710B_Akansha Vaswani & Diego Flores

Running head: A HISTORICAL ANALYSIS OF CLIENT DROPOUT 1

A Historical Analysis of Client Dropout

Akansha Vaswani & Diego Flores

San Diego State University

A HISTORICAL ANALYSIS OF CLIENT DROPOUT 2

Abstract

In this paper we explore the discourse and practices surrounding the issue of dropout from

psychotherapy in order to contextualize an action research study at the Center for Community

Counseling and Engagement (CCCE). We do this by first focusing on definitions of the term

dropout, followed by early research on the concept, which examined four main variables– client

characteristics, therapist characteristics, therapy process variables, and interventions. Secondly,

we focus on the wider shift toward patient-centered medicine, which inspired the ephiphenomena

of the evidence-based and cultural competence movements. The former, based on modernist

ideas, pivoted attention to one of the earlier variables – the therapeutic intervention. We provide

a critique of why this approach did not provide a robust explanation of what leads to dropout

from therapy – including an overreliance on randomized control trials and treatment manuals,

lack of generalizability and ignoring culture. The cultural competence movement, based more on

postmodern thought, was introduced as a concept that could help reduce dropout, especially of

minority groups by adjusting services and treatment options to account for ethnocultural

differences. Its critique is based on positing culture in reductionist ways and falling into a similar

generalizability trap as the evidence-based movement, thus failing to fully account for dropout.

Lastly, we present findings that dovetail with the current evidence-based practices in psychology

guidelines that address common factors, which account for much of the variance in outcomes

across disorders. A promising application of common factors research, the Partners for Change

Outcome Management System (PCOMS), which incorporates client feedback to manage

dropout, is described. Use of these measures has been recommended to reduce dropout,

especially for beginning therapists. It seems to address the strong arguments for “particularism”

in health care that direct our focus to one client or context at a time. The study will utilize these


notions of feedback and attention to context to improve service delivery by soliciting information

from multiple stakeholders (including clients, therapists, clinic directors and administration

staff). This will inform a collaborative restructuring of clinic policies and protocols in a way that

fits the idea of blending “clinical expertise” with “client preferences” as specified in the current

Evidence Based Practices in Psychology document published by the APA (2006).

Introduction: Defining Dropout and Dropout Rates

The definition of “dropout” has not been operationalized in counseling research for

decades and is often interchanged with many other terms. Due to the varying definitions and

terms used in this research, the rates of client attendance have varied from study to study.

Shapiro & Budman (1973) created three groups of clients based on their attendance. Clients who

made the initial call and attended an assessment session, but who did not come in for their first

therapy appointment were labeled “defector.” Clients who attended at least one therapy session,

but dropped out against the advice of the therapist were labeled “terminators.” Finally, clients

who continued past the first three sessions were labeled “continuers.” These distinctions made by

the authors carried certain meanings and ideas about who clients are based on these labels –

“defectors” needed something more from the initial call; “terminators” needed more from the

therapist; “continuers” were the ideal clients.

A meta-analysis conducted by Wierzbicki & Pekarik (1993) looked at 125 studies

published in English, between January 1974 and June 1990 and found that studies that defined

dropout in terms of failure to attend a scheduled session reported lower dropout rates than studies

which defined dropouts as not meeting the therapist’s judgment of treatment completion. The

dropout rate for not attending a scheduled session was on average 35%, whereas the dropout rate

for not meeting therapist’s judgment was 48% In a replicated study published in 2012, Swift and


Greenberg looked at 669 studies conducted since June 1990 and found similar results. Dropout

rates were highest in studies that defined dropout according to the therapist’s judgment (38%)

and lowest when meeting a certain number of sessions (18%) (Swift & Greenberg, 2012).

Overall, they concluded that the dropout rate in psychotherapy is about 20%, but therapists report

the rate as 40%. This study also found that university clinics and therapists at the trainee level

have some of the highest rates of client dropout, 30% and 25% respectively (Swift & Greenberg,

2012). With this information, it is vital that university training facilities be a place for

researching client attendance and dropout rates. It is also important to understand how these

facilities can better provide services for the clients. Moreover, research on dropout has scarcely

made attempts to contact clients about their reasons for continuing or dropping out of therapy.

This paper is not intending to define dropout, but rather contextualizes an action research

study at the Center for Community Counseling & Engagement (CCCE). The following sections

provide a historical analysis of how dropout and recommended actions to address it have been

conceptualized in the research literature.

SECTION 1

Early Research

Client demographics. Most of the research that was being published about client

dropout early on, focused primarily on adult individual psychotherapy and looked at four main

variables that affected client attendance. These variables include client characteristics, therapist

characteristics, therapy process variables, and interventions (Bischoff & Sprenkle, 1993). This

early research placed a large amount of weight on client characteristics as the barrier that

prevented clients from continuing with their mental health services. These included demographic

information socio-economic status, ethnicity/race, age, education level, marital status, and


gender. When research began to be published about retention in Marriage and Family Therapy,

client demographics were still the main focus of the research. Now that there were parents,

siblings, partners, and other relatives being part of the therapy process, researchers were

interested in which client’s demographics were more influential in determining whether clients

dropout or complete therapy.

One group of researchers found that in heterosexual couples therapy, when both partners

were invested in searching for counseling services, the couple were less likely to drop out (Slipp,

Ellis, & Kressel, 1974). However, when either partner, particularly the male, was not involved in

seeking out services, the couple was more likely to terminate services early. Fathers have also

been shown to influence a family’s decision to continue or cancel services (Berg & Rosenblum,

1977). These conclusions were based on correlational research and feedback from clients about

their reasons for dropping out was not solicited.

In 1993, Bischoff & Sprenkle reviewed the previous 20 years of research about dropout

rates in Marriage and Family Therapy. In their review, they found that most demographic

variables for both clients and therapists resulted in non-significant findings when looking at

dropout rates. Also, self-referred clients stayed in therapy longer than clients required to attend

therapy. Previous to this study, only a handful of studies looked at the differences between

child/family/couple therapy dropout rates and individual dropout rates. One of the main

differences is between child and adult therapy dropout rates. The rates of dropout for child and

adolescent therapy programs tend to be among the highest counseling dropout rates (Kazdin,

1997; Block & Greeno, 2011). While it is among the highest rates, research about child therapy

dropout has received little attention. Couples therapy is also severely lacking research that looks

at continuance and dropout rates; although the estimate is that approximately half of couples


drop out of therapy (Doss, Hsueh, & Carhart, 2011; Allgood & Crane, 1991). The lack of

definitive information on dropout rates for these therapy modalities needs to be addressed in

future research so that steps can be made to understand the needs of these clients that are not

currently being met.

Therapist variables. Another variable that has been looked at in dropout research is

therapist variables. Therapists’ ability to empathize with clients, form a therapeutic relationship,

and overall positive feelings with clients were found to be predictors of client retention

(Rosenzweig & Folman, 1974). Other early research on therapist variables focused on

demographics such as race and sex. These early studies produced mixed results and have been

found to be not as significant as other variables (Bischoff & Sprenkle, 1993). However, research

has consistently found that the therapists’ level of experience does have an effect on client

attendance. Greenspan and Kulish (1985) studied client dropout rates in a private mental health

clinic and found that clients who saw PhD level staff had lower dropout rates than therapists with

a M.S.W or M.A. in Psychology. Research continued to support this finding that therapists with

more experience or higher education have less client dropout rates (Pang, Lum, & Angvari,

1996; McIvor, Ek, & Carson, 2004; Swift & Greenberg, 2012). The CCCE has three levels of

therapists practicing throughout the year. There are two cohorts (n=55-60) of first year students

in practicum, second year trainees (n=8-10), and a handful (n=3-4) of Marriage and Family

Therapy intern’s (post-degree therapists) who see individuals, couples, or families throughout the

year. The administrative team who make decisions about clinic policies is comprised of some

year one and all the year two and post-degree therapists. Thus the research finding that students

and trainees experiences high rates of client dropout has implications for the CCCE, which is


affiliated to a Marriage and Family therapy and Community Based Block graduate training

programs.

Ethnicity and dropouts. In the early research, socio-economic status, race, and gender

were most strongly associated with client dropout rates (Wierzbicki & Pekarik, 1993). These

cultural factors have continued to be studied in this field of research to the present day. One

recent article focused on finding barriers that prevent African-American and Hispanic parents

from attending family-focused interventions (Coatsworth, Duncan, Pantin, & Szapocznik, 2006).

The authors found that when parents have ideas about the goals of therapy, their needs should be

addressed early on, otherwise there is a risk that the families will not attend more than three

session’s. Their research looked at 143 families, all either African-American or Hispanic. In

looking at their results, the authors made distinctions in three types of attender parents. The first

group, non-attenders, consisted of parents who never attended any sessions. The second group,

labeled consistent high attenders, were parents who rarely missed a session The final group,

variable attenders, was split into two sub-groups called decreasing low attenders who had low

attendance throughout the sessions, and decreasing high attenders who started off attending

every session, but eventually stopped attending.

This is one of the first articles to make distinctions about the varying levels of attendance

of client’s. However, this article did not take into account the different cultures that make up

“Hispanic” families. There are over 15 countries that fall into the “Hispanic” category, meaning

that their official language is Spanish. Countless more countries have populations that also speak

Spanish. The people from these countries all have varying experiences when it comes to mental

health, power, privilege, oppression, and resiliency. To claim that Hispanic families tend to be a

certain type of client would be to devalue the individual experiences of those families.


SECTION 2

The Empirically Supported Treatments (ESTs) Movement

The publication of DSM III in 1980 marked the beginning of the shift toward the bio-

medicalization of mental health. This was influenced by a critique of the subjective nature of

psychodynamic and biopsychosocial formulations, that questioned the legitimacy of psychiatry

(Rogler, 1997). Kawa and Giordano (2012) posit that the most prominent effect of this shift was

the introduction of pharmacological interventions for severe and mild DSM disorders, which

threatened to replace the traditionally used behavioral and psychotherapeutic interventions.

Moreover, even though studies demonstrated that psychotherapy works (Smith, Glass & Miller,

1980; Andrews & Harvey, 1981), the field lacked two vital aspects that were crucial for it to

compete with biological psychiatry – the first was the financial support of the pharmaceutical

companies and the second was a dearth of scientific or empirical studies demonstrating its

efficacy (APA, 1995). This also coincided with increasing pressure on mental health providers

to demonstrate the efficacy, effectiveness and cost efficiency of their interventions (Chambless

& Hollon, 1998).

The passage of the Health Management Organization (HMO) in 1973, had already led to

the outsourcing of payments by managed care organizations to providers to increase cost-

efficiency (Reed & Eisman, 2006). Suddenly, the focus shifted from early research on client and

therapist characteristics and the process of therapy, to an emphasis on the need for effective

interventions and strategies. This emphasis implicated poor, outdated or whimsical practices

used by practitioners for the dropout problem or delivery of ineffective services (Whitley, 2007).

It raised the question of what therapists were doing wrong, which was leading clients to drop out

from therapy. Thus, a discourse was constructed that blamed therapists, and implicit in this was


the solution – dissemination of best practices supported by the objective and neutral discourse of

science (Tanenbaum, 2003). Thus the APA commissioned a task force (APA, 1995) to address

“training for students at the pre-doctoral and internship level and for practitioners, and promotion

of psychological interventions to third party payers and the public” (p. 1). Based on their initial

research, the task force published a list of 22 well-established treatments called empirically

supported treatments (ESTs), which were then widely disseminated. Even though the report

outlined the limits of this approach, ESTs and their corollary manualized treatment became the

gold standard for psychotherapy. Evidence-based practice was also part of the umbrella of

evidence-based medicine, which was one of the epiphenomena of the move toward patient-

centered medicine (Whitley, 2007). The second epiphenomenon was the cultural competence

movement, which is discussed in section 3.

The APA (1995) document thus marked the beginning of the evidence-based movement in

psychology, which was aimed at reducing client dropout and providing the most appropriate

services. However, the methods used to garner “evidence” have been strongly criticized over

time. For instance, Duncan (2012) critiques the use of randomized clinical trials (RCTs) as

reductionist and impersonal as it posits therapists as deliverers of treatment interventions and

clients as diagnoses. Whitley, Rousseau, Carpenter-Song and Kirmayer (2011) point out the

challenges in generalizing or transferring evidence-based results to diverse populations,

including stringent sample controls that do not take into account comorbidities and the effects of

pharmacological interventions. Furthermore, Wolff (2000) points out that these requirements for

internal validity in implementing a RCT may result in poor generalizability of their findings in

real world settings or “socially complex service” environments. The outcomes that apply in

controlled laboratory settings thus have limited external validity in settings where outcomes are


more a result of the dynamic interplay between service providers and clients at different levels of

motivation, both of whom are often situated in protocol driven contexts. Added to this, is the

reliance on the broader social environment, which may consist of varying degrees of support or

challenge depending on the client (Wolff, 2000). Thus, any analysis of “treatment success” or

reasons for client dropout or retention has to take into account multiple contributing factors apart

from the actual intervention used, no matter what theoretical orientation guided treatment.

Additionally, the use of ESTs is predicated on assumptions that do not take into account the

whole picture of a client’s experience and thus obscures a meaningful understanding of why

psychotherapy works for some and not for others. As Westen, Novotny and Thompson-Brenner

(2004) point out, it is based on assumptions about the efficacy of brief counseling interventions

(they usually recommend between 6-16 sessions), malleability of psychological difficulties and

applicability independent of client characteristics, including culture and personality. It is also

based on application of interventions to treat symptoms as discrete DSM categories, which are

not based on foolproof empirical data. Westen et al. (2004), also describe the over reliance on

treatment manuals or a one-size-fits-all approach that gives no attention clinical expertise or

client preferences or feedback. Lastly evidence-based practices have been critiqued for an

underrepresentation of research with minority groups, LGBT clients, persons with disabilities

and an ignorance of dimensions like race, nationality, ethnicity, immigration, which have been

found to have a huge influence on clients’ experiences in therapy (Sue, Zane, Levant, Silverstein,

Brown, Olkin & Taliaferro, 2006). Thus, the movement though well intentioned, and driven by

ideas around the need for accountability to clients, had several shortcomings.


The Cultural Competence Movement

A useful antidote to the criticisms of the early EST movement was the cultural

competence movement, which served to bring attention back to the interpersonal nature of

therapy. Attention to the ethics of providing culturally relevant services was highlighted at the

Vail Conference in 1973 (Ridley & Kleiner, 2003). Sue and Sue (1977) then published a paper

that focused on the effects of cross-cultural miscommunication, and pointed out the Western-

based cultural biases inherent in the counseling interaction, that grossly underserved the needs of

what they referred to as third-world groups. Sue, Arredondo and McDavis (1992) then went

ahead to highlight that the even though the number of racial and ethnic minorities in the United

States was increasing, counseling training was still monocultural and perhaps worse, the field of

counseling was complicit in reproducing an unfair sociopolitical reality for ethnic and minority

groups. Cultural competence was thus the second epiphenomenon, introduced as an answer to

the dropout problem, as a “concept that could help reduce these disparities by adjusting services

and treatment options to account for ethnocultural differences” (Whitley, 2007).

In stark contrast to the evidence-based movement that was focused more on controlling

the therapist as a variable that could affect outcome (Lambert, 2010), the cultural competence

literature focused on how the variable “culture” affected the counseling process. Kirmayer

(2012a) notes that in the cultural competence literature culture was defined in terms ethnoracial

identity, and cross-cultural competencies was defined as encompassing counselor beliefs and

attitudes, knowledge and skills (Sue, Arredondo and McDavis, 1992). This spawned decades of

multicultural counseling (MCC) literature that Ridley and Kleiner (2003) categorize into the

need for MCC, the characteristics, features and dimensions of MCC, training and supervision,

assessment and specialized applications of MCC. Researchers had been documenting culturally


different expressions of mental disorders, idioms for communicating distress, and patterns of

help-seeking (US DHHS, 2001; Kleinman, 2004), as well as diverse psychological healing

practices across cultures and countries (Kirmayer, 2004). The Diagnostic and Statistical Manual

(DSM-IV) (APA, 1994) took note of this, and for the first time included an acknowledgment of

the cultural determinants of mental health by including an Outline for Cultural Formulation

(OCF). This outline, in the DSM-IV gave clinicians a way to make sense of information

pertaining to culture in assessment and treatment planning (APA, 1994) and also included a

glossary of culture bound syndromes (CBSs).

The Surgeon General Report noted that a common theme across models of cultural

competence is that they “make treatment effectiveness for a culturally diverse clientele the

responsibility of the system, not of the people seeking treatment.” (US DHHS, 2001, p.36).

Under the influence of the evidence-based movement, many cultural adaptations of ESTs began

to be systematically applied and studied, for example the use of cognitive-behavioral therapy

with African-American women diagnosed with depression (Kohn et. al, 2002). Other studies,

(Flaskerud and Liu, 1999) examined interventions like the effects of matching therapist and

clients based on variables like gender, ethnicity and language on therapy outcome and utilization

among ethnic minorities.

However, the cultural competence movement still limited the understanding of what leads

to outcomes or dropout to the terrain of what the therapist does or does not do – in other words,

are they culturally sensitive or not. Part of the problem lay in how culture was defined by

“expert” therapists. Specifically Kirmayer (2012b) and Fuller (2002) critique conceptions of

cultural competency that essentialize and reify cultural differences as rigid categories immutable

to change. Instead of more fluid definitions of culture, that take into account the ways people’s


cultural identities are constantly shifting in response to the several changing contexts they

inhabit, culture was understood as discrete categorizations free from the judgment of the person

defining it (Monk, Winslade & Sinclair, 20087). Thus, the fact that ethnoracial categories are

themselves cultural constructions is ignored (Kirmayer, 2012a). Kleinman (2006) further pointed

out how a tunnel vision focus on culture may be a red herring that keeps us from more pragmatic

or contextual understandings of client difficulties.

Coleman and Wampold (2003) assert that despite several well-articulated models of

cultural competency, very little systematic research has been conducted that tells us how to use

them. Culture was thus implicated in contributing to client dropout, but in some ways perhaps

this only reinforced stereotypical ideas about certain ethnic or cultural groups. Moreover,

Coleman and Wampold (2003) assert, that even by taking culture into account as a variable in

designing evidence based interventions, this approach continued to fall into the same

generalizability trap as ESTs. Some of the assumptions they discuss that are problematic are the

conflation of race with values, and broad racial classifications that contain too many diverse

subgroups with wide-ranging attitudes and values. Other assumptions include ignoring within

group differences – for instance presuming that differences within African-Americans are not as

salient as between African-Americans and other minority groups, and the primacy of race in

determining effectiveness, irrespective of other dimensions like SES, gender, age, etc. They thus

argue for more contextually determined culturally competent best practices, and propose an

ecological model, that understands culture in interactionist rather than reductionist ways.

SECTION 3

Common Factors Research & EBPP

The APA Presidential Task force report on Evidence-Based Practice (APA, 2006),


defines Evidence Based Practices in Psychology (EBPP) as “the integration of the best available

research with clinical expertise in the context of patient characteristics, culture, and preferences”

(p.273). This revised definition of the evidence-based movement focuses on the primacy of the

interaction between the client and the therapist, evidence-based therapeutic interventions, and the

ability to be flexible about making changes in either based on continuous monitoring and

assessment. It is also more inclusive, combining the research traditions of the earlier evidence-

based or EST and cultural competence movements. Whitley (2007) points out that the former

draws from modernist and positivist ideas that rely on quantitative, experimental or scientifically

standardized data to support its claims whereas the latter draws from multicultural and

postmodern ideas that are more interested in qualitative analyses of experience. Ramey and

Grubb (2009) support this integrationist approach by encouraging an amalgamation of the

modernist strengths of consistency and accountability and the postmodern contributions of

understanding the roles of oppression, culture, social inequities and phenomenological

experience.

An application of integrationist approach is the Partners for Change Outcome

Management System (PCOMS), which is an evidence-based practice (Substance Abuse and

Mental Health Services Administration SAMHSA, 2013) that combines empirically validated

measures of the process and outcome of therapy (Miller, Duncan, Brown, Sorrell & Chalk, 2006)

with client preferences. It is based on research on the Common Factors in across therapeutic

models, which has been found to account for most of the variance or dropout from therapy

(Duncan, 2012). Common Factors research has its origins in understanding how therapy works,

in general, toward helping clients lead more satisfying lives and positions itself as an a-

theoretical model (Duncan, 2012). Research has found over and over again that therapy does


indeed work and reports that the average client is better off than 80% of the general population

(Duncan, Miller, Wampold, & Hubble, 2010; Lambert & Ogles, 2004). Upon proving the

usefulness of therapy, a surge of research began to look at which therapy model was most

effective. The research on Empirically Supported Treatments (ESTs) was financially supported

by the APA (Tanenbaum, 2003) and has been politically influential in the allocation of insurance

reimbursements for mental health treatment. However, results from years of research came to

show that while a few therapies may work for specific diagnoses, overall there was no support to

prove that one theoretical orientation was more successful than another at helping clients get

better (Norcross & Newman, 1992). Essentially whether one pledges allegiance to a focus on a

treatment modality like Cognitive Behavioral Therapy or identifies as multiculturally informed

makes no difference!

Researchers then focused their attention on the common ingredients or similar qualities in

each theory that enabled them all to work. Frank and Frank (1991) identified four features, which

they called the Big Four that were common in effective therapies. The first factor is

client/extratherapeutic factors, which are the strengths, resources and client experiences that aid

in client recovery. These factors account for 40% of the outcome variance in therapy (Lambert,

1992). Placebo, hope, and expectancy are factors that refer to the client and therapist both

believing in the ability for the therapy to work and account for 15% of the change that occurs in

therapy. Next is the model/technique factors which are the unique beliefs and procedures each

theory ascribes to in therapy. This implies that the earlier EST or evidence-based movement,

with its emphasis on protocol driven and manualized approaches, were focused on factors that

only account for 15% of the change occurring in therapy. Lastly is the therapeutic relationship,

which is often referred to as the common factors in research. These factors include caring,


empathy, warmth, encouragement, acceptance, and alliance (Hubble, Duncan, & Miller, 1999),

and account for 30% of the improvements made in therapy.

Other literature also supports the claim that alliance is a key ingredient to preventing

dropout from therapy. For instance, Friedlander, Escudero, Heatherington, and Diamond (2011)

studied how alliances early on in therapy can affect retention. In this study, the researchers

wanted to understand the link between alliances with therapists and the parents as well as the

alliance between the parents and adolescent. The 30 adolescent’s involved in the study were

struggling with addictions to illicit substances. Most of the participants were identified as

African-American or Hispanic, and earned less than $25,000 per year. All of the families

received Multi-Dimensional Family Therapy (MDFT) and the first two sessions were coded for

themes of alliance. They concluded that problems related to alliance with parents or the

adolescent should be addressed early so as to decrease the possibility of dropout.

Based on common factors research, Duncan, Miller and Sparks (2007) propose the

solution of practice-based evidence, which is based on the notion of clients as experts or

collaborative partners in determining the direction of therapy. In order for therapy to be effective

and reduce client dropout, Duncan et al., (2004) and Miller, Duncan, Sorrell and Brown (2005)

have developed the PCOMS, which is a feedback system consisting of two 4-item measures

called the Session Rating Scale (SRS) and Outcome Rating Scales (ORS). They recommend that

these measures be routinely incorporated into sessions, to solicit information about both, the

progress or drawbacks of therapy, and the therapeutic alliance. Thus, according to Miller et al.

(2005) feedback makes for better therapists, and the provision of “empirically validated

therapists” (p.205).


Studies have been conducted that measure the effect of feedback on client retention with

positive results. For example, Lambert et al. (2003) conducted a meta-analysis of three studies

conducted at the same university clinic, where therapists (half were trainees and the other half

were professionals) were provided with ongoing indicators of client progress using the Outcome

Questionnaire-45 (OQ-45). The information also indicated when clients were not responding to

treatment as expected. The studies assessed whether this feedback had an effect on therapy

outcome and client attendance. They concluded that, especially for clients who were not

progressing as expected, feedback resulted in changes in therapist behaviors that kept clients

attending therapy for longer. For trainees, it made a significant difference in outcome across all

clients. Moreover, the mechanism of feedback led to more efficient psychotherapy, which means

that the “on-track clients” needed fewer sessions, and the “not-on-track clients” got more

sessions, instead of dropping out.

The PCOMS is more robust than the OQ-45, because it not only provides feedback to the

therapist but also the client. Zimmerman, Chelminksy, Young and Damrymple (2011) argues,

that in order to be accountable to our clients we must not only evaluate outcome, but also

communicate these findings to our clients. Several studies using the PCOMS with individual

clients have demonstrated the superiority of treatment guided by feedback. For example Reese,

Norsworthy and Rowlands (2009) report from two RCTs at a university counseling center and a

graduate training clinic, that 50% of clients in the feedback condition showed statistically

significant treatment gains compared to the treatment as usual (TAU) condition. They also

displayed gains in fewer sessions and reliable change at a higher rate (80% vs 54.2 in Study 1;

66.67 vs. 41.4% in Study 2). Based on their findings, they argue that a continuous assessment

and feedback system like PCOMS benefit all clients, not only clients who are predicted to have


poor outcomes. Another quasi-experimental study by Miller, Duncan, Brown, Sorrell and Chalk

(2006), found positive results on effectiveness and retention of clients using the PCOMS in an

employee assistance program. This finding is significant especially because unlike the earlier

EST research, no efforts were made to control the research process or treatments delivered, or

train the therapists in any specific modalities (Duncan, 2012). Thus, these findings directly

address the dropout problem in psychotherapy, by providing therapists with useful data about

how they can match their interventions to better suit client needs.

Another study, the first ever examining the effects of feedback with couples, by Anker,

Duncan and Sparks (2009) used the PCOMS with 410 couples at a community family counseling

clinic, who were assigned to either a feedback or treatment as usual (TAU) condition. As

hypothesized, the feedback condition led to better outcomes, with an effect size of 0.5. This

translated to the couples in the feedback condition achieving almost 4 times the rate of clinically

significant change, maintenance of these changes at a 6-month follow-up and lower incidence of

separation or divorce. Similar results were found by Reese, Toland, Slone and Norsworthy

(2010) in a study on couples receiving therapy from second year practicum students in a

marriage and family therapy training clinic. Four times as many couples in the feedback

condition achieved clinically significant change compared to the TAU, and also improved more

rapidly. More recent research (Schuman, Slone, Reese & Duncan, 2014) has also demonstrated

that the benefits of the PCOMS extend to group psychotherapy settings.

Duncan (2012) states that feedback technologies like the PCOMS dovetail with the

current definition of EBPP according to APA (2006) report. This report, by virtue of it being

commissioned by a reputed body like the APA, has legitimized other forms of knowledge or

evidence as worthy of consideration, including for example, aspects tracked by the PCOMS like


client feedback and preferences, helpful aspects of the therapist-client relationship/alliance, and

studying clinicians who produce best outcomes (APA, 2006). Feedback systems thus fit

contemporary integrationist ideas, promoted by the APA, because their claims of efficacy and

effectiveness are based on RCTs, but unlike earlier EST research, most of their research is

conducted in naturalistic settings, with an emphasis on collaboration between client and

therapist.

Moreover, Duncan (2012) asserts that the Heart and Soul of Change Project (HSCP),

which focuses on improving services via the PCOMS feedback system, rather than being focused

on fidelity to certain treatment modalities is based on core values including the salience of client

voice in determining service delivery, a belief in recovery, utilization of common factors that cut

across theoretical models and the incorporation of social justice in care. He adds that the HSCP

aligns well with the recovery-oriented and consumer involvement movements, and that the

practice of soliciting feedback addresses power differentials between providers and clients, and

is application of multicultural counseling. This can be particularly useful for clients from non-

dominant cultures, who as the cultural competence movement pointed out, have been

traditionally disenfranchised due to Western-based psychological models and structures.

Tanenbaum (2014) writes compellingly of how epidemiological data and aggregates still

seem to have the strongest hold on the decision-making processes around who gets what

treatment within the business of health-care. She argues for the routine inclusion of particularism

in health care, which involves a process of decision-making, where what works for the “average”

client is meaningless, without a thorough deliberation of previous clinical expertise and client

feedback. Thus, even though PCOMS is now listed as an evidence-based practice by the

Substance Abuse and Mental Health Services Administration (SAMHSA, 2013) and listed in the


National Registry of Evidence-based Programs and Practices (NREPP), it is recommended to

implement it one client at a time (n=1), based on each individual’s perception of the therapeutic

process (Duncan, Miller & Sparks, 2007).

In the present study we are hoping to take the case for particularism and feedback a step

further, by gathering context-specific information to improve service delivery at the Center for

Community Counseling and Engagement. We will do this by soliciting information from several

sources (including clients, therapists and clinic directors and Admin staff) thus leading to a more

collaborative restructuring of services, clinic policies and protocols. In fact, lack of feedback

from multiple sources is one of the limitations of the PCOMS system (Miller, Duncan, Sorrell &

Brown, 2005). This also fits the idea of blending “clinical expertise” with “client preferences” as

specified in the current EBPP document published by the APA.

Conclusion

This review highlights that client dropout has always been a concern for researchers

interested in the effectiveness of psychotherapy. Early research investigated multiple variables

that could be implicated in dropout, including client and therapist characteristics, therapy process

variables, and interventions. Beginning in the early 1990s, the move toward the profession

needing to be more evidence-based and accountable to a growing and diverse clientele, inspired

over a decade of research on empirically tested interventions and cultural competencies that

could address the dropout issue. More recent conceptualizations of how to address dropout argue

for integrationist and collaborative approaches that combine evidence-based interventions along

with client preferences, which are continually monitored and modified by soliciting client

feedback. Given that university clinics and therapists at the trainee level have some of the highest

rates of client dropout, and the research finding on the primacy of the therapist alliance and


collaboration, the CCCE will benefit from an action research study that investigates the reasons

behind client attendance and dropout rates.


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