Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives.

Abstract

A substantial number of patients do not improve from psychotherapy, some even deteriorate, and some terminate treatment prematurely. Identifying therapist variables that may lead to treatment failures from patients’ perspectives can inform how psychotherapists can increase effectiveness. Using a semistructured protocol, we interviewed 24 patients who had experienced unsatisfying individual face-to-face psychotherapy within the last 2 years. The study procedures were guided by the consolidated criteria for reporting qualitative research. The manifest content analysis provided 13 subcategories grouped into four categories: (a) psychotherapists’ negative traits (inflexible, unengaged, unemphatic, insecure), (b) unprofessionalism (superficial, violating personal boundaries, breaking confidentiality, nontransparent), (c) incompetence (unstructured, poor assessment or understanding, poor knowledge, too passive), and (d) mismatch (therapist–patient mismatch). To reduce the risk of treatment failure, psychotherapists may need a multifaceted set of relational skills, theoretical and technical competence, ethical sensitivity, and engagement. Some of the identified subcategories were complex constructs (e.g., unengaged) that may need time and effort to develop for psychotherapists. Other identified subcategories were obvious inappropriate behaviors in professional psychotherapy (e.g., breaking confidentiality). However, the categories found in this study need further quantitative investigation to assess the validity, frequency, and relative impact on treatment outcomes.

Psychotherapist factors that patients perceive are associated with treatment failure.

“…The open questions resulted in four new therapist behaviors that should be taken into consideration in future investigations of patients’ negative experiences of psychotherapy. Of these, it is worth noting that inappropriate sexual behaviors or comments were not identified in the qualitative study that preceded this study (Alfonsson et al, 2023). The inappropriate behaviors or comments were only reported by a handful of participants, and this low frequency may explain why they did not appear in the qualitative interviews.…”

“…An online self-report instrument was constructed based on the findings of Knox et al (2023) and Alfonsson et al (2023). The survey also included participant background and treatment variables, such as This document is copyrighted by the American Psychological Association or one of its allied publishers.…”

“…Based on the categories identified by Knox et al (2023) and Alfonsson et al (2023), an online instrument with 14 main items and 150 subitems was constructed to cover all relevant therapist variables. The subitems were designed to comprehensively cover all experiences within each theme identified in the previous study and, therefore, resulted in a varying number of subitems for each main item.…”

“…In an effort to map the most crucial therapist-related factors, Knox et al (2023) interviewed patients ( n = 13) who had experienced treatment failure and found five categories of therapist factors that contributed to the failure: (1) psychotherapists’ insensitive/inappropriate responses to patient’ concerns about the psychotherapy; (2) psychotherapists’ insensitive/inappropriate comments and/or actions; (3) psychotherapists who did not manage the psychotherapy effectively; (4) psychotherapists who lacked competence, training, or experience; and (5) psychotherapists who did not foster the psychotherapy relationship. Interestingly, a recent study by Alfonsson et al (2023), who also interviewed patients who had experienced treatment failure or premature termination, found four similar categories of therapist-related factors: (1) negative traits, (2) unprofessionalism, (3) incompetence, and (4) therapist–patient mismatch. Similar categories were found in the qualitative part of a mixed-methods study of lay people’s expectations of competent psychotherapists by Kühne et al (2021): (1) following therapeutic principles, (2) being professional, (3) having a friendly personality, (4) good communication skills, (5) showing empathy and understanding, (6) being skilled, (7) being available, (8) being effective, and (9) being experienced.…”

“…The final items used in the survey are presented in Supplemental Table1. Please also seeAlfonsson et al (2023) for a comprehensive description of each item.…”