Client Retention Paper. Scott J. Busby. Abilene Christian University

Transcription

1 Running head: CLIENT RETENTION PAPER Client Retention Paper Scott J. Busby Abilene Christian University

2 CLIENT RETENTION PAPER 2 Introduction Client retention and attrition are concepts linked to the outcome of psychotherapy. According to Swift and Greenberg (2012), whereas clients who remain in therapy have consistently improved in regard to their presenting problem(s), clients who drop out of therapy are more likely to relapse or show no significant improvement in regard to their presenting problem(s). Because of the prevalence of client attrition, researchers have spent vast amounts of time exploring the underlying factors that influence clients to prematurely discontinue treatment as well as those factors that influence clients to remain in therapy. Based upon the findings of these studies, investigators have developed many strategies by which clinicians may hope to increase retention in their clients. The information provided by researchers on the subject of client retention will be particularly relevant to my personal development as a therapist at the Marriage and Family Institute. I am hopeful that my findings will provide me with an awareness by which I can most effectively administer treatment while retaining my client caseload. Client Attrition Swift and Greenberg (2012) described the phenomenon of client dropout to be when a client starts an intervention but discontinues prior to recovering from the problems (symptoms, functional impairment, distress, etc.) that led him or her to seek treatment (p. 547). Though such a description may seem to address only the problem that client dropout poses for clients themselves, this phenomenon truly holds ramifications for each individual or system associated with the therapeutic process. Consequences Client dropout engenders difficulties not only for clients, who show poorer treatment outcomes upon premature discontinuation of treatment, but also for therapists, who lose the time

3 CLIENT RETENTION PAPER 3 and revenue associated with the client and who sometimes perceive dropout to be a commentary on their therapeutic skills (Swift & Greenberg, 2012). As a result, clinicians in these circumstances often suffer from a sense of inadequacy and defeat (Swift & Greenberg, 2012). Furthermore, Swift and Greenberg (2012) suggested that mental health institutions also suffer the consequences of premature discontinuation because such occurrences restrict the number of clients the agency can serve. Lastly, according to Swift and Greenberg (2012), when clients drop out of treatment, society as a whole suffers because the burden of mental illness is maintained as a result of sustained dysfunction in the individual (p. 547). The effects of this consequence are heightened by the fact that, according to Reis and Brown (2006), therapy dropouts, as opposed to those who continue treatment, are more likely to be the typical chronic or overutilizing patient (p. 311). Prevalence Client dropout is an extraordinarily common and debilitating occurrence in the psychotherapy process. Indeed, Wierzbicki and Pekarik (1993) reported an average dropout rate of 47% across 125 studies. Garfield (1994) substantiated these claims and reported that 30% to 57% of all clients discontinue treatment prematurely, often presenting only for the intake session and many attending no more than four sessions. Furthermore, according to Taft, Murphy, Elliott, and Morrel (2001), dropout rates typically range from 40% to 60% within the first 3 months of treatment (p. 51). Regardless of the demographic or population under scrutiny, however, client dropout is a regular phenomenon. Kazdin (1990) reported that, among referred adolescents with behavioral problems, 50%-70% do not submit themselves to treatment or, once started, fail to complete treatment. Gondolf and Foster (1991) further reported that, among abuse perpetrators referred to batterer treatment programs, only 10% actually completed the program. By

4 CLIENT RETENTION PAPER 4 contrasting these two vastly different populations of clients, one can see how deeply the problem of client attrition permeates the field of mental health. For this reason, since the 1970s, researchers have sought to understand the factors that contribute to client dropout (Reis & Brown, 2006). Contributing Factors Robbins, Turner, Alexander, and Perez (2003) reported that many demographic and interpersonal factors have been shown to be strong predictors of dropout in the clinical research literature. Furthermore, they stated: Knowledge of these variables is essential for therapists to anticipate sources of resistance and other factors that may lead to dropout (Robbins et al., 2003, p. 534). Modality. Imel, Laska, Jakupcak, and Simpson (2013) reported that there is evidence to support the notion that exposure-based treatments in which clients are asked to divulge traumatic experiences to their therapist may be poorly received and thus, a contributing factor to attrition. Thus, adopted modality and its reception by clients is a reason for which clients may prematurely discontinue treatment. Demographic and background variables. According to Taft, Murphy, Elliott, and Morrel (2001), among abusive male clients, research has revealed a number of demographic and background factors related to dropout. Included are lower age, lower education, lower income, unmarried status, and higher unemployment or a history of unemployment (Taft et al., 2001, p. 51). Furthermore, Taft et al. (2001) reported that mandated clients are more likely to continue therapy than are self-referred clients and that Caucasian males are more likely to remain in batterer s treatment than are ethnic minorities. Robbins, Turner, Alexander, and Perez (2003)

5 CLIENT RETENTION PAPER 5 support the notion that demographic factors contribute to client dropout, regardless of the purpose for treatment. Therapeutic alliance. Robbins, Turner, Alexander, and Perez (2003) stated: It is now generally recognized that the therapeutic alliance is an important process variable in psychotherapy research and a consistent predictor of outcome (p. 535). In regard to client attrition, a contributing factor is the balance of the therapeutic relationship. For example, high levels of parent-therapist alliance may be threatening to an adolescent who frequently receives criticism at the hands of his family members. Such an imbalance of the therapeutic alliance could threaten family attendance should the adolescent become resistant to the process of therapy and thus, the process of change. Client Retention Just as there are many factors that contribute to client attrition, there is also research to suggest that certain techniques and practices may promote client retention. Collaborative Approach Reis and Brown (2006) suggested that client perspective on the therapeutic process is a key factor for client retention. When clients are provided a space in which to express their expectations, opinions, and frustrations, Reis and Brown (2006) reported that attrition rates are lower and outcomes are significantly more positive than when the process is less collaborative (p. 312). Thus, a collaborative approach to psychotherapy is a contributing factor to client retention. Length of Treatment Client retention is also largely dependent upon client expectations of duration of treatment. Reis and Brown (2006) suggested that, between clients and clinicians, there is a

6 CLIENT RETENTION PAPER 6 discrepancy of expected length of psychotherapy. Whereas clients often expect psychotherapy to be brief, many clinicians are suspicious of brief modalities. Furthermore, Reis and Brown (2006) reported that, in many cases, client expectations regarding duration of therapy become self-fulfilling prophecies. Therefore, clients will abandon the therapeutic process after meeting their own expectations for duration. Thus, Reis and Brown (2006) reported that brief therapies often result in higher rates of client retention. Level of Training Stein and Lambert (1995) reported evidence to suggest that therapists with higher levels of training and experience maintain higher levels of client retention. Swift and Greenberg (2012) provided support for this idea by reporting that, in particular, university and training facilities are associated with higher rates of dropout. For clinicians, Stein and Lambert s (1995) study suggested that greater amounts of training could be associated with retention of clients for longer periods of time. Strategies for Maintaining Client Retention Because investigators have devoted so much time to understanding the factors that underlie client retention and attrition, many strategies and techniques have been suggested to provide higher rates of client retention. Training. Swift and Greenberg (2012) suggested that, in training or university-based settings, instructors and supervisors should teach therapists-in-training the factors associated client retention and attrition and should further instruct them in client retention strategies. In this way, teaching students about client retention strategies is a strategy unto itself.

7 CLIENT RETENTION PAPER 7 Client preparation. Reis and Brown (2006) conducted a study in which a sample group was made to watch a video that explained the therapeutic process before they began treatment. In such a way, clients were educated about the process of therapy and informed about what to expect from treatment. Their findings revealed an increase in client retention among those who viewed the tape. This preparation video allowed clinicians to address such issues as expectations regarding therapy roles and behaviors, [and] treatment duration, factors that Swift and Greenberg (2012) have identified as relevant to client retention (p. 558). Such a strategy of client preparation could increase the probability of client retention. Brief therapies. Brevity of treatment has been associated with high rates of client retention. In light of these findings, Reis and Brown (2006) suggested that clinicians collaboratively establish a short duration of treatment before its commencement. The authors proposed that such an arrangement fosters greater patient collaboration and engagement and enhances the working alliance, thus reducing the patient s tendency to drop out (Reis & Brown, 2006, p. 312). Therapeutic alliance. Robbins, Turner, Alexander, and Perez (2003) emphasized the importance of responding appropriately to the competing demands made by family members in the early stages of therapy (pp ). Because the balance of the therapeutic alliance is of the utmost importance as a determining factor of retention, therapists, according to the authors, must seek to create a balanced atmosphere in which each individual can express him or herself without fear of reprisal. Clinical Implications During my brief career as an intern at the Marriage and Family Institute at Abilene Christian University, I have seen only one client family with my co-therapist. For the past

8 CLIENT RETENTION PAPER 8 several weeks we have been unable to schedule an appointment with them and have received several cancellation phone calls. As I read the literature regarding client retention, the information concerning the importance of the therapeutic alliance in the early phases of therapy seemed exceptionally relevant to this client system. Though my co-therapist and I did not intentionally ally with the parental subsystem against the adolescent identified patient, I am concerned that we failed to disrupt a pattern of accusatory statements spoken by the parent and thus established an unbalanced therapeutic relationship with our clients. Though we cannot be certain, it is possible that our adolescent client does not perceive the therapeutic process to be a safe environment in which he can express himself and thus, he may have grown disinterested in treatment and change. If that is the case, the remaining family members may perceive little change in his behavior and also grow disenchanted with treatment. Although the application of my new knowledge was somewhat unsettling, I was pleased to find such an immediate application of the concepts I encountered. In future contexts, I will possess a heightened awareness of the balance of the therapeutic relationship and may, as a result of my new knowledge, be emboldened to disrupt accusatory comments. In addition, the client preparation portion of my literature review greatly informed the way in which I will conduct intake interviews in the future. Besides the information we are required to discuss with clients, I may seek to incorporate some additional information regarding the process of therapy at the Marriage and Family Institute, especially information regarding length of treatment. Furthermore, I will strive to be much more collaborative in addressing client expectations of therapy in the early phases of treatment. I will make it my business to understand what my clients expect from me and from the process so that I can serve them in a highly collaborative fashion.

9 CLIENT RETENTION PAPER 9 Conclusion Client retention is an ongoing area of research. Although many of the factors influencing client retention and attrition are known, many remain unknown. However, of the known factors, strategies have been developed to help clinicians avoid client dropout and encourage client attendance and participation in treatment. Though many of these factors, such as demographic factors, are out of the therapist s control, many others center upon the client s perception of the therapeutic process, a perception that the therapist may influence. As a result, strategies for increasing client retention often involve collaborative, educative, and alliance-enhancing efforts on behalf of the clinician. Though client retention is ultimately in the hands of the client, therapists may do much to increase the likelihood of client participation and attendance.

10 CLIENT RETENTION PAPER 10 References Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp ). New York: Wiley. Gondolf, E. W., & Foster, R. A. (1991). Preprogram attrition in batterer programs. Journal of Family Violence, 6, Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal Of Consulting And Clinical Psychology. Kazdin, A. E. (1990). Conduct disorders. In A. S. Bellack & M. Hersen (Eds.), International handbook of behavior modification and therapy (2nd ed., pp ). New York: Plenum Press. Reis, B. F., & Brown, L. G. (2006). Preventing therapy dropout in the real world: The clinical utility of videotape preparation and client estimate of treatment duration. Professional Psychology: Research And Practice, 37(3), Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A. (2003). Alliance and dropout in family therapy for adolescents with behavior problems: Individual and systemic effects. Journal Of Family Psychology, 17(4), Stein, D. M., & Lambert, M. J. (1995). Graduate training in psychotherapy: Are therapy outcomes enhanced?. Journal Of Consulting And Clinical Psychology, 63(2), Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: metaanalysis. Journal Of Consulting And Clinical Psychology, 80(4),

11 CLIENT RETENTION PAPER 11 Taft, C. T., Murphy, C. M., Elliott, J. D., & Morrel, T. M. (2001). Attendance-enhancing procedures in group counseling for domestic abusers. Journal Of Counseling Psychology, 48(1), Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24,