’ failure to attend a given session, such as the second, reported lower drop out rates than did studies that used therapist judgment or the total number of sessions attended. Specifically, the average rate of premature termination when defined by failure to attend a particular session was

35.87% (SD = 16.47%). Wierzbicki and Pekarik (1993) reported that this rate was significantly lower than when premature termination was defined by number of sessions attended (M = 48.23%,

SD = 21.39%) or by therapist judgment (M = 48.43%, SD = 23.59%), F (2, 118) = 3.22, p < .05.

A review of the literature on premature termination reveals that, in contrast to therapist judgment, definitions based on frequency of attendance or the total number of sessions attended appear to be used because they are reliable and convenient. Such definitions are reliable in the sense that raters can readily agree as to whether a patient attended less than one session per week or less than ten sessions in total. These definitions are convenient because when researchers find that the patient sample attended an average of ten sessions, they define premature termination as attendance at fewer than ten sessions. Alternately, if patients attended for an average of four months, then premature termination is defined as attendance for less than four months. The practical advantage of using these definitions is that they allow for roughly equal samples of appropriate and premature

terminators to be obtained, which facilitates statistical analysis. However, few researchers provide a theoretical rationale as to why these definitions are used.

The rationale for using therapist judgment to define premature termination is inherent in the therapeutic process. When a patient approaches a clinic for psychotherapeutic service, some form of screening usually takes place by the entry staff (Levinson and Astrachan, 1974). Typically, the patient meets with a mental health provider for an intake interview in which the clinician determines the nature of the patient’s request for services. The interview attempts to determine whether the patient meet the clinic’s criteria for receiving services, and whether the clinic has the services necessary to meet the patient’s needs or wants. If not, the patient is referred to another agency, or some alternative treatment is offered. If the patient meets clinic criteria and services are available, therapy begins. Where therapy begins depends upon the patient’s initial goals. For example, many patients want to feel less depressed or anxious, or communicate better with a significant other. That is their goal. If they do not meet it and they stop coming to treatment, they have prematurely terminated. As the only other person privy to this goal, the therapist would appear to be a good judge of premature termination.

When premature termination is based on attendance at an arbitrary number of sessions, rather than therapist judgment, a large number of patients are misclassified (Morrow, del Gaudio, &

Carpenter, 1977). That is, the determination that the patient was a dropout or an appropriate terminator was mistaken. For example, while some patients may attend 25 sessions but not invest a great amount of time or energy and thus not accomplish their goals, other patients might attend only eight sessions and still meet their goals because of their immense efforts. Using a session-based definition, the first patient would be considered an appropriate terminator, whereas clinically he or

she should be viewed as a premature terminator; similarly the second patient would be considered a dropout, but clinically should be defined as an appropriate terminator.

In their meta-analysis, Wierzbicki and Pekarik (1993) advocated for therapist-based definitions of premature termination. They asserted that while such definitions may not be as reliable, they are face valid, more flexible, and more fundamental than either the termination-by- failure method or duration-based definitions. Therapist-based definitions are fundamental in the sense that no one knows more about whether the patient terminated prematurely or appropriately than the therapist – except perhaps the patient himself or herself. However, it should be noted that no published studies allowed patients to define whether they had prematurely or appropriately terminated psychotherapy.

The first comprehensive literature review of premature termination appeared in 1975 with

Frederick Baekeland and Lawrence Lundwall’s, “Dropping out of treatment: A critical review,” a

53- page article published in Psychological Bulletin. The authors summarized findings from 362 articles published in several treatment arenas including medicine, substance abuse, and mental health. At the time, only 74 studies had been published on premature termination with psychotherapy outpatients, five of which related to child psychotherapy, seven to group, leaving 62 studies of adults in individual therapy.

In their review, Baekeland and Lawrence set out to answer several questions about premature termination from individual psychotherapy. First, they tried to identify what type of patient terminates prematurely, whether there are one or several kinds of dropouts, and whether attrition could be reliably predicted. The authors also questioned why patients drop out. They postulated three causes including characteristics of the patient, treatment setting, or therapist.

Finally, the authors asked what happens to dropouts, whether or not such patients should be considered treatment failures, and what – if anything – can be done to prevent premature termination.

In an attempt to consolidate findings gleaned from the 62 studies, Baekeland and Lundwall concluded:

[A]lthough the age of the patient predicts dropping out of individual psychotherapy,

the relationship between age and length of treatment is a complex one that depends

both on type of treatment and source of referral. On the other hand, it is clear that the

patient most likely to drop out is an unaffiliated, lower socioeconomic status female

who may either have paranoid or sociopathic features and enters treatment with low

levels of anxiety and/or depression. Poorly motivated, she is not very

psychologically minded, tends to use a high degree of denial, and has problems in

the area of either overt behavioral dependence or counterdependence.

The therapist most likely to lose his patient is less experienced, more

ethnocentric, dislikes his patient or finds him boring, and does not give lower

socioeconomic status patients medication. Male therapists are particularly likely to

lose very unproductive patients [those who do not progress towards treatment goals],

and female therapists, those who are highly productive [those who make rapid

progress towards their goals]. Other factors promoting patient attrition … are delay

in case assignment, low patient-therapist similarity, and discrepant treatment

expectations (p. 759).”

In 1986, Sol Garfield reviewed all but one of the 62 studies cited by Baekeland and

Lawrence and an additional 23 articles that had been published in the intervening years. He concluded that patient attrition was most consistently related to social class – low SES, low level of education, and minority status – and not with the other variables mentioned by Baekeland and

Lundwall.

Both of these reviews used a box-score approach to tabulate findings. In this procedure, for example, if four of six articles found age significantly related to dropping out, then this was deemed a consistent finding. Prior to the advent of meta-analysis, this was the typical review approach.

However, the box-score approach cannot account for such differences between studies as sample size and the definition of premature termination used. As noted earlier, in some studies premature termination was defined as patients not returning for any scheduled session, while in others the therapist’s assessment that patients left treatment before having met their initial treatment goals defined premature termination.

Meta-analysis has been considered a more accurate and objective means of evaluating a large body of research as it requires explicit criteria for including studies and calculates a common metric, effect size (d), to be compared across studies (c.f., Cook & Leviton, 1980; Glass, McGaw,

& Smith, 1981; Rosenthal, 1984; Smith, Glass, & Miller, 1980; Wolf, 1986). While meta-analytic techniques were developed in the early 1980s, it was not until 1993 that a study was published on premature termination using meta-analysis. Michael Wierzbicki and Gene Pekarik (1993), in their article “A Meta-Analysis of Psychotherapy Dropout,” reviewed the 62 articles cited by Baekeland and Lundwall (1975), the other 23 cited by Garfield (1986), and an additional 127 articles

published between 1984 and 1990, for a total of 212. The authors included in their analysis only those studies that (a) were published in English, (b) reported a dropout rate from psychotherapy, (c) included only patients – not therapy analogues, and (d) addressed diagnoses other than substance abuse or dependence, leaving 125 studies for analysis.

Based on their initial review of the literature, Wierzbicki and Pekarik (1993) identified 42 variables significantly associated with premature termination. They excluded ten of these variables because they were redundant because they were examined in only a few published studies. The authors categorized the remaining 32 variables of interest into four domains: study, demographic, psychological, or therapist variables. Study variables included year of publication, definition of dropout (failure to attend a scheduled session, therapist judgment, or number of sessions attended), treatment mode (individual therapy versus group/family/couple therapy), setting (university counseling center or department of psychology clinic, private clinic/private practice, public clinic/community mental health center, or other), patient type (adult, children, or mixed) and sample size. Demographic variables included sex, race, age, education, SES (mean Hollingshead and Redlich rating), and marital status.

Psychological variables included emotional, behavioral, psychotic, substance abuse, and health/developmental disorders. For all disorders the authors recorded the percentage of each type included in the patient sample. Other variables included prior treatment, waiting period (mean number of weeks between intake assessment and the beginning of treatment), mean number of sessions, and referral source. Therapist variables included sex, race, experience (mean number of years in practice), and professional degree (percentage of therapists with a PhD, MD, MSW, MA, or other type).

One of the more important issues the authors addressed was whether premature termination should be of major concern to researchers and therapists alike. That is, if the overall rate of premature termination was relatively low, why bother with it? Wierzbicki and Pekarik (1993) calculated a mean drop out rate of 46.86% (SD = 22.25)1 across studies. The authors indicated that the drop out rate was not significantly related to any of the study variables (publication year, treatment mode, setting, or patient type). Thus, nearly every other patient terminated prematurely, a stable phenomenon in children and adults over the last 50 years2 regardless of whether patients attended group or individual treatment at university clinics or community mental health centers.

Wierzbicki and Pekarik (1993) also analyzed those variables for which there were at least ten studies reporting an effect size – a common metric used to directly compare studies regardless of what statistic they used (z, t, F, X2, r) – or for which an effect size could be computed based on the raw data reported. Only six of the 32 variables investigated had ten or more studies that yielded an effect size; race, education, income, sex, age, and marital status. Thus, demographic variables were the only ones used in the meta-analysis to differentiate premature terminators from appropriate terminators. Of these, only race, education, and income had a significant effect size (M effect size = .23 - .37, all ps < .01): African-Americans and other minority groups, those with a low level of education, and those with low income levels were at increased risk of dropping out. With regard to the non-significant variables, women were no more likely to drop out than men. The old were no more likely to drop out than the young. And the married were no more likely to drop out than those who were not married.

1 The 95% confidence interval was 42.9% to 50.8%. 2 Studies examined by Wierzbicki and Pekarik were published as early as 1953.

These three comprehensive studies provide qualitative (box score) and quantitative (meta- analytic) evidence for the assertion that race, education and income are significantly related to premature termination from psychotherapy. However, based on the observation that non-significant effects were more likely to have been reported with insufficient information so as to allow

Wierzbicki and Pekarik (1993) to calculate an effect size, the mean effect sizes listed above should be regarded as the upper estimate for these variables. The question therefore remains as to what other factors might contribute to premature termination.

Neither Baekeland and Lundwall (1975), Garfield (1986), nor Wierzbicki and Pekarik

(1993) offered any suggestions as to why race, education, and income were associated with premature termination while gender, age, and marital status were not. These demographic variables have in common not only the fact that they are easily and typically collected – thus their recurrence as variables of investigation – but also that people commonly use them to define themselves relative to one another as similar or dissimilar, and upon which they form stereotypes. Based on experience, people associate specific groups with certain categories of behavior. Stereotypes, as heuristics, allow one to feel better able to predict other people’s behavior – regardless of how accurate or inaccurate those predictions may be.

Given the stereotypes associated with race, education, income, gender, age, and marital status, communication across different levels of these variables (e.g., an African-American person communicating with a white person) might be more difficult than communication within them (e.g., two white people communicating). Extended to psychotherapy, communication is facilitated by similarity and hampered by differences between patient and therapist for the above variables

(Flaskerud, 1986; Takeuchi, Mokuau, & Chun, 1992). Imagine, for example, a young, white, single

male therapist working towards a PhD in Clinical Psychology communicating in session with an elderly African-American woman twice divorced, once widowed, now dating, without a high school education, living on welfare, who has worked mainly as a waitress or janitor. Each categorical difference – like a gap or chasm between them – must be bridged for treatment to be effective.

Premature termination may be associated with race, education, and income, but not gender, age, and marital status, because differences in race, education, and income create a greater communication gap between patient and therapist than do differences in gender, age, and marital status. Thus, while distances created by differences in the former cannot easily be bridged, differences in the latter can. The result might be a greater frequency of premature termination when patient and therapist differ on race, education, or income as compared to gender, age, and marital status.

Race

The communication gap between patient and therapist may reflect both contemporary and historical differences, particularly with regard to race. As mentioned, African-American patients and those from other minority groups are more likely than whites to drop out of treatment. In order to explain their relatively greater frequency of premature termination, some have suggested that

African-Americans do not value psychotherapy or are not as introspective as whites. However, research has repeatedly suggested that racial mistrust better explains why African-Americans drop out of treatment more often than whites (Briley, 1977; Gardner, 1971; Wright, 1975; Yeh, Eastman,

& Cheung, 1994).

The obvious possibility is that slavery and the ensuing state of relative oppression has resulted in an expectation on the part of African-American patients for mistreatment when dealing with white counselors. Indeed, more recent research suggests that African-Americans expect less satisfactory treatment and hold more negative attitudes towards entering treatment with white as opposed to African-American therapists (Nickerson, Helms, & Terrell, 1994). This, in part, may explain African-Americans’ reluctance to enter treatment (Andrulis, 1977; Neighbors & Jackson,

1984; Smead, Smithy-Willis, & Smead, 1982; Temkin-Greener & Clark, 1988).

Given the mistrust that typically exists between African-Americans and whites, therapeutic relationships have been shown to develop slowly as both parties proceed with caution in their attempts to understand one another’s viewpoints (Gardner, 1971). Racial mistrust is therefore an obstacle to effective treatment (Grier & Cobbs, 1968; Ridley, 1984; Sue & Sue, 1990; Vontress,

1971) and a likely cause of premature termination (Terrell &Terrell, 1984).

Patients who receive services across ethnic and/or racial lines (e.g., an African-American patient in treatment with a white therapist) are more likely to drop out than patients who receive services from therapists of the same race and/or sex (Flaskerud, 1986). Takeuchi, Mokuau, and

Chun (1992) found that premature termination was reduced when patients were matched with therapists whom they trusted. Ethnic/racial match of therapists and patients was one of the top three predictors of premature termination in a culturally diverse sample (Flaskerud, 1986).3

The effectiveness of race-based patient-matching does not appear to be due to a differential level of care. Zane, Hatanaka, Park, and Akutsu (1994) found no differences in the services provided to matched and mismatched patient-therapist dyads. Watkins and Terrel (1988) found that

African-American patients who were mistrustful of white therapists expected them to be less accepting, trustworthy, and expert. They also expected less in terms of a therapeutic outcome.

Gender

Just as historical differences between races might contribute to the communication gap that exists between racially dissimilar patients and therapists, gender differences – regardless of whether they are fundamentally biological, psychological, or social in origin – might also impact the communication gap between male-female patient-therapist combinations. While gender differences are a contentious area of research and not the primary focus of the present study, they do extend to psychotherapy process and outcome (Jones, Krupnick, & Kerig, 1987; Jones & Zoppel, 1982) and may explain some aspects of premature termination.

Male therapists display more direction and control with their patients than do female therapists (Nelson & Holloway, 1990; Wogan & Norcross, 1985). Female therapists, relative to males, show more empathy (Rice & Rice, 1973), relatedness (Kaplan, 1985), and empowerment

(Cooke & Kipnis, 1986). That is, female therapists are more likely than males to identify how patient behaviors can be understood within the context of their emotions, and suggest and encourage patients to take control of their emotions in order to change their behavior.

Differences in their overall childhood and adult development (Miller, 1984), communication (Tannen, 1990), and level of intimacy in relationships (Belle, 1982) may account for differences in therapeutic style and effectiveness of male and female therapists. However, some researchers have contested that therapist gender does not show a clear effect on treatment outcome

3 The sample (N = 300) was 23.5% Mexican, 22.8% white, 18.1% African-American, 17.1% Vietnamese, 16.8% Filipino, and 1.7% other ethnic group.

(Beutler, Crago, & Arizmendi, 1986; Garfield, 1994) and that patients themselves do not rate male and female therapists’ level of empathy differently (Zlotnick, Elkin, & Shea, 1998).

As noted previously, the relationship between patient gender and premature termination did not reveal a significant effect size in the meta-analysis conducted by Wierzbicki and Pekarik

(1993). In contrast to the findings of Baekeland and Lundwall (1975) and Garfield (1986) – that women were more likely than men to prematurely terminate – Wierzbicki and Pekarik found women and men to be equally likely to drop out of treatment. However, few if any studies have assessed premature termination of patients matched or mismatched with therapists based on gender.

As patients generally prefer therapists of their own gender (Pikus & Heavey, 1996; Simons &

Helms, 1976; Stamler, Christiansen, Staley, & Macagno-Shang, 1991), mismatching patients based on this variable may precipitate premature termination.

Education

As with race and gender, education level is a category to which stereotypes and expectations apply such that perceived differences between individuals may result in communication difficulties.

Therefore, differences in education level between patient and therapist might be related to premature termination. Unfortunately, no published studies could be located that directly examined the association between premature termination and the degree of similarity between patient and therapist education level.

While some negative results do exist in the published literature (Beckham, 1992), as previously mentioned, Baekeland and Lundwall (1975), Garfield (1986), and Wierzbicki and

Pekarik (1993) found patient education level to be significantly related to premature termination:

The higher the patients’ educational status, the more likely they were to complete treatment. This

has been found not only with white and African-American patients, but also Mexican, Vietnamese, and Filipino clients (Flaskerud, 1986). The association between education level and premature termination also holds for such diverse diagnostic categories as batterers (Grusznski & Carrillo,

1988) and anorexics (Vandereycken & Pierloot, 1983).

In contrast to race and gender, the education level of the therapist can to some extent be assumed. Psychiatry residents have a medical degree as well as additional training. Clinical psychology and social work students have a master’s level education or higher. This, coupled with the finding that the higher a patient’s education level the less likely he or she is to drop out, suggests that dissimilarity in education level may be important in premature termination.

Income

At a practical level, patients with the lowest income (young, single, female minorities without a high school education) may have to choose between paying for treatment and paying for food or other necessities. As mentioned, low-income status is a reliable predictor of premature termination (Gill, Singh, & Sharma, 1990; Nevid, Javier, & Moulton, 1996), as is a history of unemployment (Christensen, Valbak, & Weeke, 1991). The income levels that coincide with unemployment and occupational status are also associated with premature terminations in multivariate studies – those that simultaneously examine differences along several variables (Gill,

Singh, & Sharma, 1990; Tehrani, Krussel, Borg, & Munk-Jorgensen, 1996). Obviously enough, patients who feel they cannot afford treatment discontinue services before meeting their goals

(Swett & Noones, 1989). Similarly, patients who do not have mental-health insurance have higher attrition rates than do patients who have adequate mental health coverage (Swett & Noones, 1989).

As with education, a certain level of income can be assumed for most therapists. Excluding those in training, most clinicians earn more than the median income for any given year. It may be that a discrepancy between patient and therapist income levels is predictive of premature termination. Whether the differences are real or perceived – as with race, gender, and education – patients and therapists alike may allow their beliefs about how much money the other is making to affect their views of treatment, which may ultimately hamper therapy. This may also be true with therapist trainees – who typically make much less – because their economic outlook is relatively bright.

Initial discomfort level

The meta-analysis by Wierzbicki and Pekarik (1993) suggested that race, education, and income level had a low to moderate effect on premature termination rates. Additionally, sex, age, and marital status were not significantly related to premature termination. The question remains as to what other variables might explain premature termination.

Patient discomfort level at the time of intake may also affect premature termination. That is, the extent to which the patient’s symptoms – whether sleeplessness, headache, or loneliness – upset them may be related to whether or not they drop out. The evidence is mixed, however. While some studies have found an inverse relationship between premature termination and patients’ general level of discomfort (Kelly, Soloff, Cornelius, & George, 1992; McCallum, Piper, & Joyce, 1992;

Sterling, Gottheil, Weinstein, & Shannon, 1994; Tutin, 1987), others have not (Persons, Burns &

Perloff, 1988). Some studies have found that the patients’ presenting complaint and accompanying

Axis I diagnosis (non-characterological disorders) have been associated with attrition (Greenspan &

Kulish, 1985). However, other studies have found that diagnosis does not predict whether patients

will complete therapy (Alexander & Eagles, 1993). One explanation for these discrepancies relates back to the rationale for meta-analyses: Differences in definitions of premature termination result in different rates of premature termination.

Therapeutic factors identified by patients

Variables that patients associate with effective treatment – when asked – include (a) their feeling hopeful about the future, (b) believing their therapist gave them good advice, (c) liking their therapist (d), feeling understood by their therapist and (e) feeling encouraged by their therapist

(Conte, Buckley, Picard, & Karasu, 1994).

Hopefulness. C. R. Snyder (2000) defined hope as the perceived capability to (1) derive pathways to desired goals and (2) motivate oneself via agentic thinking to initiate and sustain movement along those pathways. In theory, how people think about themselves and the consequences and causes of various life events determines – to some extent – whether or not they become depressed (Abela, & Seligman, 2000).

With some similarities and differences hope has been included in various motivational and emotional theories, including optimism, self-efficacy, self-esteem, and problem solving, and has also been implicated as one of the common factors among differing psychotherapies (Wintson &

Muran, 1996). Lazarus (1980) considered effective psychotherapy to be both an art and science consisting of inspiring hope and achieving self-efficacy.

Hopelessness has been associated with some but not all depressive symptoms (Alloy &

Clements, 1998) in a wide range of patients, including those with cancer (Gil & Gilbar, 2001). The hopelessness theory of depression postulates that a negative attributional style puts people at risk for developing depressive symptoms. Joiners (2001) found that in three samples of university

students (N = 802), a negative attributional style was more often associated with hopelessness depression symptoms (e.g., difficulty making decisions or getting started) than with endogenous depression symptoms (e.g., loss of satisfaction, interest in sex, etc.).

Unfortunately, no large-scale studies have examined the impact of hope on premature termination. In a small sample of patients with bulimia nervosa, patients who dropped out of treatment showed a greater degree of hopelessness than did those who completed the program

(Steel, Jones, Adcock, Clancy, Bridgford-West, & Austin, 2000).

Looking to the group-psychotherapy literature, instilling hope has been regarded as one of many therapeutic factors (Bloch & Reibstein, 1980; Bloch, Reibstein, Crouch, Holroyd, & Themen,

1979; Kivlighan & Goldfine 1991), particularly during the early stages of group development

(MacKenzie, 1997). Yalom (1985; 1995) identified instilling hope as one of 11 therapeutic factors of group psychotherapy, a finding based on evidence from faith healing and placebo studies as well as research suggesting that a pre-therapy expectation of help is predictive of positive outcome.

Instilling hope is commonly a part of such groups as Alcoholics Anonymous and Recovery, Inc., a self-help group for current and former psychiatric patients. Seligman and his colleagues (Seligman,

Schulman, DeRubeis, & Hollon, 1999) have shown that group workshops based on a cognitive- behavioral model that views depression as related to a pessimistic explanatory style was useful in preventing both depression and anxiety in asymptomatic university students followed over a three- year period.

Good advice. Lieberman, Yalom, and Miles (1973) found that getting advice was ranked fourth among 14 variables related to how student-participants said they learned best in encounter groups. The authors believed that participants experienced getting advice as meaning someone

cared for them and that they could make changes in their life (p. 373). Yalom (1995) noted that while getting good advice is typically not directly beneficial to any patient, the indirect message – that the patient is cared for and interesting – is beneficial. Strupp, Schacht, Henry, and Binder

(1992) noted that when patients perceive therapist advice as constructive and helpful, premature termination is forestalled.

As might be expected, giving and receiving advice is a complex process in psychotherapy.

Patients may experience therapist advice as good at a practical level, an emotional level, or both.

For example, therapist statements to a client that he or she talk more with their spouse about their feelings of depression may make sense and therefore be seen as good advice. But even if it does not make sense to the patient, it may be experienced as good at an emotional level because the patient got something from the therapist.

Therapists, too, give advice not only as a form of intervention (i.e., to be of help), but also to allay their own feelings of anxiety and helplessness. It is as if the therapist is saying to himself or herself, “What this patient is going through would never happen to me because I would do X and

Y.” Similarly, giving advice on the part of the therapist, as opposed to addressing the client’s underlying emotional concerns, may be seen as an attempt to stem the patient’s emotional bleeding or suppress their affect. Here, it is as if the therapist is telling the patient that he or she need not feel so miserable because if they just did X and Y, things would be OK.

Ultimately, it is the patient – not the therapist – who decides whether the advice given was good or not. And it is this determination that is likely to influence whether patients terminate treatment prematurely.

Likeability. The extent to which patients rate their therapists as “likeable” or attractive has been associated with premature termination. That is, the more attracted a patient is to their therapist, the less likely the patient is to drop out (Tryon, 1989). Other studies have not evidenced such a relationship (Kokotovic & Tracey, 1987). To some extent, the differences may depend on whether the therapist likes the patient. Caracena (1965), Katz and Solomon (1958), and McNair,

Lorr, and Callahan (1963) all found that therapists who did not like their patients were more likely to lose them (i.e., the patients dropped out). The differences may also be due to the manner in which attractiveness was measured.

Understanding. In several major theories of psychotherapy, feeling understood by the therapist plays an important role in treatment (Kohut, 1984; Rogers, 1959). However, a differentiation must be made between understanding, an intellectual grasping of the patient, and empathy, an emotional knowing of him or her (Starcevic, 1996). Both understanding and empathy assume that the therapist can know the innermost meanings and feelings of the patient, and furthermore that the therapist can express this to the client.

Patients of less effective therapist trainees felt less understood than patients of more effective therapists (Lafferty, Beutler, & Crago, 1989). In respect to warmth, understanding, empathy, and genuineness, Beckham (1992) found that premature termination patients tended to view their therapists more negatively than did those remaining in treatment. Therapists who are judged by clients to have accurately predicted their behaviors were seen as more understanding than therapists who made reflections or asked questions (Alpher & Turkat, 1986).

Encouragement. Encouragement is the state of being inspired, fostered, or heartened. With regard to psychotherapy, it is the extent to which the client feels motivated to make the changes

necessary to alleviate their symptoms. This is true regardless of whether change entails losing weight, taking medication on a regular basis, or learning a new skill such as assertion or anger management. At the group level (Yalom, 1995) this concept is more often related to group members’ statements to their peers, “You can do it!”

Patient expectations

Researchers have shown a recurring interest in clients’ expectations for treatment (Bordin,

1955; Hardin, Subich, & Holvey, 1988; Krause, Fitzsimmons, & Wolf, 1969; Tinsley & Harris,

1976), which are believed to play a role in premature termination. Patients enter treatment with various expectations, realistic and otherwise. At some point during therapy, patients must compare their expectations – what they thought would happen – to what is happening. Clients who are pleasantly surprised (i.e., something happened that exceeded expectations) might be more likely to remain in treatment than patients who were surprised by something negative (e.g., an adverse reaction to medication or extreme discomfort when talking about past abuse).

Patient expectations for treatment have been shown to affect the course and outcome of therapy (Penn, 1985; Richardson, 1993). Premature termination is common among clients who express either passive (“the therapist should cure me”) or dependent (“the therapist must always be there for me”) expectations (Reiser, 1985). Gunzburger, Henggeler, and Watson (1985) found that premature termination was positively associated with lower expectations for a positive therapeutic outcome, a finding also obtained with group psychotherapy patients (Connelly, Piper, de Carufel, &

Debbane, 1986). In contrast, Hardin, Subich, and Holvey (1988) found no differences in the expressed expectations of premature terminators in comparison to clients who completed therapy, even when controlling for problem type.

University psychology clinic patients who dropped out after their initial intake session reported fewer therapy expectations confirmed than those who continued in treatment (Horenstein

& Houston, 1976). Intervention studies have shown that clients’ motivation and outcome can be improved when their expectations are clarified in early interviews (Krause, Fitzsimmons, & Wolf,

1969). However, negative findings also exist. In a sample of community mental health center patients, those who dropped out were not significantly different from those who completed in terms of their treatment expectations (Feister, 1977).

The patient’s perspective

Overall, investigations of premature termination have predominately focused on sociodemographic variables; race, education, income, gender, age, and marital status. In part, this has been due to the relative ease with which these variables can be collected, either before or after clients terminate treatment. In contrast, relatively few studies have assessed patient opinions about their therapist or treatment (e.g., their hopes, expectations, or surprises). Buddeberg (1987) interviewed premature terminators and found that they generally held a more positive attitude towards quitting than did their therapists. Indeed, patients saw premature termination as a readiness to assume responsibility for their problems. Thus, from the client’s perspective, “premature termination” may be an inappropriate label.

In order to examine the impact patients’ opinions had on premature termination – data rarely collected in prior research – it was hypothesized that, compared to clients who completed or continued treatment, premature terminators would have significantly lower scores for all therapeutic factors: (a) feeling hopeful about therapy, (b) getting good advice, (c) liking their therapist (d), feeling understood and (e) feeling encouraged. A second hypothesis pertained to the

demographic variables. As previously mentioned, racial status, education, and income were the only variables for which significant effect sizes (albeit low to moderate) were obtained in a meta- analysis (Wierzbicki & Pekarik, 1993). In the present study, because communicating across these boundaries was assumed to be more difficult than communicating within them, it was hypothesized that gender- and race-matching would be the best predictors of completing or continuing in treatment. In other words, patients who were not matched with therapists based on race or gender would be more likely to drop out. Finally, related to the above two hypotheses, it was hypothesized that premature termination clients, compared to completer/continuers, would voice fewer hopes for therapy, more negative surprises, and would have experienced therapy as less effective for reasons related to the therapeutic factors, race, or gender issues.

Chapter Two

Method

The present study examines data collected as part of a larger project that investigated the psychosocial and economic effectiveness of a waiting-list group (c.f., Klein, Stone, Reynolds, &

Hartman, in press; Reynolds, Wright, Klein, Stone, Kraus, Hartman, & Creedon; 1998; Stone &

Klein, 1999).

Participants

Participants were 319 consecutive patients who approached Central Clinic during the study period. While a few clients came from the nearby university, most were inner-city residents.

Typically, one in three patients describe their race and ethnicity as African-American. One in four clients report having less than a high school education. One in three indicate they are unemployed, and the median income is about $5,500. Demographics specific to the present sample are reported below.

Design

The original waiting-list study – from which the present data were obtained – entailed offering patients an intermediary service other than waiting until a permanent provider became available. The waiting-list group was designed to provide prompt service to individuals seeking treatment who would otherwise have waited weeks or months before being assigned a provider.

The waiting-list group oriented patients to treatment by allowing them to present their problems, discuss themselves freely, and set goals from week to week.

The waiting-list group research project was designed as an effectiveness study. Therefore, patients were not randomly selected from the general patient population, nor were they randomly assigned to treatments. The aim was to approximate the typical operation of the clinic as dictated by 33

its overall mission – to improve patients’ general functioning. Addition considerations included the director of the clinic not allowing for random selection or assignment because of the possibility that funding agencies would react negatively, and the researchers’ concerns that patients themselves would react negatively (Klein, Stone, Reynolds, & Hartman, in press).

Measures

OQ-45. Lambert, Lunnen, Umphress, Hansen, and Burlingame (1994), creators of the

Outcome Questionnaire-45 (OQ-45) define it as a 45-item self-report measure of symptom discomfort (i.e., psychopathology), which assesses three main areas: Symptom Distress,

Interpersonal Relations, and Social Role. The symptom distress scale contains items assessing depression and anxiety-based intra-psychic problems. Satisfaction and problems with interpersonal relations are measured by the interpersonal role scale, including items about friction, conflict, isolation, inadequacy and withdrawal in dealing with friends, family, and marriage. Employment, family, and leisure-related performance difficulties were assessed by the social role scale, which contains items about one’s ability to work, love, and play.

The OQ-45 is internally consistent (alpha = .93) and reliable. The test-retest reliability is

.84. Its concurrent validity was estimated by correlating the OQ-45 with the Symptom Checklist-

90-R, the Beck Depression Inventory, the Taylor Manifest Anxiety Scale, and the State-Trait

Anxiety Inventory. The range was .64 to .88, p < .01 for all correlations. It should be noted that the authors of the OQ-45 identified a cutting score of 63 for classifying individuals as members of the patient population. The present patient sample is similar to other samples drawn from community mental health centers (c.f. Lambert et al., 1994).

Follow-up interview. An interview was designed by the waiting-list research group to address patients’ views on treatment and their use of various community resources. The question format for patients’ views on treatment is contained in Appendix A. Approximately 90-120 days after the intake appointment, patients were asked to rate their overall benefit from treatment, and the extent to which they felt their therapists were likable, encouraging, gave good advice, made them feel hopeful, and understood them. The anchors for the five-point Likert scale were: (1) not at all, (2) slightly, (3) moderately, (4) very much, and (5) highly. Patients were also asked open-ended questions about their hopes for, surprises with, and most and least useful aspects of treatment. An experienced clinical psychologist conducted a majority of follow-up interviews. However, research assistants conducted the remainder. The assistants consisted of experienced senior-level undergraduates, as well as graduate students in clinical psychology.

Setting

The waiting-list group project took place at Central Clinic, a university-affiliated urban mental health center. At the time, Central Clinic served as a training site for psychiatry residents and students in various clinical psychology and social work programs. The clinic was situated on the University of Cincinnati’s medical campus, near several major hospitals. It was approximately one-half hour by bus and fifteen minutes by car from the downtown area. Its hours of operation were from 8 a.m. until 5 p.m., Monday through Friday, and some hours on Saturday. The clinic typically received 15 to 20 treatment requests per week.

Procedure

From January 1 through May 17, 1996 all patients who applied for services at the Adult

Treatment Division of Central Clinic had an intake interview for 45-60 minutes with a staff social

worker. In addition, each patient received a packet that contained information about the agency, available treatments, as well as questionnaires necessary for the initial evaluation, including the

OQ-45. During this session, the intake worker decided whether Central Clinic was the appropriate agency to assist in meeting the patient’s self-described needs, and developed an initial diagnosis and treatment plan. Patients’ needs typically included alleviating depression or anxiety, improving communication with loved-ones, or reducing somatic complaints such as headache. At the time of the study, it was standard policy within the agency for intake workers to refer to other agencies those patients deemed substance abusing or dependent, as well as those with psychoses or an extreme degree of suicidal or homicidal ideation. Patients who were in an acute crisis, but not actively suicidal or homicidal, were immediately assigned a therapist.

All patients screened during the study period were told about the waiting-list group, provided with an information sheet describing the project, and asked to give informed consent to participate. The information handout given to clients stated:

The group provides an opportunity for clients to talk about the current

stresses that led them to apply to the clinic. Participants will be asked to talk about

their difficulties and then hear from others, who may have experienced similar

situations or feelings. Individuals benefit from having a chance to share their

difficulties, discover the others have similar experiences, and begin to learn ways of

managing their problems.

Patients who elected to participate received a second OQ-45 immediately before their first therapy appointment from their assigned therapist. A member of the research team administered a third OQ-45 during the follow-up interview approximately 90-120 days later. Initially, patients were requested to return to the clinic for a face-to-face interview in exchange for nominal compensation ($5). However, due to a poor response rate and a high number of cancellations or

“no-shows,” patients were subsequently interviewed via phone. These individuals were also reimbursed $5 for their time. During the follow-up interview, patients were questioned about their use of community resources such as emergency rooms, private or community health care providers, police, family, friends, and asked for their evaluation and reflection on their treatment and therapist

(or therapists if they had more than one during the course of treatment).

It should be noted that data collection for the larger study required the participation of not only patients, but also clinic staff. All therapists were asked to administer an OQ-45 prior to their first meeting with the patient. While several incentives were offered to staff members, not all patients who consented to participate received a second-administration OQ-45 (c.f. Klein, Stone,

Reynolds, & Hartman, in press, for a review of the agency’s impact on the larger research project).

Numerical coding of premature terminators vs completer/continuers. Therapists at Central

Clinic were required to report certain information when they closed a case. Disposition was one such item, indicated in the following manner: Client moved within the agency (00), Case closed with referral (10), Goal met – no additional services needed (20), Needed services not available

(21), Patient rejects continuation – agency notified (22), Patient did not return – agency not notified

(23), Patient moved (24), Patient deceased (25).

For the present analysis, premature terminators were defined as those who had rejected continued services (22) or did not return (23). Completers were identified by the appropriate disposition code “Goals met,” and continuers were identified by a record review as remaining in treatment at the time of the interview. Because of the difficulty in determining whether clients who moved had done so because of conflicts with treatment or for more practical reasons, they were excluded from the analyses. The decision to group completers with continuers was based on the need for a large enough sample to attain adequate power, and because – as a combined group – these patients were expected to be dissimilar from those patients who had dropped out of treatment.

Chapter Three

Results

Participant Demographics

During the study period, 319 individuals applied for treatment at Central Clinic. Of these,

58 (18.1%) were referred to other agencies because needed services were not available. The remaining 261 persons were accepted for treatment. The sample was comprised of mostly single, white (65.9%) female (62.5%) high school graduates near 40 years of age (M = 39.9, SD = 17.1) who were unemployed (24.9%) or unavailable to work (36%), living below the poverty level

(reported median income of $5352; Range = 0 – 33,000).4 This income level is approximately one- half of that designated as “poverty level” for the county in which the clinic was located and in which most patients lived (U.S. Census Bureau, 1996). Table 1 presents summary statistics for the numerical variables and Table 2 presents the categorical variables for the client sample.

Forms of treatment entered by participants

As previously mentioned, the 261 patients accepted for treatment at the clinic were offered the chance to participate in the waiting-list group. Clients were not randomly assigned to treatments. Rather, the intake therapist made several treatment recommendations and the patient decided which option they would attend. Approximately one in seven clients (35 out of 261) chose to participate in the waiting-list group prior to meeting with their assigned provider. The remainder elected to wait until their assigned provider became available. Regardless of whether patients attended the waiting-list group, they were offered and assigned to some other form of therapy. One hundred fifty-five of the 261 clients (59.4%) accepted.

Table 1

Descriptive Statistics for Continuous Variables

M SD N

OQ-45 Total Score 94.16 25.74 218

Total Number of Sessions Attended 10.00 10.71 243

Age 39.92 17.08 243

Reported Yearly Income 6,018.45 6,018.54 242

Regardless of whether patients attended the waiting-list group, they were offered and assigned to some other form of therapy. One hundred fifty-five of the 261 clients (59.4%) accepted for treatment elected to enter individual therapy, with most attending seven sessions (Mdn).

Eighteen patients (6.9%) pursued an evaluation for psychotropic medication and attended a median of four sessions. Fifteen clients (5.7%) entered some form of group therapy (not the waiting-list group), with a median attendance of five sessions. Ten patients (3.8%) opted for either couples’ or family therapy and attended a median of 12 sessions. The remaining 63 clients (24.1%) did not enter treatment after their initial intake appointment.

One hundred patients (38.3%) from the treatment sample of 261 received an additional form of therapy, with the most common scenario being that the patient started individual treatment and was referred by their provider to a psychiatry resident working in the clinic for a medication evaluation. This was the case for 76 clients (29.1%), who attended a median of three sessions.

4 Note that 23% of the patient sample (56 of 242 reporting an income) reported “No income” (i.e., 0). The next highest category was $12/year (i.e., $1/month) reported by about 5% of the sample (12 of 242).

Table 2

Descriptive Statistics for Categorical Variables

Variable n %

Female 163 62.5 African-American 89 34.1 Educational Status Dropped out in grades 1-11 58 22.2 High school graduate or equivalent 79 30.3 Some college or vocational education 66 25.3 Four-year college degree or higher 37 14.2 Marital Status Missing Value 18 6.9 Divorced 55 21.1 Married 41 15.7 Never Married 126 48.3 Separated 16 6.1 Widowed 5 1.9 Occupational Type Manager or Professional 17 6.5 Technical/Sales/Administrative Support 17 6.5 Service – Domestic, Personal, or Protective 88 33.7 Skilled / Semi-skilled Labor 10 3.8 Other Labor 16 6.1 Student 33 12.6 Homemaker 61 23.4 Occupational Status Employed full-time 46 17.6 Employed part-time 23 8.8 Unemployed, no work history but not disabled 3 1.1 Unemployed, with a work history 65 24.9 Retired 3 1.1 Disabled 8 3.1 Unavailable (Student/Homemaker) 94 36.0

Approximately 5% of clients (14 of 261) were referred by their psychiatrist to an individual therapist, and – as with patients referred directly form intake into individual therapy – attended seven sessions (Mdn). Ten patients (3.8%) went into group, couples’, or family therapy as their second form of treatment, with an attendance of about eight or nine sessions.

Twenty-five clients (9.6%) received individual, medication, or group therapy as a third form of treatment. The attendance patterns were the same as for the first and second forms of treatment.

No clients entered a fourth form of treatment.

Comparison of patients who did and did not respond to follow-up interview

From among the 261 clients accepted for treatment, 158 (60.5%) gave informed consent.

However, it was standard policy at Central Clinic to collect some demographic and outcome data, which allowed for a comparison of more patients than had consented. Those who consented did not differ significantly from those who did not in terms of race, education, occupational status or type, marital status, gender, income, or OQ-45 total score at intake. However, patients with prior inpatient or outpatient experience were more likely to have responded to the follow-up interview than those without such experience. Among the 243 clients for whom data was available regarding inpatient or outpatient experience, 23 of 28 (82.1%) with an inpatient admission elected to participate, as compared with 86 of 215 (40.0%) of those without such experience, X2 (1, N = 243)

= 17.78, p < .001. Similarly, 27 of 37 (73.0%) patients with prior outpatient experience responded to follow-up questions as compared to only 82 of 206 (39.8%) clients without such experience, X2

(1, N = 243) = 13.95, p < .001.

Premature terminators

Twenty-five patients were judged by their therapists to have met their goals, and 55 clients indicated they were still in treatment at the time of the telephone follow-up interview. Thus, there were 77 completer/continuers. A total of 41 patients informed their therapists that they would not be continuing treatment, and 115 patients did not schedule or attend subsequent appointments.

Thus, there were 157 premature terminators. The remaining 27 clients had either moved away or were referred internally.

Hypothesis I

The first hypothesis predicted that premature terminators – as a group – would have lower symptom discomfort scores and lower opinions of their therapists than completer/continuers.

Multivariate analysis of variance (MANOVA) was used in order to avoid inflating the type I error rate, incorporate the correlations among the variables, and add power (Stevens, 1992).

Premature terminators did not differ from completer/continuers in terms of overall benefit from treatment on the self-reported measure of symptom discomfort, the OQ-45 (Ms of 8.6 vs.

12.7, respectively, F (1, 59) = 1.03, p = .31.5 However, premature terminators’ reported opinion about their overall benefit from treatment – as assessed by a single likert-scaled item – was significantly lower than that of completer/continuers (Ms of 3.0 vs. 3.9, respectively, F (1, 59) =

7.82, p = .007. Premature terminators also rated their therapists as significantly less likable and understanding, and less effective in giving good advice (F (8, 52) = 2.451, p < .03; β - 1 = .855).

These numbers are shown in Table 3.

5 All significance tests are one-tailed, unless otherwise indicated.

Due to the high number of patients who reported that they had no income at all, this variable was not included in the above analysis. A median test was used instead. There was a trend towards more premature terminators’ having reported an income below the median of $446 per month than completer/continuers, X2 (1, N = 76) = 3.548, p < .060.

Returning to the point that premature termination has been associated with race and education in previous box-score and meta-analytic reviews of the literature (Baekeland &

Lundwall, 1975; Garfield, 1986; Wierzbicki & Pekarik, 1993), African-Americans dropped out at a higher frequency than whites.

Whereas 75 of 143 (52%) whites dropped out, 60 of 86 (70%) of African-Americans did, a significant difference, X2 (1, N = 229) = 6.657, p < .01. Premature termination was also significantly associated with education level. Whereas 13 of 56 (23.2%) clients with less than a high school education had completed or remained in treatment at the time of their follow-up interview, 43 of 56 (76.8%) prematurely terminated, X2 (3, N = 226) = 15.635, p < .001.

Overall, the first hypothesis was partially supported. While it was expected that premature terminators and completer/continuers would differ in terms of their reported levels of symptom discomfort, they were not significantly different. However, as expected, they differed in terms of their self-reported benefit from treatment as well as their ratings of therapists for three of five therapeutic factors. Premature terminators, as compared to completer/continuers, rated their therapists as equally able to instill hope and give encouragement, but less likable and understanding, and less effective in giving good advice. Additionally, premature terminators were more likely to be African-American and less educated.

Table 3

Therapeutic Ratings for Premature Terminators and Completer/Continuers

Premature Non-Premature Terminators Terminators (n = 23) (n = 39) ______

M SD M SD F p

Hopefulness 3.51 1.25 3 .87 1.22 1.38 .245

Good Advice 3.21 1.44 4.26 1.05 9.39 .003

Likability 4.15 .87 4.57 .73 4.41 .04

Understanding 3.38 1.21 4.22 .85 9.38 .003

Encouragement 3.67 1.26 4.04 1.15 1.66 .203

Hypothesis II

The second hypothesis expected race and gender-based mismatching of patients to therapists would be among the best predictors of premature termination. This hypothesis was evaluated via binary logistic regression. Linear regression is appropriate when analyzing ratio- scaled dependent variables, such as income level and OQ-45 scores in the present study. However, when viewed as an outcome, premature termination is nominal (able to be categorized but neither ranked, equally spaced, nor with an absolute zero point). Specifically, premature termination as a dependent variable is dichotomous or binary (drop out versus complete/continue in treatment).

Thus, while linear regression cannot be used, discriminant analysis, probit analysis, log-linear regression and logistic regression are appropriate.

Discriminant analysis has a strict requirement that all regressors be continuous. Several of the regressors in the present study were categorical (e.g., race). Log-linear regression requires all regressors to be categorical. But some of the regressors in the present study were continuous (e.g.,

OQ-45 total score). When the regressors include a mixture of numerical and categorical variables, logistic regression is easier to use and interpret than discriminant analysis (Lea, 1997; Press, &

Wilson, 1978). In logistic regression, the independent contribution of the regressors – the independent variables – is assessed with a coefficient (b), the impact of which is expressed in terms of the likelihood (LL) or odds ratio (Exp(b)).

The importance of logistic regression in the prediction of a bivariate outcome lies in its ability to statistically control for all other factors while generating the best predictor. The regressors for the second hypothesis included: initial OQ-45 total score; salary; the five therapeutic factors of hopefulness, good advice, likeability, understanding, and encouragement; gender match; race match; educational status; occupational status; occupational type; prior inpatient admission; and prior outpatient experience.

As with all statistical models, there is some degree of error involved. For the Forward

Stepwise (Likelihood Ratio) procedure this error is reflected in the initial X2 value of 138.6

(coefficient = -.040) obtained when only the intercept is included. That is, initial X2 is -2LL for the model that accepts the null hypothesis that all the b coefficients are 0. The initial X2 serves as a comparison for all other models (those that include the regressors) in order to evaluate whether any of the regressors predict a significant amount of variance (i.e., more variance than the intercept-only model).

Subsequent iterations revealed two significant predictors, namely, good advice and understanding. That is, the extent to which clients felt the therapist gave them good advice and understood them predicted premature termination. This model was significantly different from the initial X2 value for the intercept-only model, X2 (24, N = 100) = 29.470, p < .001, rejecting the null hypothesis that none of the independent variables were linearly related to the log odds of the dependent variable.

The Cox-Snell R2 and Nagelkerke R2 are attempts to provide a logistic analogy to R2 in ordinary least squares (OLS) regression. The Nagelkerke measure adapts the Cox-Snell measure so that it varies from zero to one, as does R2 in OLS. The fitted model composed of good advice and understanding predicted 34% of the variance in premature termination. Thus, good advice and understanding – taken together – correlate with premature termination at the .58 level.

Taken together, good advice and understanding correctly classified 71% of the sample. This can be directly compared to the percent classified by blind estimation based on the most frequent outcome for all cases, complete/continue, which for this sample is 58% ((40+18)/(40+18+11+31)).

Therefore the model that included good advice and understanding increased predictive ability by about 22.4%.6 Table 4 shows the classification that tallies correct and incorrect estimates. The columns show the two predicted values of the dependent variable, while the rows are its two observed (actual) values. In a perfect model, all cases would be on the diagonal and the overall percent correct would be 100%.

6 The 13 percentage point increase, from 58 to 71, is 22.4% of 58.

Table 4

Classification of premature terminators versus completer/continuers using Good Advice and Understanding

Observed Predicted Percentage Termination Status Termination Status Correct

Premature Terminator Completer/Continuer

Premature Terminator 28 21 57.1

Completer/Continuer 8 43 84.3

Overall Percentage 71.0 a The cut value is .500

In the above analysis, race was considered a dichotomous variable. Patients and therapists were labeled either white or people of color. However, because of the importance of race and ethnicity, the data were re-examined. In this analysis, patients’ and therapists’ ethnicity was considered.

Using the Forward Stepwise (Likelihood Ratio) procedure, the error was slightly higher (X2 value of 147.7 (coefficient = -.035) that that obtained in the first analysis. Subsequent iterations revealed that good advice and understanding – taken together – re-emerged as significant predictors, X2 (24, N = 100) = 28.21, p < .001, rejecting the null hypothesis that none of the independent variables were linearly related to the log odds of the dependent variable. This model predicted 32% of the variance in premature termination.

Hypothesis III

The third hypothesis was that premature terminators would evidence higher hopes, more negative surprises, and more “least useful” aspects of treatment when compared to

completer/continuers in response to open-ended questions about these factors. The specific questions are listed in section 4 of the follow-up interview (see Appendix A).

For this sample, roughly equal proportions of terminators and completers expressed a specific desire for medication as a form of treatment, X2 (1, N = 100) = 0.43, p > .05. Six of 51

(11.8%) completer/continuers said they specifically wanted “meds,” and only one of these mentioned a particular disorder, “trichotillamania.” Eight of 49 (16.3%) dropouts also expressed a specific hope for medications. Appendix B lists the verbatim responses of both patient groups.

Patients’ orientation towards medication as a form of treatment indicated a hope for something other than “talk therapy.” While both premature terminators and completer/continuers expressed a desire for medication, dropouts more often mentioned a desire for a “quick fix” or some other service they felt could be supplied in a short time-period. For example, one premature terminator wanted a letter sent to the court saying that they were not at risk for future criminal behavior. Others expressed a desire to be evaluated for medication, not necessarily to receive medication as a treatment, but to find out if they were “OK” (i.e., whether or not they had a diagnosis).

Dropouts provided reasons for why they stopped treatment that centered around the seemingly transient nature of therapists in the clinic. As mentioned, Central Clinic was a training facility for social work, clinical psychology, and psychiatry students. While there were several permanent staff members, patients were more likely to be seen by a provider who would be leaving within 3-12 months. A number of clients noted that their therapist left the agency or that they were transferred, such that the patient decided to terminate services. Other practical issues that surfaced were child-care related.

During the follow-up interview, clients were asked about any “surprises” they experienced during treatment. Thirty-three of 49 (67%) premature terminators denied experiencing any surprises in treatment. A similar proportion of completer/continuers (35 of 51; 69%) also reported no surprises during treatment, X2 (1, N = 100) = 1.547, p = .461. Several dropouts indicated that they had difficulty talking with their therapists about certain issues, either because of the content (sexual abuse) or because of how soon the therapist wanted them to “open up.” There was no difference between groups for positive or negative surprises during treatment. Verbatim responses are listed in

Appendix C.

Patients were also asked about the most and least useful aspects of treatment. Clients who dropped out appeared less likely to have experienced a sense of universality, the idea that everyone faces difficult problems in their lives. However, the most frequently noted useful aspect for both groups appeared to be talking one-on-one with a therapist. As with the question about surprises during treatment, a majority of patients in both groups either declined comment or said there was

“nothing” that was least effective about treatment. Twenty-eight of 49 (57%) premature terminators said there was nothing that was least effective, as did 30 of 51 (59%) completer/continuers.

Appendices D and E list clients’ verbatim responses.

Chapter Four

Discussion

Since Freud first began to practice psychoanalysis, patients have been terminating services prematurely, at least from the therapist’s perspective (Freud, 1905). The literature reviews conducted by Baekeland and Lundwall (1975) and Garfield (1986), combined with Wierzbicki and

Pekarik’s (1993) meta-analysis indicated that the rate of premature termination has remained steady at about 50%. This has held true across client type, modality (individual, group, or family therapy), and setting (community mental health center, university counseling center, etc.). Furthermore, these studies revealed that race, education, and income have been consistently associated with premature termination. African-Americans and other minorities, the less educated, and low-wage earners are among those most likely to terminate prematurely. However, there has been disagreement as to why these variables are related.

One possible answer to the question of why race, education, and income have been consistently associated with premature termination in the literature rests upon a main assumption of the present study: Communicating across categories such as race, education and income is more difficult than communicating within these categories. This assumption was based on the inherent biases, stereotypes, and expectations commonly associated with these variables. Furthermore, because psychotherapy is primarily a process of communication, the expectation was that clients who were similar to their therapists would be more likely to complete or continue treatment than those who were not similar to their therapists. Based on the fact that race and gender are among the two most important means by which researchers and people categorize each other – compared to differences in age or marital status, for example – mismatching patients to therapists based on race

and gender was expected to associate with premature termination. Finally, because so many published studies focused on demographic variables – to the exclusion of either client or therapist perspectives on premature termination – an additional concern of the present study was whether patients’ reflections about therapy and their therapist would be associated with premature termination. This included patients’ ratings of five therapeutic factors: hopefulness, good advice, likeability, understanding, and encouragement, as well as open-ended responses to why they ended treatment, what their hopes had been, what if any surprises they had experienced during treatment, and the most and least useful aspects of treatment.

The present study was not intended as an experiment, per se. Clients were not randomly selected from those applying for service, nor were they randomly assigned to treatment with either similar or dissimilar therapists. Therefore it was important to ascertain whether patients who participated or completed the study were in any way different from those who did not. Among the variables examined, prior inpatient and outpatient experience made it more likely that clients would complete the study and respond to the follow-up interview. Responders and non-responders did not differ significantly along any other lines.

As a group, premature terminators rated their therapists as significantly less likable, less able to understand them, and as having given less good advice. Dropouts said their therapists were, on average, “moderately” likeable, understanding, and able to give good advice.

Completer/continuers said they felt these factors “very much” with their therapists. For this patient population it appears that getting advice, liking the therapist, and being understood – or empathized with – are important factors in remaining in psychotherapy.

Patients’ experience of therapy as promptly successful or obviously unsuccessful is one possible explanation for premature termination. That is, when patients make rapid gains, they stop treatment. Or, they might stop when they do not experience symptom improvement, and so feel they are wasting their time. In the present study, while premature terminators did not differ significantly from completer/continuers on overall benefit from treatment as indicated by the self- reported measure of symptom discomfort, the OQ-45, they did differ on their reported opinion of overall benefit from treatment as assessed with the single, five-point Likert rating. As with likeability, understanding, and good advice, this amounted to dropouts saying they felt

“moderately” improved, as compared to completer/continuers who said they felt “very much” improved. Thus, it does not appear that clients who prematurely terminate services have experienced symptom improvement, on average. This refutes the contention that patients who stop treatment have met their goals and thus should not be considered premature terminators by their therapists (Buddeberg, 1987). Rather, the evidence from the present study supports the notion that, as a group, premature terminators have indeed aborted treatment, possibly because they experienced it as less effective than anticipated, or because improvement was more difficult than anticipated.

Again, premature terminators did not differ significantly from completer/continuers on the self-report measure of symptom discomfort, the OQ-45. However, premature terminators did rate their overall opinion of how much they benefited from treatment as significantly lower than completer/continuers. That dropouts experienced – on average – a similar level of symptom improvement as completer/continuers on the OQ-45, but less improvement in terms of their own opinions, suggests that there may be a discrepancy, either between the measure or the groups. With regard to the measures, the OQ-45 assesses common manifestations of symptom discomfort, which

may not be used by clients in their own internal evaluation of how better or worse they feel. That is, the OQ-45 may not accurately assess symptom discomfort in patients with long-standing mentally illness, such as those who attend Central Clinic. The developers of the OQ-45 are in the process of adding 15 additional items to better assess treatment progress for patients with long-standing mental illness (G. Burlingame, personal communication, May 18, 2001). An alternative explanation is that premature terminators may have rationalized dropping out of treatment with the excuse that they did not make the gains they wanted; or that completer/continuers justified remaining in treatment by saying they had made adequate progress.

Communication barriers

On the assumption that communicating across racial and gender lines would be inherently more difficult than communicating within them, and therefore would adversely affect psychotherapy, it might be expected that examining the match or mismatch between patient and therapist on race and gender would accurately predict premature termination. The same held true for other variables including education, income, occupational status and occupational level.

However, when controlling for all other variables, good advice and understanding emerged as the only two significant predictors. Subsequent analyses revealed that gender matching resulted in no significant differences among the therapeutic factors, nor did race matching. Additionally, when clients were classified into one of the following four categories, race and gender match, race match only, gender match only, or no matches, again, no significant differences in the therapeutic factors were found. Thus, for the present sample, race or gender matching did not affect patients’ opinions about whether they felt more hopeful with their therapist, or got good advice from them, or liked them, or felt understood, or encouraged by them.

Good advice and understanding

One question that needs to be addressed is why clients’ opinions about the degree to which their therapists gave them good advice and understood them predicted premature termination.

Hardin, Subich, and Holvey (1988) offered one possible answer. In their study, patients were found to hold high expectations for treatment. Clients said they would take on most of the responsibility for their treatment, would be open with the therapists, and would try to remain motivated for treatment. Patients’ lowest expectations were for therapists to be self-disclosing, directive, and understanding. Again, clients did not expect their therapists to be directive or understanding.

Relative to the present study, it may be that while patients wanted therapists who were directive

(i.e., gave good advice) and understanding, they did not expect it. Thus, when they received direction and empathy, it was a positive surprise that kept them in treatment. However, it is unclear from both Hardin’s and the present study whether clients wanted advice and understanding, did not expect it, but were delighted to get it, or whether they neither expected it nor wanted it.

In the present study, few patients in either group mentioned the therapeutic factors, race, or gender. From the completer/continuer group, one client mentioned getting advice as the most effective part of treatment and another mentioned how surprised they were at their therapist’s ability to understand them. Most other responses indicated patients wanted to talk during treatment.

That is what they hoped for; and a few did not think they received enough, as seen in complaints about having to attend groups, receiving only medication, or that “one hour per week was not enough.”

Few clients mentioned aspects of the facility as being surprising or a least useful aspect of treatment. However, some patients did mention the fact that they dropped out because they were

transferred to another therapist. Unfortunately, it is unclear how many clients were transferred due to the recording procedures used in the clinic.

Generalizability

The data were drawn from a historical sample, that is, a convenience sample of all patients who applied to the clinic during the study-period. No clients were randomized to any treatments.

While one must be cautious in generalizing the results drawn from historical samples, when the sample is representative of the population to which one wishes to infer the results – as in a clinic population – these inferences are tenable. Therefore these results can be applied to the population of patients presenting for services at the clinic.

Limitations

Likert ratings

The format of the Likert scaled items did not allow clients to indicate that they had been harmed in any way by attending services at the clinic. Likert scaled items ranged from 1 (not at all) to 5 (highly). Thus, patients could not indicate negative values. Rather, they could only indicate the absence or presence of hopefulness, good advice giving, likeability, understanding, and encouragement. They could not say that therapists were very unlikable, gave extremely bad advice, or were entirely discouraging.

Consent of patients with previous therapy experience

One unexpected finding was the greater frequency of consent to participate among clients with prior inpatient or outpatient experience, relative to those clients who did not have such experience. One question is what impact their increased participation had on the outcome of the study. Subsequent analyses revealed that patients with prior inpatient experience did not differ

significantly from those without such experience in terms of the therapeutic factors, gender, race, educational status, occupational status or type. It is unclear why these clients participated in the study. Perhaps some believed treatment was contingent upon participation. Or they may have been genuinely interested in the study. Their greater participation relative to patients without such experience is unlikely to have unduly influenced the study. The same held true for clients with prior outpatient experience.

Recommendations

Good advice and understanding, taken together, were strongly associated with continuing or completing treatment in the present study. One possible intervention with regard to premature termination may be to survey clients after their initial session(s) as to how good the advice was that they received and how understood they felt by their therapist.

Premature termination was not associated with either initial OQ-45 total scores nor with the degree of change between initial intake and follow-up interview. With the consideration that neither the premature terminator group nor the completer/continuer group improved by a significant margin, it appears that the OQ-45 may not be sensitive to the changes that occur within this population. Future research should utilize a measure, such as the OQ-45 AI as it has been found to be sensitive to such changes.

A review of patients’ verbatim responses – as written down by the interviewers – revealed that clients may have defined “hope” as what they wanted to get out of treatment. Practically, there is a big difference between someone who “just wants to talk” and someone who wants medication to rid him of his desire to pull his hair out. There may also be a difference in defining expectations from preferences. It should also be noted that perhaps hopes, too, are confused with expectations

and preferences. Patients should have been given a standard definition of hopes before asking them to respond.

Additionally, based on the paucity of responses to the open-ended questions, future interviews might probe further for additional responses. Clients could be asked about the most important thing the therapist said, or what idea was brought up which changed the course of treatment. Or, if patients could come up with no hopes, surprises, or more or least effective parts of treatment, they could be given a list of things other clients had mentioned in other studies.

Overall, it remains unclear as to why race, education, and income have consistently been associated with premature termination. To some extent, premature termination from psychotherapy may reflect the larger social phenomenon of dropping out (from school, from work, from community involvement), which is a result of the fast-food mentality popular media leads many to believe in: that you can have it your way, when you want it, as you like it. And if you do not like it you can just walk away. In short, people may transpose their typical expectations for services (from teachers, employers, and fast-food vendors) to psychotherapy, resulting in a tendency for patients to go elsewhere if they do not get what they want. Unfortunately, many patients in the present sample did not address – either because they were unaware or because they wanted to avoid a difficult topic

– what was negatively surprising or least effective about psychotherapy. As such, while it was hypothesized that dissimilarity between patient and therapist would lead to premature termination, good advice and understanding – considered together – were the most powerful predictors.

Therapists are encouraged to remain aware of these factors during treatment, or address them directly with clients in order to forestall premature termination, the odds of which are otherwise about 50-50.

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Appendix A

Follow-Up Discussion: Attitudes About Central Clinic

______Name Date Researcher

0. Are you still in treatment at Central Clinic?

YES NO Æ if No then… 0a. How many times did you come to Central Clinic before you decided to stop? _____

If only 1 visit go to 0b-0e otherwise go to Question 1.

0b. Are you seeking treatment elsewhere? NO YES Æ If Yes then… 2a. What services are you currently being provided? ______

0c. What kind of treatment did you hope to get from Central Clinic?

0d. What led to your decision to stop seeking services from Central Clinic?

0e. *** GO TO QUESTION 8: USE OF COMMUNITY RESOURCES ***

1. If you think back to when you first came to Central clinic what kind of treatment did you hope for?

2. What types(s) of treatment did you receive at Central Clinic? (CIRCLE ALL THAT APPLY) a) Preliminary Process Group b) Individual Therapy c) Psychoeducational Group Therapy d) Long-Term Group Therapy e) Medication Therapy f) Other (e.g., couples therapy, family therapy, etc.) g) If patient received no treatment other than the intake, GO TO 0b-0f.

3. Overall, how much did you benefit from your treatment and therapist(s) at Central Clinic? not at all slightly moderately very much highly 1 2 3 4 5

4. 1st I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT EACH TYPE OF TREATMENT YOU RECEIVED. FOR NOW, JUST REFERRING TO… (Indicate 1st Treatment Type)

What did you hope to achieve in your… (Indicate 1st Treatment Type) therapy?

Tell me about any surprises with… (Indicate 1st Treatment Type) – either in the results or in what might have happened in this treatment along the way?

For you, what has been the most useful and effective part of… (Indicate 1st Treatment Type)?

For you, what has been the least useful and effective part of… (Indicate 1st Treatment Type)?

How much did you benefit from… (Indicate 1st Treatment Type)? not at all slightly moderately very much highly 1 2 3 4 5

Speaking now about your therapist for… (Indicate 1st Treatment Type)… a. Did you feel your therapist was likable? not at all slightly moderately very much highly 1 2 3 4 5 b. Did you feel your therapist was encouraging? not at all slightly moderately very much highly 1 2 3 4 5 c. Did you feel your therapist gave you good advice? not at all slightly moderately very much highly 1 2 3 4 5 d. Did your therapist help you feel hopeful that you would get better? not at all slightly moderately very much highly 1 2 3 4 5 e. Did you feel your therapist understood you? not at all slightly moderately very much highly 1 2 3 4 5

Appendix B

Patient's Hope for Treatment

Completer/Continuers

Tx for dizziness, ref'd by own MD

Help w/ home problems, deal w/ children

Talk about my problems, get support,

Tx for depression

Get back to my old self

Get help dealing w/ being disabled / sleep better/ get meds

Structured tx for solving problems

Tx for depression

Meds to help my problems

Meds to change everything

Tx for PTSD

Meds

Tx for anxiety

Talk to someone

Tx for PTSD

Meds

Dealing w and expressing anger

Medication for tricotilamania

Get tx for bipolar d/o

Improve relationship / become assertive

Function like a normal persons

Improve relations w/ family

Tx for depression

To help deal w/ a mother-daughter relationship

One on one treatment

Learn about my problems

One on one tx

Group or marriage tx

Tx for depression

Tx for stress

Tx for eating disorders

See shrink to calm me down

Tx for OCD and depression

Tx for depression

Tx for depression and anxiety

Someone to talk to

Tx for depression

Tx for eating d/o

One on one and meds

Premature Terminators

Tx for PTSD

One on one tx

To help relieve stress, take some of the pressure off me

Get meds /

Meds to aid sleep and anxiety

Get better

Wanting to get better

One on one for help w/ stress

Someone to talk to

Relieve depression

Letter from thp to judge saying I was not violent

Tx for depression / talk about relationship breakup

Meds, immediately, quick solutions

Tx for depression

Understand my expectations

Medication for depression

Get medication for depression / feel better

Meds for depression

Talk to someone

Support

See if I had sxs

Talk w/ someone about sx and if I should be on meds

Meds for depression/solve problems/get anger out

Decrease depression

None

Tx for conflicts in past relationships

Tx for depression

Help

Ind tx to help me cope better

Get tx for depression

Find out what's wrong w/ me

Talking about frustrations

Tx for panic

Relief from depressive sxs

Appendix C

Surprises with Treatment

Completer/Continuer

None (35 patients denied any surprises with treatment)

My problems came together like a puzzle

Thought it would be much quicker

Adverse side effects,

Thp was able to explain everything to me

Getting to a solution

How understanding the MD was

Felt supported

Meds / Relearned things from 20 yrs ago

Someone who was there for me

Having 3 therapists

How good it felt to open up

Short-term nature of tx

Thp left

EMDR

Used EMDR

Made aware of things I never thought before

Premature Terminator

None (33 patients denied any surprises with treatment)

Boring group

Thp cared about me

Thp wanted to tell me what to do / no meds

Knowledge that everyone has problems

Thp said I did not need tx

That tx helped

Reviewing old information

Sx improvement

Therapist called me if I did not make appt

Talk about sex abuse in 1st session

How emotional people became

Learned about things inside me

Did not get MD, took long time to start

Thp telling me I had to talk / Switching thp

Improvement after 1st session / pos effect of meds

Got more self-esteem from tx

Appendix D

Patients' Most Useful Aspects of Treatment

Completer/Continuers

Talking

Having someone listen, Not be laughed at

Bond w/ therapist,

Talking

Understanding herself/ knowing others deal w same issues

Sharing information about myself

Get out of relationship that was bad

Increased energy

Talking

Everyone having things in common

Talking one on one

Pinpointing problems

Knowing others had problems, too, getting suggestions

Help moving into nursing home / Changed my outlook

Talking

Thp allowed me to answer my own questions

Setting goals / gaining support / encouragement

Talk it out

One on one tx

Both meds and ind tx

Talk to someone, sx improvement, focus on me

One on one treatment

Advice

Realization that people had similar issues

Homework, sharing, CBT

Gaining information about how to open up

Talking

Learning how to shift thought patterns

Listened to me w/o bias

Controlling myself more

Feeling closer to thp, being heard

Talking w/ therapist

Someone to talk w/

Gaining information about anxiety

Talking one on one

One on one tx

Explanations

Talking, being heard

Premature Terminators

Seeing other people had more severe problems

Understanding my feelings w/o meds

Talking

Thp wrote lots of things down

A place to go

Talking

Having goals, Helping herself before others

Having others relate to my problems

Universality

Talking to someone

My being useful to others in the group

Someone to talk to / support

Learn to communicate

Talking w someone I felt comfortable w

Understanding my past

Talk w someone

One on one tx

Regained motor skills

One on one tx

Talking about things cannot talk w/ others about

Talking

Learning how to talk

Thinking in depth about things

Talking

Books thps ref'd

Meds, talking

Rapport

Talking

Someone to talk to

Appendix E

Least Useful Aspect of Treatment

Completer/Continuers

None/Nothing (30 patients denied any least useful aspects of treatment)

My missing time, sessions

Nervous

Little results

Thp needed me to have things to say

Time it takes

Time it took to learn about myself

Talking about past assault

Lack of choice in who to be my thp

Thp left clinic / Thp inadequate

Paperwork

Not enough suggestions

Talk only, no problem solving

Having to relate to others

Dealing w/ African-American people

Not enough meetings

Being treated like a Martian

Keeping a journal

Parking

Amount of pain felt in talking about issues

Therapist left clinic

EMDR

Premature Terminators

None/Nothing (28 patients denied any least useful aspects of treatment)

Seeing others w/ chronic illnesses

Medication

No results

No meds

Thp was late by 10 min

Therapist did not say much

Talking

Do not understand myself any better

Trying to be romantic w partner

Brining up the past

One hr / wk not enough

Side effects of med

Not a good match w/ therapist

Talking about sexual abuse

Lack of common sense / African-American people go through this

Got more depressed

Prescribed meds at first session

Not feeling heard

Not dealing w/ my physical problems

Switching therapists

Relaxation techniques