Case Conceptualization: Interventions and Evaluation

Article

Treatment Duration and Termination
Status Among Clients in a University-
Based Counseling Center

Alison G. Wong
1
, Rachel B. Tambling

1
, and Shayne R. Anderson

1

Abstract
Researchers have long been interested in understanding for whom therapy works and why. This study sought to identify ways in
which clients differ with regard to treatment outcomes such as treatment length, success, and termination status. Data for this
study were taken from the client documents completed prior to the first session of therapy and the therapist-completed termi-
nation summary for 305 cases from a university-based marriage and family therapy clinic. Results suggest that soft-mandated and
voluntary clients show similar success rates in treatment. Also, cases that terminated unilaterally had the lowest success rates,
though rates were approximately equal across modality. This study provides information about treatment across different client
characteristics and modalities.

Keywords
couple therapy, drop out, outcome

Researchers in the field of family therapy have long been

interested in understanding for whom therapy works and why.

While many clients are successful in their treatment, there

remain instances of drop out, early termination, and unsuccess-

ful treatment. Clients differ in many ways, meaning that their

experience in therapy may also differ. One explanation of the

differences in therapy experience that has been explored is the

referral status, mandated or voluntary, suggesting that the pres-

sure under which clients enter therapy influences their percep-

tions of treatment and may affect therapy outcomes (Snyder &

Anderson, 2009). However, literature suggests that referral

status may be more complex, examining a third form of referral

status called soft mandated (Moore, 2013). The present study

examines the relationships between various types of clients and

treatment outcomes such as treatment length, success, and

termination.

Mandated Therapy Attendance

Clients enter into psychotherapy under a variety of circum-

stances. Significant research attention has been paid to under-

standing the differences between those clients who enter

therapy under duress and those clients who enter therapy volun-

tarily. One widespread assumption in outpatient psychotherapy

is that clients are at least somewhat motivated to participate in

the therapy and have entered into therapy of their own accord

(Rooney, 1992). However, some clients enter into therapy

under duress or on the strong recommendation of a powerful

associate. Some clients, commonly referred to as mandated

clients, enter into therapy at the order of the court system, state

social services, or others who have the authority to impose

severe sanctions on clients who fail to attend therapy. Such

clients are referred to therapy for a variety of issues such as

substance abuse, child abuse or neglect, and legal issues.

Researchers (see Snyder & Anderson, 2009, for a review)

have delineated differences in motivation to change, resistance,

and therapy outcomes between voluntary and mandated clients.

Mandated clients often feel marginalized and powerless, result-

ing in anger toward authority and an outlook that is problem

focused (Rosenberg, 2000). Because mandated clients do not

initiate treatment, their attitudes about treatment and readiness

for change are not taken into consideration when the client is

told to begin treatment (Hiller, Knight, Leukefeld, & Simpson,

2002). To the client, treatment may represent a system’s oppo-

sition to the client’s choices. As a result, the client may resist

treatment because he or she refuses to accept the notion that

he or she did something wrong (Storch & Lane, 1989).

Along with mistrust of the system/systems that enforce

treatment, mandated clients frequently have difficulty enga-

ging with therapists. The therapeutic alliance is associated with

1
Department of Human Development and Family Studies, University of

Connecticut, Storrs, CT, USA

Corresponding Author:

Alison G. Wong, Department Human Development and Family Studies, Uni-

versity of Connecticut, 348 Mansfield Road, U-1058, Storrs, CT 06269, USA.

Email: [email protected]

The Family Journal: Counseling and
Therapy for Couples and Families
21(4) 371-376
ª The Author(s) 2013
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treatment outcome, and relationship is highly influenced by cli-

ents’ motivation to engage with the therapist (Martin, Garske,

& Davis, 2000). Howgego, Yellowlees, Owen, Meldrum, and

Dark (2003) observed that mandated clients do not seek a rela-

tionship with the therapist and are not motivated to engage in

treatment, which suggests a sense of mistrust and discomfort

with the therapy process.

While distinctions between voluntary versus mandated

referral status are useful, such distinctions fail to capture the

range of client experiences. Moore (2013) has proposed the use

of a term for a third category of clients, soft-mandated clients.

Soft-mandated clients are those clients who are encouraged to

attend therapy at the request of a powerful associate, but would

be subject to only mildly unpleasant sanctions should they fail

to attend (Moore, 2013). In outpatient psychotherapy, soft-

mandated clients often present for therapy at the request of state

social services, employers, religious leaders, or attorneys. The

referrer cannot impose severe sanctions for failures to attend

therapy; however, the influence of the referrer likely imposes

a great deal of pressure on potential clients to comply with the

referral to therapy.

Little is known about the experiences of soft-mandated cli-

ents. One study (Moore, 2013) found that soft-mandated clients

experience higher levels of depression and anxiety than clients

who sought therapy voluntarily. Unfortunately, little is known

about the treatment outcomes of soft-mandated clients as com-

pared to their voluntarily attending counterparts. It is possible

that, like many mandated clients, soft-mandated clients may

experience higher levels of premature termination from ther-

apy, or other poor outcomes.

Psychotherapeutic Dropout

Early client dropout has important fiscal, clinical, and research

implications. Dropout is commonly conceptualized as termina-

tion from therapy that occurred before therapy goals were

achieved or was unilateral on the part of the client and was

unexpected from the therapists’ point of view. Premature

termination from therapy continues to present a challenge to

researchers and clinicians. Studies indicate that premature

termination from psychotherapy is common in individual out-

patient treatment. Wierzbicki and Pekarik (1993), in a meta-

analysis of 125 studies of psychotherapy dropout, found a mean

drop-out rate of 46% across studies.
Premature termination from therapy is perhaps most con-

cerning because of the loss of potential for client improvement.

Clients who drop out of therapy prematurely achieve poor

outcomes similar to those who did not receive therapy (Pekarik,

1992; Stark, 1992). Clients who terminate prematurely are less

likely to be satisfied with the treatment they received (Pekarik,

1992) and unlikely to go on to received needed services

(Weisz, Weiss, & Langmeyer, 1987).

Demographic data, from both the therapist and the client,

have been heavily researched as predictors of dropout in indi-

vidual therapy though simple demographic variables often fail

to yield consistent results (Hamilton, Moore, Crane, & Payne,

2011; Wierzbicki & Pekarik, 1993). Researchers of couple

therapy have taken a similar approach to the analysis of prema-

ture termination. Most studies of dropout in couple therapy focus

on demographic variables as predictors of dropout. Couples who

have no legal commitment to one another, as well as couples

without children are more likely to prematurely terminate from

therapy (Allgood & Crane, 1991; Davis & Dhillon, 1989). Hav-

ing many presenting problems or presenting problems relating to

only one spouse significantly increases rates of dropout (Allgood

& Crane, 1991; Ward & McCollum, 2005).

Clients who have schizophrenia, psychotic, and substance

use disorders are also more likely to terminate prematurely

(Hamilton et al., 2011). Evaluations of conjoint therapy for the

treatment of addiction indicate couples are less likely to drop

out when they have a positive alliance with their treatment

provider (Raytek, McCrady, Epstein, & Hirshch, 1999), when

identified patients have lower rates of drug use and couples

have fewer presenting problems (Stanton & Shadish, 1997),

and when the members of the couple are committed to one

another (Epstein, McCrady, Miller, & Steinberg, 1994). New

research has also found that marriage and family therapists

have the lowest drop-out rates among mental health profession-

als (Hamilton et al., 2011). A better understanding of factors

that contribute to premature termination will increase effi-

ciency and efficacy in both clinical practice and psychothera-

peutic research.

There is limited research regarding the relationship between

treatment outcomes and various client profiles. For example,

little is known about clients who attend couple therapy, clients

who attend therapy at the request of a third party, or the com-

bination of the two. The majority of the literature focuses on

individual therapy with clients who attend voluntarily. Addi-

tionally, research has excluded clients who attend therapy at the

request of third party, such as a state social service provider or

agent of the court system. The relationship between various

characteristics of clients and treatment outcomes was examined

by answering the following research questions:

Research Question 1: Is there a particular type of client

who is more likely to present to therapy under the con-

dition of being soft mandated?

Research Question 2: Does the total number of sessions

attended vary by client characteristics?

a. Is there a difference in treatment length among

referral status (voluntary vs. soft mandated)?

b. Are there differences in treatment length among

client type (individual, couple, high-conflict

coparenting dyads, and family)?

c. Are there differences in treatment length across ter-

mination initiation (unilateral, therapist initiated, or

mutual)?

d. Are there differences in treatment success among

various client profiles?

e. Is any particular client type more likely to drop out

of treatment?

372 The Family Journal: Counseling and Therapy for Couples and Families 21(4)

Method

Participants

Data for this study came from a university-based marriage and

family therapy clinic in the Northeastern United States between

2008 and 2010. Participants were 305 cases of therapy at the

clinic. Cases consisted of individual (n ¼ 150), couple (n ¼
94), high-conflict couple (n ¼ 10), and family (n ¼ 45) treat-
ment. There were six cases in which the client type was not

clearly indicated by the therapist. These cases consisted of

treatment that included individual, couple, and family sessions.

Clients who attended high-conflict couple therapy were

referred by the court system, were divorced or separated, and

shared children. Each case was entered into a clinic database,

using each case file as the primary source of data. For this

particular database, information taken from case files included

information for the case as a whole rather than information

regarding each individual client. Thus, information in the data-

base focused on treatment variables rather than demographic

information.

Measures

Data from this study were obtained from the archival data of a

university-based counseling center in the Northeast. Data were

present for a variety of variables, described in detail below.

Percentages indicated for each variable represent cases in

which there were complete data. Cases with missing data were

removed from analysis.

Soft mandated versus voluntary. Clients were categorized as soft
mandated (24.6%) or voluntary (73.8%) based on how they
were referred to treatment, as indicated by the documented con-

tact found in clients’ clinical records at treatment onset. Soft-

mandated clients were those whose clinical records included

documented contact with the court system, the Department of

Children and Families (DCF), or a guardian ad litem. Voluntary

clients were those whose clinical records indicated self-referral

and included no documentation of contact with the court

system, DCF, or a guardian ad litem.

Treatment success. The success of treatment was determined by
an examination of termination documents in clients’ clinical

records. Therapists completed the termination documents after

the treatment was discontinued. Termination documents

included information such as date of intake, date of last session,

total number of sessions attended, and therapist’s description of

treatment. Coders reviewed termination documents and

assessed whether treatment was successful, unsuccessful, or

undetermined, based on therapist’ report. Treatment was rated

‘‘successful’’ (56.7% of cases) if therapist indicated that treat-
ment goals were met or were progressing, as evidenced by

observations of changes in client behavior or insight during

treatment. Treatment was rated ‘‘unsuccessful’’ (22.3% of the
cases) if therapist indicated that treatment goals were not met

and/or client prematurely ended treatment. Clients who did not

attend the intake session or stopped attending before treatment

goals were determined were rated as ‘‘undetermined’’ (10.5%).
Thirty cases were rated as never seen, which consisted of cases

in which clients completed the intake process but did not show

for their first appointment.

Termination initiation. Termination initiation was determined by
an examination of termination narratives in documents com-

pleted by therapists and entered into clients’ clinical records.

One coder reviewed the narrative written by therapists as part

of termination documents to determine whether termination

was therapist, client, or mutually initiated, based on therapists’

report. In this narrative, therapists described the reasons for

initiating therapy, the course of treatment, whether goals were

met, and the reasons for termination, if known. Termination

was rated as therapist initiated if the narrative indicated that cli-

ents had met their goals, or therapy had reached a productive

end and the narrative indicated that the therapist suggested the

clients end therapy. Termination was rated as client initiated if

therapists noted that clients requested that treatment end; if

clients ended treatment with little to no progress on treatment

goals; or, if clients did not attend scheduled sessions and failed

to respond to the therapist‘s efforts to contact them. Termina-

tion was rated as mutually initiated if the narrative indicated

that therapists and clients discussed, and agreed upon, termina-

tion timing; a planned termination session occurred; or, if a

predetermined treatment length was reached, as in the case of

some mandated clients who were required by a third party to

attend a contracted number of sessions.

Treatment length. Treatment length was determined by the num-
ber of sessions attended between date of intake and date that the

termination document was completed.

Procedures

This study used existing clinic data from a Commission on

Accreditation for Marriage and Family Therapy Education-

accredited marriage and family therapy training program in the

Northeastern United States. The marriage and family therapy

program houses a clinic on campus that specializes in provid-

ing mental health services to individuals, couples, and families

with a wide range of presenting problems. Therapists consisted

of 24 master’s and 8 doctoral students in the marriage and fam-

ily therapy program who provided treatment under the supervi-

sion of clinical faculty members who are licensed marriage and

family therapists. All therapists were versed in systemic and

family-based interventions.

Following termination, therapists completed a case termina-

tion summary. As part of this summary, therapists reported the

number of sessions attended by the clients and the way in which

the case terminated. Data for this study were taken from

the client documents completed prior to the first session of

therapy and the therapist-completed termination summary.

Data collected from documents completed prior to the first

session included referral source, releases of information, and

Wong et al. 373

correspondence received from referral sources. Cases with

intake dates from the year 2008 and later were selected for this

study because the documents from which data were collected

were implemented at the clinic in 2008. Data were entered

by two graduate-level research assistants and were reviewed

by faculty researchers.

Results

Relationship Between Client Type and Soft-Mandated
Referral

To determine whether a particular type of client was more

likely to enter therapy as soft mandated, a chi-square test was

performed. Results of the test indicated significant differences,

w2(3) ¼ 61.029, p ¼ .00. Cases that presented to couple therapy
had the lowest rate of entering therapy as soft mandated (2.7%).
Family cases also showed a lower rate of being soft mandated

(16.0%), followed by individuals (25.3%), and high-conflict
couples showed the highest rates attending as soft mandated

(56.0%). Results suggest that clients who are characterized
by more conflict are more likely to attend therapy as soft

mandated.

Treatment length. To determine if soft-mandated clients
attended more sessions than voluntary clients, an independent

samples t-test was conducted. Results of the test were signifi-

cant, t(296) ¼ �2.30, p ¼ .02. Voluntary clients attended, on
average, six sessions of therapy (M ¼ 5.97 sessions). Their
soft-mandated counterparts attended, on average, approxi-

mately nine sessions (M ¼ 8.61 sessions). These results suggest
that clients who feel more pressured to attend therapy attend

therapy longer than those who attend voluntarily.

Results of a one-way analysis of variance, investigating the

relationship between treatment length and client type, indicated

significant differences, F(3, 294) ¼ 2.63, p ¼ .05, in the num-
ber of sessions across the various types of clients. Further

investigation consisted of Tukey’s post hoc comparisons. A

Bonferroni correction was made to the expected p value to

adjust for the number of comparisons, resulting in a p value

of .013 required for significance. Post hoc comparisons showed

no significant differences, but interestingly, results indicated

that cases that presented for family therapy attended about four

more sessions than those who presented for high-conflict cou-

ple therapy, mean difference ¼ 4.09, p ¼ .06. This suggests that
high-conflict couples may experience shorter treatment lengths

than clients attending family therapy.

To determine the association between who initiated termina-

tion and number of sessions, a one-way analysis of variance

was conducted. Results of the test were significant, F(2, 201)

¼ 9.90, p ¼ .00, indicating that there were significant differ-
ences in the number of sessions attended across termination

types. To further explore differences, Tukey’s post hoc com-

parisons were used. A Bonferroni correction to the expected

p value was made to adjust for the number of tests run, resulting

in a p value of .017 required for significance. Post hoc testing

indicated that cases in which clients initiated termination uni-

laterally had shorter treatment lengths than cases in which the

decision to terminate was made with the therapist, mean differ-

ence ¼�5.85, p ¼ .00. Though not statistically significant, it is
worth noting that those cases who terminated unilaterally also

experienced shorter treatment lengths than those cases whose

terminations were therapist initiated, mean difference ¼
�6.0, p ¼ .10. These results suggest that cases who terminated
therapy unilaterally did so earlier in treatment than all other

types of cases.

Treatment success. A chi-square test was conducted to examine
the relationship between treatment success and client type.

Results of the test indicated no significant differences, w2(3) ¼
3.4, p ¼ .33, suggesting that individual, couple, high conflict,
and family cases are equally successful in treatment. Similarly,

results of a chi-square test investigating the relationship

between treatment success among soft-mandated and voluntary

clients showed no significant differences, w2(1) ¼ .32, p ¼ .57.
These results show that soft-mandated and voluntary clients are

equally successful in treatment.

A chi-square test was also conducted to assess the relation-

ship between treatment success and cases that were voluntary

or soft mandated. Despite the differences in the number of ses-

sions attended mentioned earlier, there were no differences in

the rates of success for soft-mandated and voluntary clients,

w2(1) ¼ .32, p ¼ .63. This suggests that though soft-mandated
clients attend more sessions, they fare as well as voluntary

clients in therapy.

Termination status. To assess the relationship between client
type and how treatment termination was initiated, a chi-square

test was conducted. Results of the test indicated no significant

differences, w2(6) ¼ 4.52, p ¼ .61, suggesting that unilateral,
mutual, and therapist-initiated termination were equally likely

among individual, couple, high conflict, and family cases.

Relationship between treatment length and success. To determine
the association between the number of sessions attended and

treatment success, an independent samples t-test was con-

ducted. Results of the test were significant, t(238) ¼ �4.18,
p < .01. Among cases where treatment was considered success- ful, clients attended an average of nine sessions of therapy (M ¼ 9.16 sessions), whereas those whose treatment was unsuccessful attended an average of five sessions (M ¼ 5.12 sessions). This suggests that those who attend treatment longer experience more success. Relationship between termination status and treatment success. Results of a chi-square test, investigating the relationship between who initiated termination and treatment success, indi- cated significant differences in success rates, w2(2) ¼ 14.2, p ¼ .00. Cases who initiated termination unilaterally showed the lowest success rates (60.2%); cases whose treatment termina- tion was therapist initiated showed higher success rates (87.5%); and cases whose treatment was terminated mutually 374 The Family Journal: Counseling and Therapy for Couples and Families 21(4) between therapist and client/clients had the highest success rate (90.2%). Results of this test suggest that people who terminate unilaterally had the lowest success rates. Discussion This study set out to investigate treatment length, success, and termination, and their relationship with various client profiles. Results of this study indicate how particular circumstances under which clients enter therapy can affect therapy outcomes. Evidence from this study suggests that soft-mandated and vol- untary clients show similar success rates in treatment. How- ever, soft-mandated clients attended treatment longer than their voluntary counterparts. Results also showed that high- conflict couples were more likely to attend therapy under pres- sure as soft mandated, but were equally as successful as clients who attended as individuals, couples, and families. Consistent with other research studies indicated in Snyder and Anderson’s (2009) review, clients who are pressured to attend therapy can be successful in treatment. One explanation for treatment suc- cess and longer treatment lengths among soft-mandated clients is that the pressure to attend therapy may cause soft-mandated clients to remain engaged in therapy longer, leaving more time for change to occur. More research is needed to explore the pro- cess variables that underlie successful treatment among various client profiles. Results from this analysis also provide evidence that clients who unilaterally terminate treatment do so earlier in treatment than those whose termination was mutual. Similarly, though not statistically significant, results showed that cases with uni- lateral termination showed shorter treatment lengths than those cases with therapist-initiated termination. Data also indicated that cases that terminated unilaterally also indicated the lowest success rates. These results support previous research that indi- cates that clients who drop out of therapy prematurely achieve poorer outcomes (Pekarik, 1992; Stark, 1992). However, upon further investigation, data suggested that unilateral termination was not specific to whether the client received individual, couple, family, or high-conflict couple treatment. Additional research is needed to further understand the differences among clients who terminate unilaterally and clients whose termina- tion was mutual or therapist initiated. An understanding of the circumstances in which clients are referred and terminate therapy is important for individual and family therapists for many reasons. First, evidence from this study suggests that clinicians need to thoroughly understand the pressures under which clients enter therapy. There are many circumstances that bring clients to therapy and although soft- mandated clients may not suffer severe consequences for failing to attend therapy, they experience more pressure than voluntary clients. Therapists need to tailor their interventions to meet the needs of clients who enter therapy feeling pressured so that they may feel comfortable. Another clinically relevant finding was that cases whose ter- mination was mutually initiated showed the highest success rates. This suggests that clinicians not only influence how clients perceive therapy, they also influence how treatment comes to a close. These results support the influence of the therapeutic alliance on treatment outcomes (Sprenkle & Blow, 2007). Results of this study also indicated that cases whose termination was therapist initiated showed higher success rates than those who terminate unilaterally. This suggests that thera- pists have a credible judgment regarding the appropriateness of termination. Limitations and Suggestions for Future Research In considering the results of this study, it is important to note the limitations. First, data were analyzed on a case level to determine the relationships among referral status, treatment length, termination status, and treatment success. Other analy- ses at the individual, couple, or family level may more accu- rately capture the experience of soft-mandated clients. Specific client demographics may also provide more clarity regarding the treatment differences among clients who enter and terminate treatment under varying circumstances. Second, treatment success was determined only by therapists’ report and did not include the clients’ rating. There may have existed differences between therapists’ and clients’ perspectives regarding treatment success. The limitations described are products of using archival data. Finally, therapist experience was not included as study variable. Treatment duration or suc- cess could have been influenced by the education or experience of their therapist. Despite these areas of concern, the present study contributes to the literature regarding how therapy experiences differ among various client types and circumstances under which they engage in treatment. It is the first to explore the treatment outcomes associated with soft-mandated clients, proposing that pressure to attend therapy is more continuous than it has been indicated in previous literature. Results from this study provide information about the course of therapy across different client characteristics that have the potential to inform future research in this area. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, author- ship, and/or publication of this article. References Allgood, S. M., & Crane, D. R. (1991). Predicting marital therapy dropouts. Journal of Marital and Family Therapy, 17, 73–79. Davis, H., & Dhillon, A. M. (1989). Prediction of early attribution from couple therapy. Psychological Reports, 65, 899–902. Epstein, E. E., McCrady, B. S., Miller, K. J., & Steinberg, M. (1994). Attribution from conjoint alcoholism treatment: Do dropouts differ from completers? Journal of Substance Abuse, 6, 249–265. Wong et al. 375 Hamilton, S., Moore, A. M., Crane, R., & Payne, S. H. (2011). Psy- chotherapy dropouts: …