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Article Excerpt
This study examined differences between clients who did or did not notify mental health providers of intent to discontinue treatment. Clients who did not notify were more likely to be women, attend less than four sessions, and rate their overall functioning lower. Both groups showed significant improvement, and self-reports were found to be a better indicator of progress than counselor estimates. Findings suggested that the adoption of mutual goals and empathetic counselor attitudes toward client treatment expectations might increase staff awareness of satisfied dropouts who have made therapeutic gains. Implications include benefits to staff morale and the larger Community Mental Health Center system in which almost half of all clients discontinue treatment without informing staff.
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Federal and state funding for health care has been drastically cut in the past 15 years, resulting in the rise of a managed health care system that has been championed as a strategy for economically providing quality client care. However, managed care has not met these expectations (Mowbray, Grazier, & Holter, 2002). With decreased resources, clinics have turned to client fees and insurance monies, in addition to public funding, in order to survive. In turn, administrators have passed a large portion of these financial pressures on to mental health counselors in the form of productivity standards.
Under managed care, providers are usually given productivity credit only for face-to-face client contact. This solution has neglected an historical lesson--that mental health clients frequently miss appointments or abruptly and unilaterally discontinue treatment (dropouts). Counselors struggling to achieve productivity goals overbook to account for clients' missed appointments or suddenly dropping out of treatment. Both events evoke a sense of failure in mental health counselors. Social Systems theory (Miller & Rice, 1967) takes into account the relationship between an organization and its environment (a clinic and the local community) and may be useful in understanding how external pressures affect clinical care, including effectiveness and dropouts.
A meta-analysis by Wierzbicki and Pekarik (1993) found a mean client dropout rate of 47%, regardless of treatment modality, across 125 studies. They reported this finding as consistent over the past half-century at both community mental health centers (CMHC) and university clinics serving adults and children. Nevertheless, it is uncertain that such dropouts are always treatment failures. Buddeberg (1987), for instance, found that clients generally hold a more positive attitude than counselors about ending treatment. April and Nicholas (1996) found that over three quarters of dropouts reported benefit from treatment and saw no reason to continue. Furthermore, research by Kolb, Beutler, Davis, Crago, and Shanfield (1985) and Presley (1987) suggested that, when clients and counselors disagree on the level of improvement, clients may discontinue treatment without engaging in a formal termination process.
Demographic factors have also been found to influence clients' unilateral decisions to terminate treatment. Walitzer, Dermen, and Connors (1999) found that the only consistently significant predictors of client dropout were race, education, and income. That is, minority group members, those with a low level of education, and those with low income were at increased risk of dropping out. Clients successfully completing treatment were characterized by higher social class membership, majority status, psychological mindedness, and were well matched to their counselor (Tracey, 1988). Garfield (1994) proposed a broader interaction model that includes client characteristics and expectations, counselor behavior, and features of the therapeutic system as contributors to this phenomenon. The clinical environment needs to be considered, because systemic issues such as managed care pressures, funding resources, and trainee rotations affect how care is delivered to clients and the morale of staff.
Traditionally, dropouts have been considered to be a homogenous group. The goal of this study was to examine whether there are differences in dropouts associated with whether the client informs the mental health counselor about terminating. The hypotheses were as follows: There will be no significant differences between informers and non-informers associated with (a) demographic variables (race, education, income, and gender), (b) treatment engagement and outcome (number of sessions attended and level of improvement as judged by counselors and clients), and (c) mental health (degree of psychopathology and use of medication).
METHOD
Participants and Procedures
Participants for this study were drawn from those in a larger...
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