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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 by 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. 3 4 For Angela 5 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. 6 Table of Contents Chapter One: Literature Review……...……………………………………………………….…10 Chapter Two: Method…………………………………………………………..……...….….…..32 Chapter Three: Results……………………………………………………………..……......…...39 Chapter Four: Discussion……………………………………………………………..……...…..50 7 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 8 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 9 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
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