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.

References
Allgod, S. & Crane, D. (1991) Predicting marital therapy dropouts. Journal of Marital and
Family Therapy, 17, 73-79
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders: DSM- IV. (4th ed.). Washington, DC: American Psychiatric Association.
American Psychological Association. (2006). Evidence-based practice in psychology: APA
presidential task force on evidence-based practice. American Psychologist, 61, 271–285
Anker, M., Duncan, B. , & Sparks, J. (2009). Using client feedback to improve couple therapy
outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and
Clinical Psychology, 77(4), 693-704.
Berg, B & Rosenbulum, N. (1977). Fathers in family therapy: A survey of family therapists.
Journal of Marriage and Family Counseling, 3(2), 85-91
Block, A. & Greeno, C. (2011). Examining outpatient treatment dropout in adolescents: A
literature review. Child Adolescent Social Work Journal 28, 393-420
Bischoff, R.J. & Sprenkle, D.H. (1993) Dropping out of marriage and family therapy; A critical
review of research. Family Process, 32, 353-375
Chambless, D. , & Hollon, S. (1998). Defining empirically supported therapies. Journal of
Consulting and Clinical Psychology, 66(1), 7-18.
Coatsworth, J. D., Duncan, L. G., Pantin, H., & Szapocznik, J., (2006) Differential predictors of
african american and hispanic parent retention in a family-focused preventive
intervention. Family Relations, 55, 240-251
Coleman, H., & Wampold B. (2003). Challenges to the development of culturally relevant
empirically supported therapies. In Pope-Davis, D., Coleman, H., Ming Liu, W., &

Toporek, R. (Eds.), Handbook of multicultural competencies in counseling and
psychology (pp. 227-246). London, UK: Sage Publications, Inc.
Doss, B., Hsueh, A., & Carhart, K. (2011) Premature termination in couple therapy with
veterans: Definitions and prediction of long-term outcomes. Journal of Family
Psychology 25(5), 770-774
Duncan, B. (2010). On becoming a better therapist (1st ed.). Washington DC: American
Psychological Association.
Duncan, B. (2012). The partners for change outcome management system (PCOMS): The heart
and soul of change project. Canadian Psychology, 53(2), 93 - 104
Duncan, B., Miller, S., & Sparks, J. (2007). Common factors and the uncommon heroism of
youth. Psychotherapy in Australia, 13(2), 34–43.
Duncan, B., Miller, S., & Wampold, B., & Hubble, M. (Eds.) (2010). The heart and soul of
change: Delivering what works in therapy (2nd ed.). Washington DC: American
Psychological Association.
Fischer, B. (2012). A review of American psychiatry through its diagnoses: The history and
development of the diagnostic and statistical manual of mental disorders. The Journal of
Nervous and Mental Disease, 200(12), 1022-1030.
Flaskerud, J., & Liu, P.Y. (1991). Effects of an Asian client-therapist language, ethnicity and
gender match on utilization and outcome of therapy. Community Mental Health Journal,
27(1), 31-42. DOI: 10.1007/BF00752713
Frank, J. & Frank, J. (1991). Persuasion and healing: A comparative study of psychotherapy. (3rd
ed.) Baltimore, MD: Johns Hopkins

Friedlander, M. L., Escudero, V., Heatherington, L., & Diamond, G. M. (2011) Alliance in
couple and family therapy. Psychotherapy, 48(1) 25-33
Fuller, K. (2002). Eradicating essentialism from cultural competency education. Academic
Medicine, 77(3), 198–201
Geertz, C. (1995). After the fact: Two countries, four decades, one anthropologist. Cambridge,
Mass: Harvard University Press.
Greenspan, M. & Kulish, N. (1985) Factors in premature termination in long-term
psychotherapy. Psychotherapy, 22(1), 75-82
Hubble, M., Duncan, B., & Miller, S. (1999). Introduction. In Hubble, M., Duncan, B., & Miller,
S. Editor (Eds.), The heart & soul of change (1-19) Washington, DC : American
Psychological Association
Kawa, S. , & Giordano, J. (2012). A brief historicity of the diagnostic and statistical manual of
mental disorders: Issues and implications for the future of psychiatric canon and
practice. Philosophy, Ethics, and Humanities in Medicine : PEHM,7(1), 2.
Kazdin, A. E. (1997) Parent management training: evidence, outcomes, and issues. Journal of
the American Academy of Child and Adolescent Psychiatry, 36, 1349-1356
Kazdin, A. (2005). Treatment outcomes, common factors, and continued neglect of mechanisms
of change. Clinical Psychology-science and Practice, 12(2), 184-188.
Kirmayer, L. (2004). The cultural diversity of healing: Meaning, metaphor and mechanism.
British Medical Bulletin,69(1), 33-48.
Kirmayer, L. (2012a). Cultural competence and evidence-based practice in mental health:
Epistemic communities and the politics of pluralism. Social Science & Medicine, 75(2),
249-256

Kirmayer, L. (2012b). Rethinking cultural competence. Transcultural Psychiatry, 49(2), 149-
164.
Kleinman A (2004) Culture and depression. New England Journal Medicine 351: 951–952.
Kleinman A., & Benson P (2006) Anthropology in the Clinic: The Problem of Cultural
Competency and How to Fix It. PLoS Med 3(10): e294.
doi:10.1371/journal.pmed.0030294
Kohn, L. P., Oden, T., Munoz, R. F., Robinson, A., & Leavitt, D. (2002). Adapted cognitive
behavioral ~ group therapy for depressed low-income African American women.
Community Mental Health Journal, 38, 497–504.
Lambert, M. (1992) Implications of outcome research for psychotherapy integration. In J. C.
Norcross 7 M. R. Goldfried (Eds.), Handbook of psychotherapy and behavior change
(94-129). New York, NY: Basic Books
Lambert, M. & Ogles, B. (2004) The efficacy and effectiveness of psychotherapy. In Lambert,
M. (Eds) Bergin and Garfield’s handbook of psychotherapy and behavior change (139-
193) New York, NY: Wiley
Lambert, M. , Whipple, J. , Hawkins, E. , Vermeersch, D. , Nielsen, S. , et al. (2003). Is it time
for clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology-
Science and Practice, 10(3), 288-301.
McIvor, R., Ek, E., & Carson, J. (2004) Non-attendance rates among patients attending different
grades of psychiatrist and clinical psychologist within a community mental health clinic.
Psychiatric Bulletin, 28, 5-7
Miller, S., Duncan, B. , Sorrell, R. , & Brown, G. (2005). The partners for change outcome
management system. Journal of Clinical Psychology, 61(2), 199-208.

Miller, S., Duncan, B., Brown, J., Sorrell, R., & Chalk, M. (2006). Using formal client feedback
to improve retention and outcome: Making ongoing, real-time assessment feasible.
Journal of Brief Therapy, 5(1) 5-22
Monk, G., WInslade, J., & Sinclair, S. (2008). New horizons in multicultural counseling. Los
Angeles: Sage Publications
Moras, K. (1993). The use of treatment manuals to train psychotherapists: Observations and
recommendations. Psychotherapy: Theory, Research, Practice, Training, 30(4), 581-586.
Norcross, J. & Newman, C. (1992) Psychotherapy integration. Setting the context. In Norcross,
J. & Goldfriend, M. (Eds.), Handbook of psychotherapy integration (3-45). New York:
Basic Books
Pang, A., Lum, F. C., Ungvari, G., Wong,, C., & Leung, Y. (1996) A prospective outcome study
of patients missing regular psychiatric outpatients appointments. Social Psychiatry and
Psychiatric Epidemiology, 31, 299-302
Partners for Change Outcome Management System (PCOMS): International Center for Clinical
Excellence. SAMHSA’s National Registry of Evidence-based Programs and Practices
(NREPP). Retrieved from file:///Volumes/SAVE%20WORK%20HERE/ReportNew.pdf
Ramey, H. , & Grubb, S. (2009). Modernism, postmodernism and (evidence-based) practice.
Contemporary Family Therapy, 31(2), 75-86.
Reese, R. , Toland, M. , Slone, N. , & Norsworthy, L. (2010). Effect of client feedback on couple
psychotherapy outcomes. Psychotherapy: Theory, Research, Practice, Training, 47(4),
616-630.
Ridley, C., & Kleiner, A. (2003). Multicultural counseling competence: History, themes, and
issues. In Pope-Davis, D., Coleman, H., Ming Liu, W., & Toporek, R. (Eds.), Handbook

of multicultural competencies in counseling and psychology (pp. 3-20). London, UK:
Sage Publications, Inc.
Rogler, L. H. (1997). Making sense of historical changes in the diagnostic and statistical manual
of mental disorders: Five propositions. Journal of Health and Social Behavior, 38(1), 9-
20. Retrieved from http://search.proquest.com/docview/201662833?accountid=13758
Rosenzweig, S. & Folman, R. (1974) Patient and therapist variables affecting premature
termination in group psychotherapy. Pscyhotherapy: Theory, Research, and Practice,
11(1), 76-79
Shaprio, R. J. & Budman, S. H. (1973) Defection, Termination, and Continuation in Family and
Individual Therapy. Family Process, 12, 55-67
Slipp, S., Ellis, S., & Kressel, K. (1974) Factors Associated with Engagement in Family
Therapy. Family Process, 13, 413-427
Sue, D.W., & Sue, D (1977). Barriers to effective cross-cultural counseling. Journal of
Counseling Psychology, 24(5), 420-429.
Sue, D., Arredondo, P. , & McDavis, R. (1992). Multicultural counseling competencies and
standards: A call to the profession. Journal of Counseling & Development, 70(4), 477-
486.
Sue, S., Zane, N., Levant, R. F., Silverstein, L. B., Brown, L. S., Olkin, R., & Taliaferro, G.
(2006). How Well Do Both Evidence-Based Practices and Treatment as Usual
Satisfactorily Address the Various Dimensions of Diversity? In Norcross, J.C., Beutler,
L.E., & Levant, R.F. (Eds.). Evidence-based practices in mental health: Debate and
dialogue on the fundamental questions. , (pp. 329-374). Washington, DC, US: American
Psychological Association, xv, 435 pp. http://dx.doi.org/10.1037/11265-008

Swift, J. , & Greenberg, R. (2012). Premature discontinuation in adult psychotherapy: A meta-
analysis. Journal of Consulting and Clinical Psychology, 80(4), 547-559.
Swift, J. , Greenberg, R. , Whipple, J. , & Kominiak, N. (2012). Practice recommendations for
reducing premature termination in therapy. Professional Psychology-research and
Practice, 43(4), 379-387.
Swift, J. , & Greenberg, R. (2014). A treatment by disorder meta-analysis of dropout from
psychotherapy. (2014).Journal of Psychotherapy Integration,24(3), 193-207.
Tanenbaum, S. (2003). Evidence-based practice in mental health: Practical weaknesses meet
political strengths. Journal of Evaluation in Clinical Practice,9(2), 287-301.
Tanenbaum, S. (2014). Particularism in health care: Challenging the authority of the aggregate.
Journal of Evaluation in Clinical Practice, 20(6), 934-941.
Task Force on Promotion and Dissemination of Psychological Procedures. (1995). Training in
and dissemination of empirically validated treatments: Report and recommendations. The
Clinical Psychologist, 48, 3–23
U.S. Department of Health and Human Services. (2001). Mental health: culture, race and
ethnicity. A supplement to mental health: A report of the Surgeon General. Rockville,
MD: U.S. Public Health Services, Office of the Surgeon General.
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of
empirically supported psychotherapies: Assumptions, findings and reporting in controlled
clinical trials. Psychological Bulletin, 130, 631– 663.
Whitley, R. (2007). Cultural competence, evidence-based medicine, and evidence-based
practices. Psychiatric Services, 58 (2), 1588-1590.

Whitley, R., Rousseau, C., Carpenter-Song, E., & Kirmayer, L. (2011). Evidence-based
medicine: Opportunities and challenges in a diverse society. Canadian Journal of
Psychiatry, 56(9), 514-522.
Wierzbicki, M. , & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional
Psychology: Research and Practice, 24(2), 190-195.
Wolff N. (2000) Using randomized controlled trials to evaluate socially complex services:
problems, challenges and recommendations. Journal of Mental Health Policy and
Economics 3, 97–109.

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