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.
