There is a psychotherapy drop-out crisis that the general public is largely unaware of and the mental health field apparently overlooks. Conservative estimates of the number of people who discontinue psychotherapy after starting hover around 28-33 percent, with well upwards of half doing so within the first few sessions. Trustworthy sources reveal that the median number of sessions received by people entering psychotherapy falls somewhere between seven and nine.
I call these estimates conservative because the way psychotherapy drop-out is typically defined and measured reflects medicalized models of short-term interventions aimed primarily at symptom reduction. Evidence-based treatment protocols considered adequate for improvement typically last 12-16 sessions, with a range of roughly 6 to 20 sessions depending on the type of disorder and its severity.
Admittedly, there are those people for whom a brief course of therapy aimed at symptom reduction is both preferred and satisfactory. However, it appears that such individuals are in the minority. A recent survey sponsored by the Psychotherapy Action Network (PsiAN) of more than 1500 adults in the U.S. found that 88 percent “Prefer therapy that may take longer because it helps you manage your symptoms and also addresses the root cause of problems.” Moreover, a substantial number of clients who receive short-term evidence-based treatments do not walk away recovered. One set of meta-analyses of depression treatments observed that more than half of clients studied failed to respond (experience at least a 50 percent reduction in symptoms) and only one third were in remission upon completion, or experienced symptoms at subclinical levels.
All this begs the question: How much psychotherapy does the typical person need presenting with some combination of anxiety, depression, difficult personality traits, and life distress, to obtain meaningful and lasting change?
Recent robust meta-analytic findings deliver an answer. A study out of University College London assessing the results of sixteen randomized trials of long-term intensive psychotherapy substantiated that obtaining a course of treatment greater than or equal to 9 months, or 30 sessions, is associated with significant and sustained alleviation of depression, compared to active, less intensive treatments. Another research team out of Amsterdam found that obtaining 50 psychotherapy sessions a year (beginning twice weekly) produced faster and greater amelioration of depression and difficult personality traits than approximately 25 sessions.
Consequently, if we land on 30-50 sessions of psychotherapy as a ballpark reasonable number of sessions for the typical anxious and depressed client facing interpersonal challenges to obtain meaningful and sustained change, it falls woefully short of the median 7-9 sessions most people typically receive when they pursue psychotherapy.
What accounts for this underutilization? Obviously, there are the material and logistical reasons that people cite for discontinuing: cost/financial hardship, inadequate insurance coverage, transportation issues, scheduling conflicts. Nonetheless, in my estimation a pivotal overlooked reason is the discrepancy between what most people embarking on psychotherapy seek from the experience and what legions of practitioners are trained to provide.
The PsiAN survey cited above underscored how 73 percent of participants agreed that “The most valuable aspect of therapy is sharing your thoughts and feelings without feeling judged or ashamed”; and 67 percent of those asked why people sought therapy endorsed the statement: “To better understand yourself and the root of your issues.” Extrapolating from these results, it would seem that most people cultivate preferences for age-old notions of psychotherapy that have proven remarkable durable: A culturally sanctioned space to candidly share whatever is on your mind for as long is needed to obtain fundamental salutary shifts in how you feel about yourself and your life.
Yet, current professional training diverges from this ethos, underscoring evidence-based treatments, or short-term, protocol-driven approaches to psychotherapy focused on symptom reduction. The National Psychotherapy Training Survey, conducted over the past few decades points to greater numbers of clinical psychology Ph.D. programs (81 percent, up from 56 percent) and Psy.D. programs (59 percent, up from 33 percent) requiring evidence-based practice training, and 75 percent of programs across the mental health disciplines surveyed offered some mix of didactic and supervised training in these methods.
Even though in the psychotherapy world it is common knowledge that the therapy alliance—good rapport rooted to relational sensitivity and responsiveness to client needs—constitutes one of the most robust predictors of psychotherapy outcome, formal coursework devoted to alliance building remains remarkably rare. In a survey of APA-accredited clinical and counseling psychology doctoral programs, only 17 percent required students to take even one alliance-related course, and only 13 percent offered an elective course specifically covering the therapeutic alliance.
We have to wonder whether the training and education of countless psychotherapists sets them up to force feed clients formulaic models of treatment they are well-versed in, rather than fall back on the tried-and-true old standards of careful and caring listening—striving to make the client fit the therapy, rather than the therapy fit the client.
There may be something to my point of view. A recent study looking at premature psychotherapy discontinuance zeroed in on seven themes: therapist misattunement, inert therapeutic relationships, unmanaged therapist responses, unmanaged therapist interventions, rigid protocol adherence, readiness for change, and repeating interpersonal dynamics.
We know with confidence that it bodes well for psychotherapy continuance when practitioners can be responsive to clients’ needs and preferences. We also know with confidence that a strong psychotherapy alliance is associated with lower drop-out numbers. Taking matters a crucial step further, if we are to turn the tide of psychotherapy drop-out, the mental health field will need to seriously grapple with prioritizing the type of education and training of psychotherapists that optimizes the sort of genuine relating, open-ended listening, and emotional responsiveness that renders psychotherapy meaningful and effective enough for clients to want to stick with it.
The life of Conrad Aiken an American writer would be a compelling historical narrative on this specific topic. I would be interested in you or someone ‘s take on his life and how treatment helped or didn’t help him.
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My immediate reaction upon reading this rationale (yet another!) for the alleged benefits of psychotherapy was this:
Perhaps a large percentage of clients who dropped out “prematurely” after just a few sessions with a so-called mental health expert had a sudden insight, i.e. they finally came to realize the fallacious premises and intellectual vacuity of the psychiatric cult..
I submit that it’s the motley host of psychiatrists, psychologists, clinicians, researchers, academics, etc. consciously propagating the myths of the discredited DSM who are most in need of intensive de-programming. However, the “difficult personality traits” and off-putting behavioral “symptoms” (smugness, condescension) they often exhibit lead me to conclude that breaking away from their cult will be an arduous task. Given that the incentives to profit from it are so powerful, the prognosis for recovery would seem poor.
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I’m not sure why this is a “crisis.” It’s just information, important information. I tend to agree with the author that failure of therapists to prioritize genuine relationships with their clients is probably a main driver of therapy dropouts. And shorter courses of therapy are also less likely to lead to lasting change. But the very idea of “therapy” comes out of damage done by our society and its institutions, and it is a rare therapist who actually brings this kind of perspective into their sessions.
It is interesting, however, to see that the standard applied is a 50% reduction in symptoms. I wonder how many antidepressant trials even come close to that kind of a standard.
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Do you contextualize the observation as a system, capable of being improved through better management practices?
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Not really. It’s a matter of human interaction, and therapists may or may not be any good at it, as research has clearly shown. There are a lot of societal changes that would improve outcomes a lot more than more therapy, much more than half of which probably makes things worse.
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Steve, I doubt that therapists are necessarily best qualified to offer “genuine relationships” to their clients. Empathetic support and insight can also be found in peer groups, without the inherent power imbalance of the therapist-client interaction, and at far less expense.
Also, I object to use of the word “symptoms” in regard to signs of emotional distress, such as depression, anxiety, and compulsive thoughts or behavior. I believe medicalized language is inappropriate for describing mental states that have not been proven to originate in some type of physical pathology.
That’s the crux of my rejection of the biomedical psychiatric paradigm, which conflates real medical conditions with metaphorical descriptions.
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I agree on both counts.
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You know, to bring this up again, but really thereNEEDSTOBE…. (sorry I friend of mine was given something by Versace, I had to tell her about, the one that wrote the Figaro song, not too bad either, it’s nice as a baritone to be singing something other than popping up the tears of draft targets and fightingly unfair attempts at creating empathy for animal welfare; when told about the Versace, she behaved just like that, grabbed two jugs of what she’d been off of long enough to completely drown all of that to tell me: ‘yes….” It was)…. there needs to be (sorry) therapy for the Harry Potter age. For example, regarding teleporting, I usually wait too long. But, being in a gay marriage where the kids change ages, since we don’t do genetic or physical impregnation, really, they did teleport away what needed to be taken care of, to not last too long, and replaced it with……. There’s a famous guy made it so far, he is not on television all places, not US. He sounds like he’s inhaling an inner tube, because that way he might have ended up there. On TV. So, a patch from such an inner device — but for a bike — ended up where what wasn’t there to not end up too far along…….
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This is connecting disparate issues to try to somehow make a case that longterm psychodynamic therapy is desirable and good.
We tell potential therapy seekers to shop around. There should be lots of therapies that don’t get very far because there was not a great connection. Therapists should be ok with that.
If it takes 50 sessions for therapy to produce meaningful and lasting benefits, tell patients that before they start. That is meaningful consent. You can’t gauruntee results but you can share the evidence that forms your understanding of why you do/recommend longterm psychodynamic therapy. Set the expectation. A lot of people are not up for that and can’t afford that. That is ok. Your treatment is not for them. If therapists think people need 50 sessions in therapy to see meaningful change, and patients don’t know that, but therapists dont tell them, this is a crisis of informed consent.
Addressing some symptoms is enough for people–it is all they want out of the experience. Many psychodynanic therapists dont even have panels with people that would come in “symptomatic”–they sell their services as getting to understand yourself better, not manage/heal pathology. PsiAN wants it both ways–for insurance payers to treat them like health professionals and pay them accordingly, all the while not providing a health service.
PsiAN is just an professional advocacy organization for psychodynamic therapists–all of their research conclusions are going to be more recommending more therapy and more payouts to therapists, regardless findings in their market research. Much of their market research can be interepreted just as well as people supporting treatments that help them learn skills to manage symptoms and feel better quicker without relying on relational dependence at the costs of $10k a year.
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Actually in historical terms of clinical treatment there was a vast change in the early 1970’s. And I see it as luck of the draw to happen to meet a human being who has some sort of healer aspects to how they are. Abd Steve is completely right about environment playing a huge role and all the various environments I would add .
After 1980 after years of clinical treatment accepted as taking years or sometimes like lifetime like with many who under went psychoanalysis the money association and short term therapy configured into our current Gordian Knot. Agencies were funded by government or private groups were forced into short term because less money used.
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I work in the UK Talking Therapies service formally IAPT. Over the years I’ve started to think the service isn’t really there to help suffering people.
Its mostly there to service targets and maintain its funding and the illusion of a so called 50% recovery rate – based on nonsense questionnaires like the PHQ9 and GAD7. It also has a massive drop out rate and no one cares, zero follow up.
I think it also serves a more important role in helping to maintain a disordered political and economic status quo.
Human beings suffer because of what happens to us and what resources we might have or not to help us manage but these services take myriad cultural disorders and place the problems and solutions between people ears. The what has happened to people is generally reduced to a mere trigger for some alleged personal disorder.
Once the weight of a disordered neoliberal school, work place, relationship, poor neighbourhood, debts, poor diets, bad physical health, poor sleep, chronic screen time, algorithmic manipulations and a millions other things causes us to suffer then its off to the GP or the algorithm for answers.
Soon the signals of your suffering will be turned into symptoms and personal disorders and you are fed into a system like the one I’m in.
A new personal narrative and often an entire identity takes shape ‘I am depressed’ or ‘I have depression’ or ‘I am neurodiverse’ or fill in the blank with any number of unsubstantiated DSM labels offering a fake explanation for why we suffer. The establishment does not correct this misinterpretation of a none explanation, but colludes with it, by misusing terms like ‘diagnosis’ and ‘treatment’
Then we’re off to the races, the revolving door or poorly evidenced, psychotherapy all in position because they are sanctioned by and often share the values of capitalist neoliberalism and its heroic individualism.
Then you are fed psychiatric drugs under the guise they are ‘treatments’ for unsubstantiated DSM labels – you then collect labels and more drugs and the therapy revolving door keeps on spinning – the managers, the teachers, the parents in fact everyone now feed the need to keep this going – its all tied to multiple self and vested interests.
All of this works very well indeed to obfuscate our many and varied culture disorders and keep us all blaming ourselves for our disordered, thoughts, behaviours, attitudes, ‘attachment styles’ or whatever psychobabble in in vogue – and man we’re all communicating in psychobabble now – we’re literally losing the capacity to describe our suffering outside of medicalised language.
Its also all very big business – the latest DSM fad of so called ‘adhd’ is becoming as popular as Mcdonalds.
Of course no therapists are incentivised to to read any of the critical literature pulling apart therapy on methodological grounds and showing none of it has any real solid evidence beyond say exposure therapy in some cases. Most of it takes for granted and is based on ‘treating’ the unsubstantiated DSM labels – tis a house of cards made out of profit and pain.
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Marx, you forgot your Marx. “Alienation,” is how I see what you refer to as, “Cultural disorders.” In the lack of a proletrian movement for socialism this will continue.
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Well said. Wow. Thank you for articulating such a powerful perspective. I have found it very difficult to get practicing therapists to even listen to survivor stories. They just don’t want to look. It’s very sad to me. I work in crisis work and am not a therapist. I try to be the best listener I can be and very kind and loving. I meet people in person. I also gently challenge my co-responders who may be trained therapists to slow down in their quick analyzing and try to consider the person’s social factors. It’s hard but I am known for being very non-judgmental and loving on my team. Thank you for expressing in your comment what I feel most days and am not allowed to express for fear of being reprimanded. I imagine lots of other people who work in these fields are also scared to speak up fully. One thing I know is my coworkers are extremely loving people and they care deeply. I continue to build strong relationships with them and show them kindness and no judgment as well. We are all in this together. We all deserve to be heard and loved.
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Over four years I have triedva dozen different clinicians ftom social worker to clinical psychologist
I ended wirh half of them wirhin a few sessions overwhelmingly because they were not competent. Really basic stuff like not double-booking clients.
Two asked me to leave, one so unethicallly that their Board sustained my complaint and sent them a warning letter.
Most did not understand how to deal with hypoarousal, dissociation, and complex trauma. Only one – my current one – has had sny training in dissociation, and it shows.
Evidence-based rarely asks the question, for whom?
There is little to no research on therapy addressing the hypoarousal response rather than hyperarousal. Much research slso excludes those clients seen as most at risk.
Those I know in therapy for trauma agree it is long term – years, not one year. For many of us it takes a year just to begin to trust our therapist. Ajd given how hard it id to find one, we often stay too long with an unsuited therapist. Length of time alone does not guarantee better outcomes.
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agreed – i have 40+ yrs of experience in the field and the standard is shockingly low. In fact, in the 1980s, I had so many bad experiences with therapists that I thought there was something wrong with me – indeed there was. Unfortunately I was in my late 50s when I finally found a therapist that could work with dissociation & CPTSD – even after working with world-famous somatic therapists who themselves were severely blocked
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Interesting. It’s amazing you’ve finally found someone that coudl work with some of the problems you were facing. Would you mind sharing what kind of method she or he uses? But it might not be about a “method” in particular. I’ve tried many of those “world famous somatic practices and they didnt help me. I used to have a lot of motivation but I don’t anymore, it’s hard to keep hope when everything I do to heal my “traumas” seems to have faile.
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I dropped out because none of the various therapists I’ve had did anything other than bob their heads and tell me “That must have been difficult,” or asked “How did that make you feel?” That’s a disgrace. I wanted techniques to help with social anxiety and to rebuild my low self-esteem caused by my mother using me as her emotional punching bag growing up. I got more out of YouTube videos and Google’s AI than I ever got from any of these counselors who all seemed to have pretty significant emotional problems and no wisdom.
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No one should underestimate how effective YouTube videos or AI guidance can be when most human counselors rely on scripted, pre-packaged responses.
Fake as all get out.
The only thing real about human-led therapy is the bill they hand you at the end.
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Congrats for not buying the bullshit most therapists routinely spew — the idea that talk therapy is the best, or even the only, way out of distress.
This is patently untrue.
Dumping their crap was the best decision I ever made.
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The finding that 88% of respondents prefer longer therapy that addresses root causes really reframes the “drop-out crisis” — perhaps many people aren’t dropping out so much as declining a model that doesn’t match what they actually want. Your point about training is striking too; if only 17% of doctoral programs require even one course on the therapeutic alliance, it’s no wonder misattunement drives people away. It makes me wonder whether the field measures the wrong outcomes when it defines success as brief symptom reduction rather than the deeper self-understanding most clients say they value.
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Enrico thinks there’s a therapy drop-out crisis.
That all depends on which side of the fence you’re on.
Sometimes it’s better to forget your problems instead of continually talking about them.
Especially to strangers paid to feed off them for a living.
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“Sometimes it’s better to forget your problems instead of continually talking about them.”
Very wise!
Thought I would say so.
It is possible for us (all of us) to control where we place our attention.
Think “pink flamingo” and likely many of us will think of lawn ornaments.
Think “somebody did me wrong” and many humans can spin up outrage.
Think “gratitude” (even if, fake it till you make it) and this is the surest cure to “self pity” that I know of.
I used a therapist, briefly (<5 visits). The gift the therapist gave me, was that she believed me. As most of us know, the entire mental health profession, doesn’t believe a word we say. Upon closing our relationship, I was asked what I had learned? I had learned that Boy Scouts helping little old ladies across the street is a myth. The lasting benefit? I ceased entirely, looking outside myself, for answers.
Practice managing one’s own attention. It might take a lifetime, but it is possible.
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Congrats for entirely ceasing to look outside yourself for answers.
That’s the only thing of value that I got out therapy.
Turns out to have been just what I needed.
But I doubt my former therapists would see it that way.
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Not surprisingly, great comments here! I’d echo several. But I will however say, why the hell should someone pay a person crazy money to have a conversation scarcely more empathetic and likely less wise than the local bartender on a slow night? I think the real crisis is that the therapy-con has reached a multi-faceted economic juggernaut, and maybe people are fleeing it because they get ‘far better’ advice from their YouTube podcast, than the manufactured institutionalized bullshit todays therapist regurgitate. Sorry, but me thinks this crisis is more of a collective awakening, one the psych-disciplines effectively created from their years of dumbed-down behavioral fundamentalism shamelessly executed to appease neoliberal ethos and its societal dictates. As far as I’m concerned, the $10k I forked over to my Ph.D. therapist during the nineties, would have been better spent donating to a crack house.
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Whoever thought of charging money for a pair of ears had a heck of a lot of nerve.
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On second thought, it takes a heck of a lot more nerve to coin a term like “therapeutic alliance”.
That’s just adding insult to injury.
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Bravo, Kevin, for the unvarnished truth!
What a load of crap it is to pay someone for empathy and insight, apart from the real burden of a stigmatizing DSM psychiatric label and a prescription for the latest fad in drug treatment.
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The author assumes people need psychotherapy. Maybe therein lies the problem.
Our culture dictates therapy.
Maybe that’s the real crisis.
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I chucked a therapist once. I felt great. Whenever I found myself aporoaching situations I knew I would end with me feeling bad I decided to avoid it. I avoided a lot of situations I used to find difficult.
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