Provide Education About Patterns of Change in Psychotherapy

As we continue our exploration of client retention and how this can decrease stress for clinicians by decreasing early termination of clients we will be looking at Chapter 6 - “Provide Education About Patterns of Change in Psychotherapy” from the book, Premature Termination in Psychotherapy - Strategies for Engaging Clients and Improving Outcomes, written by Joshua K. Swift and Roger P. Greenberg.

“An investment in knowledge pays the best interest.” - Benjamin Franklin

Providing clients with a forewarning about patterns of change and potential setbacks can help them better navigate therapy and thus be better prepared for the struggles they may face.  When setbacks do come up, without forewarning, clients may see these struggles as a sign that therapy is not working; thus, they may perceive that their present therapy is having little benefit and anticipate that attending treatment will yield few benefits in the future.

There are two distinct ways in which a lack of knowledge about patterns of change may lead to premature termination from therapy.  

First, clients may drop out because they expect therapy to be brief, and they see initial improvement as a sign of recovery.

• Clients generally expect therapy to work quickly.  For some, the speed at which change occurs will not meet their expectations, and, as a result, they will experience disappointment and likely drop out.
• In contrast, others may mistake early gains as complete recovery and thus drop out, thinking that they have finished the therapy endeavor.
• According to the phase model of psychotherapy, most clients experience change in a predictable, step-like manner.  First, they experience some early improvements, referred to as remoralization, which generally occur within about four sessions.  Clients who expect treatment to take only a few sessions may mistakenly view these early improvements as a resolution of their problems.
• True recovery in terms of significant decreases in symptoms (remediation) or improved functioning (rehabilitation) takes much longer.
• Thus, education about the phase model of psychotherapy may be useful in helping clients understand that lasting change is likely to take some time.

Second, clients may expect a linear pattern of progression but get discouraged when therapy becomes difficult or setbacks are encountered.

• Therapy is not all a bed of roses; it can be difficult work.
• Instead of avoiding painful and threatening experiences and emotions, in therapy, we ask clients to face them.  For some, this may result in increased distress and symptoms.  Although we do not endorse the adage that things have to get significantly worse before they get better, we expect that almost all clients will experience at least minor setbacks sometime during the course of therapy.
• On the basis of results from one study, at least 10% of clients will experience sudden and significant deterioration during treatment (Lutz et. al. 2013).
• For all clients, when a setback or increased distress is experienced, it can easily be seen as a sign that therapy is not working, that the benefits are not present.
• If therapy becomes too painful, clients may even see therapy as a burden.
• In both instances, clients may choose to drop out prematurely, believing the costs associated with attending outweigh any potential benefits that, in their mind, may not even come.
• Hence, educating clients about nonlinear patterns of change and the fact that potential setbacks are a routine occurrence in the process may also reduce the likelihood of premature termination in psychotherapy.

After receiving education about the phase model, clients will be able to recognize that early improvements in hope that occur in the first few sessions are a good thing, but not an indication that complete recovery has occurred.  Additionally, when they have been educated about potential setbacks, clients will be able to recognize that a lack of linear progression does not mean that therapy is failing.  Instead, they will be prepared to talk with their therapist about the deterioration they notice early on so that changes can be made, rather than simply dropping out.

By recognizing early improvements, clients can hope that further improvements will follow, and by recognizing setbacks as temporary and normal, clients can maintain their hope that therapy will eventually bring about the change that they desire.