Factors associated with premature termination of psychotherapy by children.

Chung, Woo Sik ; Pardeck, John T. ; Murphy, John W. 等

Identifying children who fail to complete psychotherapy is critical for two reasons: Those who drop out do not receive needed clinical services; and clinics have invested a great deal of costly staff time in the treatment. If factors which lead to premature termination can be identified, practitioners can take appropriate preventive actions.

Limited research has been conducted on the reasons children prematurely drop out of treatment; however, a number of factors have been identified with adult populations. These include the importance of client input into the treatment plan (Heine & Trosman, 1960), client satisfaction with his or her therapist (Garfield, 1963), practical problems that confront the client (e.g., transportation) (Becham, 1992), and social class (Garfield, 1986).

The few notable studies that have explored why children drop out of psychotherapy prematurely include one by Gould, Shaffer, and Kaplan (1985) who report that demographic, personality, and psychopathology measures offer little explanation. However, Lasky and Salmone (1977) found that the client's age and gender may be factors that influence continuation of treatment. Viale-Val, Rosenthal, Curtiss, and Marohn (1984) report that adolescents as a specific age group often do not complete treatment. They also found that race and social class were possible predictors of early termination. Further, they report that if a child had an initial positive reaction to treatment, early termination was unlikely.

Given the fact that past research has identified only a limited number of variables associated with premature termination of treatment by children, the present research explores factors that have been found to be associated with older populations who experience this serious clinical problem. Specifically, the purpose of this study was to explore the influence of satisfaction with the treatment plan, the therapist, and related treatment variables on early termination. Other practical concerns related to the client's family, including financial matters, were also explored.

METHOD

The sample included 72 children who had dropped out of psychotherapy prematurely over a one-year period. Of these, 45 participated in the research. The average age of the participants was 13.5 years with an age range from 6 to 18 years. There were 22 males and 23 females.

The 45 children in the survey were receiving inpatient services from a midwestern psychiatric hospital prior to premature termination. The psychiatric services included a children's unit (ages 4 to 12), a preadolescent unit (ages 10 to 14), and an adolescent unit (ages 12 to 18). The following list identifies the psychological problems treated in each unit:

Children's unit: ineffective coping techniques; aggression/harm to self or others; impulsive, active mood/unable to stay on task in groups; depressed mood, sad affect/tearfulness; out of parental/school control; lack of boundaries; encopresis; and enuresis.

Preadolescent unit: depressive symptoms; suicidal behavior; aggressive behavior; history of running away; and history of sexual abuse.

Adolescent Unit: self-destructive behavior; aggressive behavior; elopement risk; depression; alteration in social norms; sexual abuse; anxiety; defiance of authority; substance abuse; family conflicts; and manipulative behaviors.

The research instrument which explored the phenomenon of early treatment termination was composed of 12 items and a comment section. The survey was conducted by telephone, and the adult caretaker was interviewed for all children under 18 years of age (98% of the cases). A one-group chi-square was the primary statistical test used in the data analysis.

FINDINGS AND CONCLUSIONS

As noted in Table 1, several of the survey items indicated statistically significant results. One important finding is that the child's family was generally supportive of early treatment termination; however, the results were not statistically significant when the role of financial considerations in the termination process was analyzed.

As would be expected, the therapist plays a significant role in the early treatment termination process. Item 3 shows that over 60% of the respondents did not feel that the physicians were professional and caring. A similar pattern is found in Item 4 for the staff; however, these results are not statistically significant.

Findings in Items 5 and 6 are statistically significant. It can be concluded from these data that the atmosphere of the hospital contributed to early treatment termination, and that the respondents viewed the facilities as generally restrictive and controlling. However, there was no statistically finding that other patients contributed to premature termination.

As indicated in Table 1, the treatment plan (Items 8 and 9) plays a statistically significant role; 67% of the respondents reported that the child's treatment plan was not adequately explained, and 72% felt it did not meet the child's needs.

Outside responsibilities (Item 10) did not appear to be a factor. As would be expected, there were statistically significant findings for Item 11: 67% of the respondents felt the treatment was too restrictive and that outpatient therapy probably would have been more desirable. Item 12 shows statistically significant findings which suggest that a large percentage of the respondents would not bring the child back to the facility if more treatment were needed.

Further analysis of the data (not reported in Table 1), through the use of the Mann-Whitney U statistical test showed that age and gender of the children were not statistically significant; that is, these factors had no impact on how the respondents answered each survey item.

The following comments are indicative of those made by the respondents and help explain why the children dropped out of treatment early.

1. Doctor never returned patient's parents' phone calls, and they were never able to speak with the doctor in person. Patient needed help, not a baby-sitter.

2. Patient was exposed to others who were much worse off. Parents called three times per day for 3 days, and patient was informed of the call only once. Patient never met the doctor. Staff did not help arrange follow-up counseling. The patient was even more depressed than before.

[TABULAR DATA FOR TABLE 1 OMITTED]

3. Too many patients and too many restrictions. Needed more freedom. Needed more information and input from doctor and staff.

4. Parents felt they should have had more contact with doctors. Mother saw the doctor only one time in two weeks. Patient is now receiving outpatient treatment at other facilities.

Some important conclusions can be drawn from this study. It is clear that the therapist plays a critical role in the process; if the therapist is professional and caring, the child is more likely to remain in treatment. Further, the treatment plan should be adequately explained and meet the needs of the child. It should be noted, however, that these conclusions are tentative and that additional research needs to be conducted on the problem of premature termination of treatment.

REFERENCES

Becham, E. E. (1992). Improvement after evaluation in psychotherapy of depression: Evidence of a placebo effect? Journal of Clinical Psychology, 45, 945-950.

Garfield, S. L. (1963). A note on patient' reasons for terminating therapy. Psychological Reports, 13, 38.

Garfield, S. L. (1986). Research on client variables in psychotherapy. In S. L. Garfield, & A. E. Bergin (Eds.), Psychotherapy and behavior change (pp. 213-256). New York: Wiley.

Heine, R. W., & Trosman, H. (1960). Initial expectations of the doctor-patient interaction as a factor in continuance in psychotherapy. Psychiatry, 23, 275-278.

Gould, M. S., Shaffer, D., & Kaplan, D. (1985). The characteristics of dropouts from a child psychiatry clinic. Journal of the American Academy of Child Psychiatry, 24, 316-328.

Lasky, R. G., & Salmone, P. R. (1977). Attraction to psychotherapy: Influences of therapist status and therapist-patient age similarity. Journal of Clinical Psychology, 33, 511-516.

Viale-Val, G., Rosenthal, R., Curtiss, G., & Marohn, R. (1984). Dropout from adolescent psychotherapy: A preliminary study. Journal of the American Academy of Child Psychiatry, 23, 562-568.

John W. Murphy, Ph.D., Professor, Department of Sociology, University of Miami, Coral Gables, FL 33124.

John T. Pardeck, Ph.D., LCSW, Professor, School of Social Work, Southwest Missouri State University, Springfield, MO 65804.

Reprint request to Woo Sik Chung, Ph.D., Associate Professor, Graduate School of Social Work, Boston College, Chestnut Hill, MA 02167.