Premature termination is when your client terminates before the agreed time or against the therapist’s current recommendation. This is a common problem for many beginning psychologists and one which many find frustrating and disturbing.
There is a great review article in this in one of last year’s Harvard Review of Psychiatry. Unfortunately full text is not available free online.
The review summarises a number of studies looking into why clients terminate early or do not complete recommended number of sessions. The primary factors identified in the review include:
- Pre-therapy preparation
- Time limited
- Treatment negotiation including goal setting
- Appointment reminders
- Motivation enhancement
- Facilitation of therapeutic alliance
- Facilitation of affective expression
This type of termination impacts on the therapist
Surprisingly, very little has been written about the effects of patient-initiated premature termination on therapists. Most commonly, it is acknowledged that patient-initiated premature termination can be demoralizing to therapists, particularly for beginning therapists.5 Therapists may believe that they have failed, or were rejected by, the patient. Such a belief may, in turn, impair therapists’ confidence and effectiveness. There may be a sense among therapists that they have wasted their time and effort when they experience a premature termination. Narcissistic injury is also common among therapists. That is, for therapists whose own self-esteem is closely tied to their ability to help others, the loss of a patient through premature termination threatens their sense of self-worth. Painful reactions to losing a patient through premature termination, such as hurt, rejection, or anger, may interfere with other aspects of the therapist’s professional or personal life.
It also impacts on the client:
From a clinical perspective, the patient may not receive full benefit from treatment, including the benefit of a worked through termination. The patient often experiences a sense of dissatisfaction or failure, which can result in a worsening of problems. Indeed, patients who terminate prematurely report less therapeutic progress and more psychological distress. Premature terminators are more likely to be characterized as chronic patients, with a tendency to over utilize services, in some cases contacting mental health services at twice the rate of patients classified as appropriate terminators. In the context of group therapy, patient-initiated premature termination can be even more disruptive. Discontinuation disrupts group solidarity and can precipitate other premature terminations. Patient-initiated premature termination may destroy or delay meaningful work for the rest of the group, often leaving other group members feeling insecure, worried, or angry.
The next few postings will focus on a number of these issues one by one and expand on what therapists can do to minimize this.