Abstract
In the marriage and family therapy (MFT) field, minimal attention has been given to in-session therapy processes that influence clients’ decisions to persist in therapy or prematurely discontinue therapy. To prevent premature discontinuation, therapists need a better understanding of why clients leave treatment before completing it. In this grounded theory study, we interviewed 19 clients of MFTs to examine how they made decisions about therapy persistence or discontinuation. Factors that impacted participants’ decision to discontinue therapy were: client motivation, the therapeutic alliance, therapy productiveness, including the therapist’s understanding of the problem, the therapist’s frame of the problem, therapy pacing, and neutrality in relational therapy. Results support the importance of common factors in facilitating therapeutic change.
Similar content being viewed by others
References
Adams, J. F., Piercy, F. P., & Jurich, J. A. (1991). Effects of solution focused therapy’s “formula first session task” on compliance and outcome in family therapy. Journal of Marital and Family Therapy, 17, 277–290. https://doi.org/10.1111/j.1752-0606.1991.tb00895.x.
Anderson, H., & Goolishian, H. A. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for critical theory. Family Process, 27, 371–393.
Barrett, M. S., Chua, W., Crits-Christoph, P., Gibbons, M. B., Casiano, D., & Thompson, D. (2009). Early withdrawal from mental health treatment: Implications for psychotherapy practice: Correction to Barrett et al (2008). Psychotherapy: Theory, Research, Practice, Training, 46(2), 248–248. https://doi.org/10.1037/a0016184.
Beutler, L. E., & Harwood, T. M. (2000). Establishing a therapeutic relationship. Prescriptive Psychotherapy. https://doi.org/10.1093/med:psych/9780195136692.003.0004.
Bischoff, R. J., & Sprenkle, D. H. (1993). Dropping out of marriage and family therapy: A critical review of research. Family Process, 32, 353–375. https://doi.org/10.1111/j.1545-5300.1993.00353.x.
Blow, A., Morrison, N., Tamaren, K., Wright, K., Schaafsma, M., & Nadaud, A. (2009). Change processes in couple therapy: An intensive case analysis of one couple using a common factors lens. Journal of Marital and Family Therapy, 35, 350–368. https://doi.org/10.1111/j.1752-0606.2009.00122.x.
Blow, A. J., Sprenkle, D. H., & Davis, S. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298–317. https://doi.org/10.1111/j.1752-0606.2007.00029.x.
Bohart, A. C., & Wade, A. M. (2013). The client variables in psychotherapy. In M. Lambert (Ed.), Bergin & Garfield’s Handbook of psychotherapy and behavior change (pp. 219–257). New York: Wiley.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the alliance. Psychotherapy: Theory, research and practice, 16, 252–260. https://doi.org/10.1037/h0085885.
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage.
Chenail, R. J., St. George, S., Wulff, D., Duffy, M., Wilson-Scott, K., & Tomm, K. (2012). Clients’ relational conceptions of conjoint couple and family therapy quality: A grounded formal theory. Journal of Marital and Family Therapy, 38, 241–264.
Davis, S. D., & Piercy, F. P. (2007a). What clients of couple therapy model developers and their former students say about change, part I: Model-dependent common factors across three models. Journal of Marital and Family Therapy, 33, 318–343. https://doi.org/10.1111/j.1752-0606.2007.00030.x.
Davis, S. D., & Piercy, F. P. (2007b). What clients of MFT model developers and their former students say about change, Part II: Model independent common factors and an integrative framework. Journal of Marital and Family Therapy, 33, 344–363. https://doi.org/10.1111/j.1752-0606.2007.00030.x.
Echevarria-Doan, S., & Tubbs, C. (2005). Let’s get grounded: Family therapy research and grounded theory. In D. Sprenkle & F. Piercy (Eds.), Research Methods in Family Therapy (pp. 41–62). New York: Guilford.
Garfield, S. L. (1986). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 213–256). New York: Wiley.
Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 190–228). New York: Wiley.
Glaser, B. G. (1987). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: The Sociology Press.
Glaser, B. G., & Strauss, S. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine Publishing Company.
Hamilton, S., Moore, A. M., Crane, R. D., & Payne, S. H. (2011). Psychotherapy dropouts: Differences by modality, license and DSM-IV diagnosis. Journal of Marital and Family Therapy, 37, 333–343. https://doi.org/10.1111/j.1752-0606.2010.00204.x.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149.
Kazdin, A. E. (1990). Premature termination from treatment among children referred for antisocial behavior. Journal of Child Psychology and Psychiatry, 31, 415–425. https://doi.org/10.1111/j.1469-7610.1990.tb01578.x.
Kazdin, A. E., Holland, L., & Crowley, M. (1997). Family experience of barriers to treatment and premature termination from child therapy. Journal of Consulting and Clinical Psychology, 65(3), 453–463. https://doi.org/10.1037//0022-006x.65.3.453.
Kegel, A. F., & Flückiger, C. (2014). Predicting psychotherapy dropouts: A multilevel approach. Clinical Psychology & Psychotherapy, 22(5), 377–386. https://doi.org/10.1002/cpp.1899.
Knerr, M., Bartle-Haring, S., McDowell, T., Adkins, K., Delaney, R. O., Gangamma, R., … Meyer, K. (2011). The Impact of initial factors on therapeutic alliance in individual and couples therapy. Journal of Marital and Family Therapy, 37(2), 182–199. https://doi.org/10.1111/j.1752-0606.2009.00176.x.
Knudson-Martin, C. (2013). Why power matters: Creating a foundation of mutual support in couple relationships. Family Process, 52, 5–18.
Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Basic Books.
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th edn., pp. 139–193). New York: Wiley.
Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. In M. J. Lambert (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 203–223). Oxford university press: Oxford. https://doi.org/10.1093/acprof:oso/9780199737208.003.0010.
Lebow, J. (1984). Assessing consumer satisfaction in mental health treatment settings: A guide for the administrator. Administration in Mental Health, 12(1), 3–14. https://doi.org/10.1007/bf00818533.
Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.
Marchionda, D. M., & Slesnick, N. (2013). Family therapy retention: An observation of first-session communication. Journal of Marital and Family Therapy, 39, 87–97. https://doi.org/10.1111/j.1752-0606.2011.00279.x
Masi, M. V., Miller, R. B., & Olson, M. M. (2003). Differences in dropout rates among individual, couple, and family therapy clients. Contemporary Family Therapy, 25(1), 63–75. https://doi.org/10.1023/a:1022558021512.
Miller, W. R., & Rollnick, S. (2002). Setting the record straight: What motivational interviewing is NOT. PsycEXTRA Dataset. https://doi.org/10.1037/e603162009-007.
Mueller, M., & Pekarik, G. (2000). Treatment duration prediction: Client accuracy and its relationship to dropout, outcome and satisfaction. Psychotherapy: Theory, Research, Practice, Training, 37, 117–123. https://doi.org/10.1037/0033-3204.37.2.117.
Odell, M., & Quinn, W. H. (1998). Therapist and client behaviors in the first interview: Effects on session impact and treatment duration. Journal of Marital and Family Therapy, 3, 369–388. https://doi.org/10.1111/j.1752-0606.1998.tb01091.x.
Oka, M., & Whiting, J. (2013). Bridging the clinician/researcher gap with systemic research: The case for process research, dyadic and sequential analysis. Journal of Marital and Family Therapy, 39, 17–27. https://doi.org/10.1111/j.1752-0606.2012.00339.x.
Patton, M. Q. (1990). Qualitative evaluation and research methods. Beverly Hills, CA: Sage.
Pekarik, G. (1986). The use of termination status and treatment duration patterns as an indicator of clinical improvement. Evaluation and Program Planning, 9, 25–30. https://doi.org/10.1016/0149-7189(86)90004-2.10.
Pekarik, G., & Stephenson, L. A. (1988). Adult and child client differences in therapy dropout research. Journal of Clinical Child Psychology, 17(4), 316–321. https://doi.org/10.1207/s15374424jccp1704_3.
Phillips, E. (1987). Ubiquitous decay curve: Service delivery similarities in psychotherapy, medicine and addiction. Professional Psychology: Research and Practice, 18, 650–652. https://doi.org/10.1037/0735-7028.18.6.650.
Pinsof, W. M., & Wynne, L. C. (2000). Toward progress research: Closing the gap between family therapy practice and research. Journal of Marital and Family Therapy, 26, 1–8. https://doi.org/10.1111/j.1752-0606.2000.tb00270.x.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of the structure of change. Self Change. https://doi.org/10.1007/978-1-4612-2922-3_5.
Reis, B. F., & Brown, L. G. (1999). Reducing psychotherapy dropout: Maximizing perspective convergence in the psychotherapy dyad. Psychotherapy: Theory, Research, Practice, Training, 36, 123–136. https://doi.org/10.1111/j.1752-0606.2010.00204.x.
Saatsi, S., Hardy, G. E., & Cahill, J. (2007). Predictors of outcome and completion status in cognitive therapy for depression. Psychotherapy Research, 17(2), 185–195. https://doi.org/10.1080/10503300600779420.
Shadish, W. R., & Baldwin, A. S. (2003). Meta-analysis of MFT interventions. Journal of Marital and Family Therapy, 29, 547–570. https://doi.org/10.1111/j.1752-0606.2003.tb01694.x.
Shadish, W. R., Hu, X., Glaser, R. R., Kownacki, R., & Wong, S. (1998). A method for exploring the effects of attrition in randomized experiments with dichotomous outcomes. Psychological Methods, 3, 3–22. https://doi.org/10.3102/10769986029004421.
Shadish, W. R., Ragsdale, K., Glaser, R. R., & Montgomery, L. M. (1995). The efficacy and effectiveness of marital and family therapy: A perspective from meta-analysis. Journal of Marital and Family Therapy, 21, 345–360. https://doi.org/10.1111/j.1752-0606.1995.tb00170.x.
Simon, G. M. (1993). Revisiting the notion of hierarchy. Family Process, 32, 147–155.
Simon, W., Lambert, M. J., Harris, M. W., Busath, G., & Vazquez, A. (2012). Providing patient progress information and clinical support tools to therapists: Effects on patients at risk of treatment failure. Psychotherapy Research, 22(6), 638–647. https://doi.org/10.1080/10503307.2012.698918.
Sledge, W. H., Moras, K., Hartley, D., & Levine, M. (1990). Effect of time-limited psychotherapy on patient dropout rates. American Journal of Psychiatry, 147(10), 1341–1347. https://doi.org/10.1176/ajp.147.10.1341.
Snyder, C. R., Cheavens, J., & Sympson, S. C. (1997). Hope: An individual motive for social commerce. Group Dynamics: Theory, Research, and Practice, 1, 107–118.
Sprenkle, D. H., & Blow, A. J. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113–129. https://doi.org/10.1111/j.1752-0606.2004.tb01228.x.
Sprenkle, D. H., Davis, S. D., & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: The Guilford Press.
Strauss, A. (1987). Qualitative analysis. New York: Cambridge University Press.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.
Strauss, E. S., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.
Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193–207. https://doi.org/10.1037/a0037512.
Walitzer, K. S., Dermen, K. H., & Connors, G. J. (1999). Strategies for preparing clients for treatment: A review. Behavior Modification, 23, 129–151. https://doi.org/10.1177/0145445599231006.
Wampler, K. S., & Bartle-Haring, S. (2015). Collecting and pooling assessment and outcome data in couple and family therapy training clinics: Reasons to do it, common problems, and some suggestions for avoiding them. Journal of Marital and Family Therapy, 42(2), 213–216. https://doi.org/10.1111/jmft.12143.
Ward, A., & Knudson-Martin, C. (2012). The impact of the balance of power on the couple system: A qualitative analysis of couple sessions. Journal of Couple and Relationship Therapy, 11, 1–17. https://doi.org/10.1080/15332691.2012.692943.
Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. New York: Norton.
Weeks, G. R., & D’Aniello, C. (2017). Teaching reframes in a master’s level marriage and family therapist program. Journal of Family Psychotherapy. https://doi.org/10.1080/08975353.2017.1297068.
Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). Effectiveness of psychotherapy with children and adolescents: A meta-analysis for clinicians. Journal of Consulting and Clinical Psychology, 55(4), 542–549. https://doi.org/10.1037//0022-006x.55.4.542.
Westmacott, R., Hunsley, J., Best, M., Rumstein-McKean, O., & Schindler, D. (2010). Client and therapist views of contextual factors related to termination from psychotherapy: A comparison between unilateral and mutual terminators. Psychotherapy Research, 20(4), 423–435. https://doi.org/10.1080/10503301003645796.
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190–195. https://doi.org/10.1037/0735-7028.24.2.190.
Woodward, C. A., Santa-Barbara, J., Levin, S., & Epstein, N. B. (1978). The role of goal attainment scaling in evaluating family therapy outcome. American Journal of Orthopsychiatry, 48, 464–476. https://doi.org/10.1111/j.1939-0025.1978.tb01335.x.
Zimmermann, D., Rubel, J., Page, A. C., & Lutz, W. (2016). Therapist effects on and predictors of non-consensual dropout in psychotherapy. Clinical Psychology & Psychotherapy, 24(2), 312–321. https://doi.org/10.1002/cpp.2022.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
D’Aniello, C., Piercy, F.P., Dolbin-MacNab, M.L. et al. How Clients of Marriage and Family Therapists Make Decisions About Therapy Discontinuation and Persistence. Contemp Fam Ther 41, 1–11 (2019). https://doi.org/10.1007/s10591-018-9469-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10591-018-9469-7