Research on attrition consistently finds that dropout can occur early in psychotherapy and involve a substantial proportion of clients. This study investigated hypotheses based on the early therapeutic environment (ETE) model, a common factors theory that predicts that working alliance, client distress, and client expectancies (outcome and efficacy) influence client attendance and engagement. Using archival data from 350 clients in a private practice setting, two constructs of the ETE model (working alliance and client distress) were available to evaluate client attendance variables (session count [SC], therapy length [TL] in days, and weekly frequency [WF]). The expected positive correlation was found between SC and length of therapy in days; analyses also indicated a negative correlation between therapy frequency and both SC and length in days. Study findings provided partial confirmation of the ETE model, with higher alliance scores and moderate distress scores associated with longer attendance in the entire sample. These relations were absent, however, with clients who completed fewer than 11 sessions. Overall, results suggest the presence of a variable duration effect where attendance length relates to differential therapy outcomes. Individuals who participate in therapy for a relatively small number of sessions, occurring frequently, often achieved measurable distress reduction. For longer-term clients, results suggest that a combination of moderate distress and an established working alliance form a therapeutic environment that sustains client attendance. Findings suggest two basic guidelines for enhancing client attendance: As early as possible, maximize the client's experience of the alliance and modulate the client's level of distress.
Public Health Significance StatementAttrition is a significant problem in counseling and psychotherapy, requiring the development of theory and methods to identify clients who are more likely to drop out. This study evaluates a model identifying factors that may influence attrition, including the working alliance between client and therapist and level of client distress. Results indicate that alliance and distress predict client attendance, particularly for clients who attend short-term therapy.