‘I Just Stopped Going’: A Mixed Methods Investigation Into Types of Therapy Dropout in Adolescents With Depression

Abstract

What does it mean to ‘drop out’ of therapy? Many definitions of ‘dropout’ have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client’s experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11–17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: ‘dissatisfied’ dropout, ‘got-what-they-needed’ dropout, and ‘troubled’ dropout. ‘Dissatisfied’ dropouts reported stopping therapy because they did not find it helpful. ‘Got-what-they-needed’ dropouts reported stopping therapy because they felt they had benefitted from therapy. ‘Troubled’ dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of ‘dropout’ cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.

Young People Who Meaningfully Improve Are More Likely to Mutually Agree to End Treatment

“…Further, existing research suggests the most common reason for non-mutual treatment endings in YP therapeutic settings was a therapeutic relationship disconnect (Carter, 1995 ; Garcia and Weisz, 2002 ). Although the current findings show significant associations between meaningful change and mutual agreement to end treatment, a recent study found no significant evidence linking YP depressive symptoms to mutual agreement on treatment ending (O'Keeffe et al, 2019b ). This inconsistency may warrant further investigations if we are to generalize findings across symptom type, treatment type, and the level of impact the psychosocial difficulties may have on the YP and their families.…”

“…Therefore, it is important to broaden our understanding of the influence of demographics, referral process, and symptom improvements on case closure. Evidence that non mutual case closure may not necessarily be a problem may reflect more self-efficacy, competence, self-rated improvement, and autonomy among YP and their carers (Simon et al, 2012 ; O'Keeffe et al, 2019b ). Despite this wealth of knowledge, we are yet to fully understand if symptom improvement is an indicator of a “good” outcome.…”

Barriers and Facilitators in Adolescent Psychotherapy Initiated by Adults—Experiences That Differentiate Adolescents’ Trajectories Through Mental Health Care

“…Moreover, 28–75% of young clients quit treatment prematurely ( Swift and Greenberg, 2012 ). Their reasons are diverse: Some are dissatisfied, some perceive (whether or not the therapist concurs) that they have achieved what they wanted, and some quit because of difficulties outside therapy ( O’Keeffe et al, 2019 ). In-session events and therapist behaviors are linked to adolescents dropping out of treatment ( O’Keeffe et al, 2020 ), but it has been difficult to predict which young people are at risk of dropping out ( de Haan et al, 2013 ; O’Keeffe et al, 2018 ).…”

Exploring harm in psychotherapy: Perspectives of clinicians working with children and young people

“…Yet, children and young people frequently report being left out of conversations during appointments (Edbrooke‐Childs, Calderon, Wolpert, & Fonagy, 2015; Hayes, Edbrooke‐Childs, Town, Wolpert, & Midgley, 2019). This can result in an increased risk of drop out as the patient does not feel comfortable talking to the clinician, as well as not liking the structure and activity of the prescribed therapeutic modality (O’Keeffe, Martin, Target, & Midgley, 2019).…”