Abstract
Researchers have long been interested in understanding for whom therapy works and why. This study sought to identify ways in which clients differ with regard to treatment outcomes such as treatment length, success, and termination status. Data for this study were taken from the client documents completed prior to the first session of therapy and the therapist-completed termination summary for 305 cases from a university-based marriage and family therapy clinic. Results suggest that soft-mandated and voluntary clients show similar success rates in treatment. Also, cases that terminated unilaterally had the lowest success rates, though rates were approximately equal across modality. This study provides information about treatment across different client characteristics and modalities.
Keywords
Researchers in the field of family therapy have long been interested in understanding for whom therapy works and why. While many clients are successful in their treatment, there remain instances of drop out, early termination, and unsuccessful treatment. Clients differ in many ways, meaning that their experience in therapy may also differ. One explanation of the differences in therapy experience that has been explored is the referral status, mandated or voluntary, suggesting that the pressure under which clients enter therapy influences their perceptions of treatment and may affect therapy outcomes (Snyder & Anderson, 2009). However, literature suggests that referral status may be more complex, examining a third form of referral status called soft mandated (Moore, 2013). The present study examines the relationships between various types of clients and treatment outcomes such as treatment length, success, and termination.
Mandated Therapy Attendance
Clients enter into psychotherapy under a variety of circumstances. Significant research attention has been paid to understanding the differences between those clients who enter therapy under duress and those clients who enter therapy voluntarily. One widespread assumption in outpatient psychotherapy is that clients are at least somewhat motivated to participate in the therapy and have entered into therapy of their own accord (Rooney, 1992). However, some clients enter into therapy under duress or on the strong recommendation of a powerful associate. Some clients, commonly referred to as mandated clients, enter into therapy at the order of the court system, state social services, or others who have the authority to impose severe sanctions on clients who fail to attend therapy. Such clients are referred to therapy for a variety of issues such as substance abuse, child abuse or neglect, and legal issues.
Researchers (see Snyder & Anderson, 2009, for a review) have delineated differences in motivation to change, resistance, and therapy outcomes between voluntary and mandated clients. Mandated clients often feel marginalized and powerless, resulting in anger toward authority and an outlook that is problem focused (Rosenberg, 2000). Because mandated clients do not initiate treatment, their attitudes about treatment and readiness for change are not taken into consideration when the client is told to begin treatment (Hiller, Knight, Leukefeld, & Simpson, 2002). To the client, treatment may represent a system’s opposition to the client’s choices. As a result, the client may resist treatment because he or she refuses to accept the notion that he or she did something wrong (Storch & Lane, 1989).
Along with mistrust of the system/systems that enforce treatment, mandated clients frequently have difficulty engaging with therapists. The therapeutic alliance is associated with treatment outcome, and relationship is highly influenced by clients’ motivation to engage with the therapist (Martin, Garske, & Davis, 2000). Howgego, Yellowlees, Owen, Meldrum, and Dark (2003) observed that mandated clients do not seek a relationship with the therapist and are not motivated to engage in treatment, which suggests a sense of mistrust and discomfort with the therapy process.
While distinctions between voluntary versus mandated referral status are useful, such distinctions fail to capture the range of client experiences. Moore (2013) has proposed the use of a term for a third category of clients, soft-mandated clients. Soft-mandated clients are those clients who are encouraged to attend therapy at the request of a powerful associate, but would be subject to only mildly unpleasant sanctions should they fail to attend (Moore, 2013). In outpatient psychotherapy, soft-mandated clients often present for therapy at the request of state social services, employers, religious leaders, or attorneys. The referrer cannot impose severe sanctions for failures to attend therapy; however, the influence of the referrer likely imposes a great deal of pressure on potential clients to comply with the referral to therapy.
Little is known about the experiences of soft-mandated clients. One study (Moore, 2013) found that soft-mandated clients experience higher levels of depression and anxiety than clients who sought therapy voluntarily. Unfortunately, little is known about the treatment outcomes of soft-mandated clients as compared to their voluntarily attending counterparts. It is possible that, like many mandated clients, soft-mandated clients may experience higher levels of premature termination from therapy, or other poor outcomes.
Psychotherapeutic Dropout
Early client dropout has important fiscal, clinical, and research implications. Dropout is commonly conceptualized as termination from therapy that occurred before therapy goals were achieved or was unilateral on the part of the client and was unexpected from the therapists’ point of view. Premature termination from therapy continues to present a challenge to researchers and clinicians. Studies indicate that premature termination from psychotherapy is common in individual outpatient treatment. Wierzbicki and Pekarik (1993), in a meta-analysis of 125 studies of psychotherapy dropout, found a mean drop-out rate of 46% across studies.
Premature termination from therapy is perhaps most concerning because of the loss of potential for client improvement. Clients who drop out of therapy prematurely achieve poor outcomes similar to those who did not receive therapy (Pekarik, 1992; Stark, 1992). Clients who terminate prematurely are less likely to be satisfied with the treatment they received (Pekarik, 1992) and unlikely to go on to received needed services (Weisz, Weiss, & Langmeyer, 1987).
Demographic data, from both the therapist and the client, have been heavily researched as predictors of dropout in individual therapy though simple demographic variables often fail to yield consistent results (Hamilton, Moore, Crane, & Payne, 2011; Wierzbicki & Pekarik, 1993). Researchers of couple therapy have taken a similar approach to the analysis of premature termination. Most studies of dropout in couple therapy focus on demographic variables as predictors of dropout. Couples who have no legal commitment to one another, as well as couples without children are more likely to prematurely terminate from therapy (Allgood & Crane, 1991; Davis & Dhillon, 1989). Having many presenting problems or presenting problems relating to only one spouse significantly increases rates of dropout (Allgood & Crane, 1991; Ward & McCollum, 2005).
Clients who have schizophrenia, psychotic, and substance use disorders are also more likely to terminate prematurely (Hamilton et al., 2011). Evaluations of conjoint therapy for the treatment of addiction indicate couples are less likely to drop out when they have a positive alliance with their treatment provider (Raytek, McCrady, Epstein, & Hirshch, 1999), when identified patients have lower rates of drug use and couples have fewer presenting problems (Stanton & Shadish, 1997), and when the members of the couple are committed to one another (Epstein, McCrady, Miller, & Steinberg, 1994). New research has also found that marriage and family therapists have the lowest drop-out rates among mental health professionals (Hamilton et al., 2011). A better understanding of factors that contribute to premature termination will increase efficiency and efficacy in both clinical practice and psychotherapeutic research.
There is limited research regarding the relationship between treatment outcomes and various client profiles. For example, little is known about clients who attend couple therapy, clients who attend therapy at the request of a third party, or the combination of the two. The majority of the literature focuses on individual therapy with clients who attend voluntarily. Additionally, research has excluded clients who attend therapy at the request of third party, such as a state social service provider or agent of the court system. The relationship between various characteristics of clients and treatment outcomes was examined by answering the following research questions:
Research Question 1: Is there a particular type of client who is more likely to present to therapy under the condition of being soft mandated?
Research Question 2: Does the total number of sessions attended vary by client characteristics? Is there a difference in treatment length among referral status (voluntary vs. soft mandated)? Are there differences in treatment length among client type (individual, couple, high-conflict coparenting dyads, and family)? Are there differences in treatment length across termination initiation (unilateral, therapist initiated, or mutual)? Are there differences in treatment success among various client profiles? Is any particular client type more likely to drop out of treatment?
Method
Participants
Data for this study came from a university-based marriage and family therapy clinic in the Northeastern United States between 2008 and 2010. Participants were 305 cases of therapy at the clinic. Cases consisted of individual (n = 150), couple (n = 94), high-conflict couple (n = 10), and family (n = 45) treatment. There were six cases in which the client type was not clearly indicated by the therapist. These cases consisted of treatment that included individual, couple, and family sessions. Clients who attended high-conflict couple therapy were referred by the court system, were divorced or separated, and shared children. Each case was entered into a clinic database, using each case file as the primary source of data. For this particular database, information taken from case files included information for the case as a whole rather than information regarding each individual client. Thus, information in the database focused on treatment variables rather than demographic information.
Measures
Data from this study were obtained from the archival data of a university-based counseling center in the Northeast. Data were present for a variety of variables, described in detail below. Percentages indicated for each variable represent cases in which there were complete data. Cases with missing data were removed from analysis.
Soft mandated versus voluntary
Clients were categorized as soft mandated (24.6%) or voluntary (73.8%) based on how they were referred to treatment, as indicated by the documented contact found in clients’ clinical records at treatment onset. Soft-mandated clients were those whose clinical records included documented contact with the court system, the Department of Children and Families (DCF), or a guardian ad litem. Voluntary clients were those whose clinical records indicated self-referral and included no documentation of contact with the court system, DCF, or a guardian ad litem.
Treatment success
The success of treatment was determined by an examination of termination documents in clients’ clinical records. Therapists completed the termination documents after the treatment was discontinued. Termination documents included information such as date of intake, date of last session, total number of sessions attended, and therapist’s description of treatment. Coders reviewed termination documents and assessed whether treatment was successful, unsuccessful, or undetermined, based on therapist’ report. Treatment was rated “successful” (56.7% of cases) if therapist indicated that treatment goals were met or were progressing, as evidenced by observations of changes in client behavior or insight during treatment. Treatment was rated “unsuccessful” (22.3% of the cases) if therapist indicated that treatment goals were not met and/or client prematurely ended treatment. Clients who did not attend the intake session or stopped attending before treatment goals were determined were rated as “undetermined” (10.5%). Thirty cases were rated as never seen, which consisted of cases in which clients completed the intake process but did not show for their first appointment.
Termination initiation
Termination initiation was determined by an examination of termination narratives in documents completed by therapists and entered into clients’ clinical records. One coder reviewed the narrative written by therapists as part of termination documents to determine whether termination was therapist, client, or mutually initiated, based on therapists’ report. In this narrative, therapists described the reasons for initiating therapy, the course of treatment, whether goals were met, and the reasons for termination, if known. Termination was rated as therapist initiated if the narrative indicated that clients had met their goals, or therapy had reached a productive end and the narrative indicated that the therapist suggested the clients end therapy. Termination was rated as client initiated if therapists noted that clients requested that treatment end; if clients ended treatment with little to no progress on treatment goals; or, if clients did not attend scheduled sessions and failed to respond to the therapist‘s efforts to contact them. Termination was rated as mutually initiated if the narrative indicated that therapists and clients discussed, and agreed upon, termination timing; a planned termination session occurred; or, if a predetermined treatment length was reached, as in the case of some mandated clients who were required by a third party to attend a contracted number of sessions.
Treatment length
Treatment length was determined by the number of sessions attended between date of intake and date that the termination document was completed.
Procedures
This study used existing clinic data from a Commission on Accreditation for Marriage and Family Therapy Education-accredited marriage and family therapy training program in the Northeastern United States. The marriage and family therapy program houses a clinic on campus that specializes in providing mental health services to individuals, couples, and families with a wide range of presenting problems. Therapists consisted of 24 master’s and 8 doctoral students in the marriage and family therapy program who provided treatment under the supervision of clinical faculty members who are licensed marriage and family therapists. All therapists were versed in systemic and family-based interventions.
Following termination, therapists completed a case termination summary. As part of this summary, therapists reported the number of sessions attended by the clients and the way in which the case terminated. Data for this study were taken from the client documents completed prior to the first session of therapy and the therapist-completed termination summary. Data collected from documents completed prior to the first session included referral source, releases of information, and correspondence received from referral sources. Cases with intake dates from the year 2008 and later were selected for this study because the documents from which data were collected were implemented at the clinic in 2008. Data were entered by two graduate-level research assistants and were reviewed by faculty researchers.
Results
Relationship Between Client Type and Soft-Mandated Referral
To determine whether a particular type of client was more likely to enter therapy as soft mandated, a chi-square test was performed. Results of the test indicated significant differences, χ2(3) = 61.029, p = .00. Cases that presented to couple therapy had the lowest rate of entering therapy as soft mandated (2.7%). Family cases also showed a lower rate of being soft mandated (16.0%), followed by individuals (25.3%), and high-conflict couples showed the highest rates attending as soft mandated (56.0%). Results suggest that clients who are characterized by more conflict are more likely to attend therapy as soft mandated.
Treatment length
To determine if soft-mandated clients attended more sessions than voluntary clients, an independent samples t-test was conducted. Results of the test were significant, t(296) = −2.30, p = .02. Voluntary clients attended, on average, six sessions of therapy (M = 5.97 sessions). Their soft-mandated counterparts attended, on average, approximately nine sessions (M = 8.61 sessions). These results suggest that clients who feel more pressured to attend therapy attend therapy longer than those who attend voluntarily.
Results of a one-way analysis of variance, investigating the relationship between treatment length and client type, indicated significant differences, F(3, 294) = 2.63, p = .05, in the number of sessions across the various types of clients. Further investigation consisted of Tukey’s post hoc comparisons. A Bonferroni correction was made to the expected p value to adjust for the number of comparisons, resulting in a p value of .013 required for significance. Post hoc comparisons showed no significant differences, but interestingly, results indicated that cases that presented for family therapy attended about four more sessions than those who presented for high-conflict couple therapy, mean difference = 4.09, p = .06. This suggests that high-conflict couples may experience shorter treatment lengths than clients attending family therapy.
To determine the association between who initiated termination and number of sessions, a one-way analysis of variance was conducted. Results of the test were significant, F(2, 201) = 9.90, p = .00, indicating that there were significant differences in the number of sessions attended across termination types. To further explore differences, Tukey’s post hoc comparisons were used. A Bonferroni correction to the expected p value was made to adjust for the number of tests run, resulting in a p value of .017 required for significance. Post hoc testing indicated that cases in which clients initiated termination unilaterally had shorter treatment lengths than cases in which the decision to terminate was made with the therapist, mean difference = −5.85, p = .00. Though not statistically significant, it is worth noting that those cases who terminated unilaterally also experienced shorter treatment lengths than those cases whose terminations were therapist initiated, mean difference = −6.0, p = .10. These results suggest that cases who terminated therapy unilaterally did so earlier in treatment than all other types of cases.
Treatment success
A chi-square test was conducted to examine the relationship between treatment success and client type. Results of the test indicated no significant differences, χ2(3) = 3.4, p = .33, suggesting that individual, couple, high conflict, and family cases are equally successful in treatment. Similarly, results of a chi-square test investigating the relationship between treatment success among soft-mandated and voluntary clients showed no significant differences, χ2(1) = .32, p = .57. These results show that soft-mandated and voluntary clients are equally successful in treatment.
A chi-square test was also conducted to assess the relationship between treatment success and cases that were voluntary or soft mandated. Despite the differences in the number of sessions attended mentioned earlier, there were no differences in the rates of success for soft-mandated and voluntary clients, χ2(1) = .32, p = .63. This suggests that though soft-mandated clients attend more sessions, they fare as well as voluntary clients in therapy.
Termination status
To assess the relationship between client type and how treatment termination was initiated, a chi-square test was conducted. Results of the test indicated no significant differences, χ2(6) = 4.52, p = .61, suggesting that unilateral, mutual, and therapist-initiated termination were equally likely among individual, couple, high conflict, and family cases.
Relationship between treatment length and success
To determine the association between the number of sessions attended and treatment success, an independent samples t-test was conducted. Results of the test were significant, t(238) = −4.18, p < .01. Among cases where treatment was considered successful, clients attended an average of nine sessions of therapy (M = 9.16 sessions), whereas those whose treatment was unsuccessful attended an average of five sessions (M = 5.12 sessions). This suggests that those who attend treatment longer experience more success.
Relationship between termination status and treatment success
Results of a chi-square test, investigating the relationship between who initiated termination and treatment success, indicated significant differences in success rates, χ2(2) = 14.2, p = .00. Cases who initiated termination unilaterally showed the lowest success rates (60.2%); cases whose treatment termination was therapist initiated showed higher success rates (87.5%); and cases whose treatment was terminated mutually between therapist and client/clients had the highest success rate (90.2%). Results of this test suggest that people who terminate unilaterally had the lowest success rates.
Discussion
This study set out to investigate treatment length, success, and termination, and their relationship with various client profiles. Results of this study indicate how particular circumstances under which clients enter therapy can affect therapy outcomes. Evidence from this study suggests that soft-mandated and voluntary clients show similar success rates in treatment. However, soft-mandated clients attended treatment longer than their voluntary counterparts. Results also showed that high-conflict couples were more likely to attend therapy under pressure as soft mandated, but were equally as successful as clients who attended as individuals, couples, and families. Consistent with other research studies indicated in Snyder and Anderson’s (2009) review, clients who are pressured to attend therapy can be successful in treatment. One explanation for treatment success and longer treatment lengths among soft-mandated clients is that the pressure to attend therapy may cause soft-mandated clients to remain engaged in therapy longer, leaving more time for change to occur. More research is needed to explore the process variables that underlie successful treatment among various client profiles.
Results from this analysis also provide evidence that clients who unilaterally terminate treatment do so earlier in treatment than those whose termination was mutual. Similarly, though not statistically significant, results showed that cases with unilateral termination showed shorter treatment lengths than those cases with therapist-initiated termination. Data also indicated that cases that terminated unilaterally also indicated the lowest success rates. These results support previous research that indicates that clients who drop out of therapy prematurely achieve poorer outcomes (Pekarik, 1992; Stark, 1992). However, upon further investigation, data suggested that unilateral termination was not specific to whether the client received individual, couple, family, or high-conflict couple treatment. Additional research is needed to further understand the differences among clients who terminate unilaterally and clients whose termination was mutual or therapist initiated.
An understanding of the circumstances in which clients are referred and terminate therapy is important for individual and family therapists for many reasons. First, evidence from this study suggests that clinicians need to thoroughly understand the pressures under which clients enter therapy. There are many circumstances that bring clients to therapy and although soft-mandated clients may not suffer severe consequences for failing to attend therapy, they experience more pressure than voluntary clients. Therapists need to tailor their interventions to meet the needs of clients who enter therapy feeling pressured so that they may feel comfortable.
Another clinically relevant finding was that cases whose termination was mutually initiated showed the highest success rates. This suggests that clinicians not only influence how clients perceive therapy, they also influence how treatment comes to a close. These results support the influence of the therapeutic alliance on treatment outcomes (Sprenkle & Blow, 2007). Results of this study also indicated that cases whose termination was therapist initiated showed higher success rates than those who terminate unilaterally. This suggests that therapists have a credible judgment regarding the appropriateness of termination.
Limitations and Suggestions for Future Research
In considering the results of this study, it is important to note the limitations. First, data were analyzed on a case level to determine the relationships among referral status, treatment length, termination status, and treatment success. Other analyses at the individual, couple, or family level may more accurately capture the experience of soft-mandated clients. Specific client demographics may also provide more clarity regarding the treatment differences among clients who enter and terminate treatment under varying circumstances. Second, treatment success was determined only by therapists’ report and did not include the clients’ rating. There may have existed differences between therapists’ and clients’ perspectives regarding treatment success. The limitations described are products of using archival data. Finally, therapist experience was not included as study variable. Treatment duration or success could have been influenced by the education or experience of their therapist.
Despite these areas of concern, the present study contributes to the literature regarding how therapy experiences differ among various client types and circumstances under which they engage in treatment. It is the first to explore the treatment outcomes associated with soft-mandated clients, proposing that pressure to attend therapy is more continuous than it has been indicated in previous literature. Results from this study provide information about the course of therapy across different client characteristics that have the potential to inform future research in this area.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.