Psychological Services 2006, Vol. 3, No. 1, 51– 60
Copyright 2006 by the American Psychological Association 1541-1559/06/$12.00 DOI: 10.1037/1541-1559.3.1.51
Does Time Between Application and Case Assignment Predict Therapy Attendance or Premature Termination in Outpatients? Lorraine R. Reitzel
Nadia E. Stellrecht, Kathryn H. Gordon, Elizabeth N. Lima, LaRicka R. Wingate, Jessica S. Brown, Amanda S. Wolfe, Lisa M. Zenoz, and Thomas E. Joiner, Jr.
University of Texas, M.D. Anderson Cancer Center
Florida State University This study assessed whether timeliness of case assignment predicted 2 types of patient termination: nonattendance to therapy before intake but after completing the application process and premature termination once therapy had begun. The patients in this study represented all adults applying to an outpatient clinic for therapeutic services over a 5-year period (N ⫽ 313, 142 male). Results indicated that the timeliness of case assignment was a significant predictor of whether a patient attended intake, with those enduring a longer delay in case assignment more likely to not pursue therapeutic services. Timeliness of case assignment was not related to premature termination from therapy. Potential moderators, including patient ethnicity, gender, age, personality disorder diagnosis, and symptom severity, did not affect the relationship between the variables of interest. Keywords: case assignment, therapy nonattendance, premature termination
For example, in a follow-up study of outpatient patients who failed to attend therapy after intake and placement on a waiting list, only 29% reported their presenting problem had satisfactorily resolved (Christensen, Birk, & Sedlacek, 1977). Another study found that 39% of patients terminated prematurely because of a self-reported reduction in the need for treatment that was supported by a decrease in symptom severity scores; however, other patients in this study did not demonstrate this pattern, suggesting that premature terminators are a heterogeneous group (Pekarik, 1983b). Patient attrition is also a problem for mental health providers, as limited resources are invested in patients who do not follow through with therapy. As dropout and premature termination are relatively common events with the potential for detrimental outcome, it is important to investigate and remedy factors that might influence them, especially given the dearth of empirical studies focused on the prevention of premature termination (Ogrodniczuk, Joyce, & Piper, 2005). Previous studies about variables influencing nonattendance and premature termination have yielded inconsistent results with a number of patient, therapist, and administrative variables cited. Patient characteristics include symptom
Patient nonattendance (dropout) and premature (unilateral) termination of therapeutic services are common problems faced by mental health providers. Research suggests that 30% of patients drop out of treatment before its initiation (Issakidis & Andrews, 2004), and 30% to 60% of all outpatients prematurely terminate without consulting their therapist (Pekarik, 1983a). An average premature termination rate of 47% was found across 125 studies conducted in diverse treatment settings (Wierzbicki & Pekarik, 1993). Although patient nonattendance or premature termination might be an indicator that the patient’s problem has ameliorated, or that an adequate outside support network has been achieved (Hatchett & Park, 2003), it is more commonly viewed as a negative outcome.
Lorraine R. Reitzel, Department of Health Disparities Research, University of Texas M. D. Anderson Cancer Center; Nadia E. Stellrecht, Kathryn H. Gordon, Elizabeth N. Lima, LaRicka R. Wingate, Jessica S. Brown, Amanda S. Wolfe, Lisa M. Zenoz, and Thomas E. Joiner, Department of Psychology, Florida State University. Correspondence concerning this article should be addressed to Thomas E. Joiner, Department of Psychology, Florida State University, Tallahassee, FL 32306-1270. E-mail:
[email protected] 51
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presentation, low education (Wierzbicki & Pekarik, 1993), degree of social isolation (Baekeland & Lundwall, 1975; Garfield, 1986), gender, minority group membership (King & Canada, 2004), and socioeconomic status (Kazdin, Stolar, & Marciano, 1995); therapist variables include experience level, high levels of ethnocentricity, dislike or disinterest in patients, and low expectations for patient improvement (Baekeland & Lundwall, 1975); and administrative variables (cf. Mennicke, Lent, & Burgoyne, 1988) include interruption of the therapeutic relationship and delay in case assignment (Baekeland & Lundwall, 1975). Delay in case assignment is especially salient because it is a potentially alterable factor, unlike many of the patient and therapist variables cited. As such, the effect of timeliness of case assignment on patient nonattendance to therapy and premature termination from therapy deserves empirical scrutiny. May (1991) proposed that case assignment delay might predict patient attrition because of its effects on patient satisfaction; however, only 7%–19% of respondents in studies on this point reported that the wait between the admission interview and case assignment was too long (1981, 1984, 1981, 1984; Freund, Russell, & Schweitzer, 1989). However, Archer (1984) found that patients with more urgent or severe concerns were more likely to report their time on a wait list was too long and were more likely to seek professional help elsewhere. Similarly, Shueman, Gelso, Mindus, Hunt, and Stevenson (1980, as cited in May, 1991) found that patients with more severe presenting problems were less likely to feel helped by the admission interview alone. Finally, interesting gender effects were found in at least one study (Christensen et al., 1977), where men were more likely to drop out of therapy because of case assignment delay than women, with 62% of male versus 25% of female dropouts reporting problem resolution before case assignment. Therefore, while results about timeliness of case assignment and attrition with regard to patient satisfaction are mixed, there appears to be a connection between high symptom severity and patient intolerance of case assignment delay. If a relationship between the timeliness of case assignment and attendance to therapy exists, perhaps it is attributable to the timely provision of hope that provides relief and motivates
the patient to attend the intake session and remain in therapy. Previous research suggests that the expectation of a positive resource can serve as a stand-in for the resource itself (Aspinwall, Hill, & Reed, 1999; Reitzel, Burns, Repper, Wingate, & Joiner, 2004). We might expect patients to experience hope whether case assignment was timely or not; however, research suggests that those with greater symptom severity are less tolerant of assignment delay. Perhaps the relief associated with the expectation of upcoming treatment coupled with a quickly negotiated session increases the likelihood of attendance through increased patient self-efficacy (cf. Mennicke et al., 1988). The experience of efficacy in convincing treating personnel of the need for timely treatment might be particularly relevant for patients with high symptom severity because of the greater impairment in functioning (and by logical extension, decreased global self-efficacy) that accompanies more severe symptoms. Previous studies examining the effect of delay or wait time for therapy on patient nonattendance and premature termination from therapy have yielded varied results. For example, Benway, Hamrin, and McMahon’s (2003) review of family clinic studies cited five (Carpenter, Morrow, DelGaudio, & Ritzler, 1981; Foreman & Hanna, 2000; Kourany, Garber, & Tornusciolo, 1990; MacDonald, Brown, & Ellis, 2000; Stern & Brown, 1994) that found the length of time between referral and initial appointment significantly predicted nonattendance. Similarly, Booth and Bennett (2004) found waiting time significantly predicted initial appointment attendance in an alcohol disorder treatment clinic. The results of other studies are mixed, with some supporting the proposed relationships between a delay in case assignment and premature termination (Folkins, Hersh, & Dahlen, 1980; Rodolfa, Rapaport, & Lee, 1985), and others finding null results (Anderson, Hogg, & Magoon, 1987; Freund, Russell, & Schweitzer, 1991; Sparks, Daniels, & Johnson, 2003). Although most studies have consisted of retrospective chart reviews, some studies have been prospective. For example, Festinger, Lamb, Kirby, and Marlowe (1996) found a same-day versus a standard (1- to 7-day delay) intake appointment increased attendance to an initial therapy appointment, although there was
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no effect on later premature termination. In another prospective study, Festinger, Lamb, Marlowe, and Kirby (2002) found patients offered intake appointments approximately 24 hr following their initial clinic contact were four times more likely to attend than those scheduled for later intake appointments. In light of the conflicting findings in the extant literature, it remains unclear whether delay in case assignment is an important factor in the prediction of patient attrition. According to some researchers (Hatchett & Park, 2003; Kokotovic & Tracey, 1987), varying definitions of patient attrition are to blame. For example, patient attrition may be defined as nonattendance after making contact with the clinic, nonattendance after a screening/admission interview, or nonattendance after intake. Because of definitional inconsistencies, conclusions in this area are elusive. This study contributes to the literature by using well-defined attrition indices—nonattendance to therapy (failure to attend therapy at all, including intake sessions) and premature termination (unilateral termination by the patient after contact with assigned therapist) —and by controlling for initial symptom severity in the examination of the effect of timeliness of case assignment on attrition. Given a paucity of recently conducted studies on this topic and the examination of dual attrition indices, this study makes a necessary contribution to the extant research. Further still, few studies examine potentially important moderator variables; the present study will address this issue. Moderators were based on previous research or rationally derived and include patient ethnicity (cf. King & Canada, 2004), patient age, patient gender (cf. Christensen et al., 1977), whether or not the patient had a personality disorder diagnosis,1 and initial symptom severity (cf. Archer, 1984). We predicted that, as case assignment delay increased, nonattendance and premature termination would increase. We hypothesized selected moderator variables might affect these relationships, with personality disorder diagnosis and greater symptom severity leading to more attrition with longer assignment delays. Demographic variables such as patient minority status, younger age, and male gender were also expected to be associated with more attrition with longer assignment delays.
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Method Participants The patients were adults applying to the clinic for therapeutic services from November 1998 to October 2003. On application, patients were informed of the research and training nature of the clinic and consented to research inclusion. The patient sample comprised 313 patients (142 male, 171 female) with an average age of 27.3 years (SD ⫽ 9.7, range ⫽ 18 – 62). The ethnic composition was as follows: 80.1% Caucasian, 10.3% African American, 6.3% Hispanic, and 2.6% Asian/Pacific Islander, and 0.7% Native American.2 The Florida State University Psychology Clinic, although university affiliated, primarily serves nonstudent patients who present with clinical disorders typical of a community mental health outpatient clinic. Of the patients in this sample who attended the intake session (with overlapping ns due to comorbidity), 143 were diagnosed with mood disorders, 63 with substance-related disorders, 59 with personality disorders, 57 with anxiety disorders, 24 with adjustment disorders, 13 with eating disorders, 2 with psychotic disorders, and 75 with another disorder not captured in the above diagnostic categories. Of these patients, 48.54% had Axis I comorbidity and 20.16% presented with comorbidity between Axis I and Axis II, suggesting that our patients present complicated clinical pictures common in community mental health settings.
Procedure Timeliness of case assignment. Timeliness of case assignment was measured as the number of days between the screening appointment and assignment to a therapist. When a prospective patient called the clinic, they were scheduled for a screening appoint1
Personality disorder diagnosis at intake could not be examined as a moderator of the relationship between timeliness of case assignment and therapy nonattendance because of a lack of diagnostic information for patients who did not attend therapy. 2 Ethnicity was unknown for 11 patients. Percentages reported are based on valid cases for this variable. Actual ns can be found in Table 1. Ethnicity was generally representative of the larger community.
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ment. During this appointment, they completed an application for services and clinic screening measures and were seen by a therapist to assess symptom severity and the immediate risk of dangerousness. Throughout the duration of this study period, there were multiple screening appointment slots per week, and prospective patients were scheduled within a week’s time. Screening therapists were trained with the same protocol and used a standardized screening application form, which included informing the patients of a wait list, as applicable. The case assignment process was based on caseload availability; so screening therapists were generally not assigned the cases they screened. Prospective patients who did not attend screening appointments were not included in this study for lack of relevant information. Although a case could be assigned after the screening appointment, immediate assignment was occasionally impossible due to a clinic waiting list or short administrative delay (e.g., office closure). When there was a wait list, policy dictated weekly contact with the prospective patient regarding the status of their case assignment. The clinic’s assistant director called patients to provide updates on the wait list and to remind patients they would be contacted by their therapist after case assignment. Queries from wait-list patients were generally answered by providing a 1- to 2-week estimate of continued wait with a promise of another update call in a week. Once a case was assigned, the therapist had 2 working days to contact the patient and schedule an intake per clinic policy. When a prospective patient was not responsive to scheduling attempts, three or more patient contacts were attempted over a period of 3 weeks, by phone and mail, before the case was closed. Supervisory staff and the assistant director regularly reviewed patients’ charts to monitor the therapists’ compliance with these clinic policies. Patient nonattendance. Patient nonattendance was a dichotomous variable with one value for patients who attended no sessions after case assignment and one value for patients who attended one or more sessions. Premature termination. Premature termination was a dichotomous variable capturing whether a patient’s departure from therapy was unilateral or bilateral. A case was coded as premature termination when the patient stopped
attending therapy before its termination and against the recommendation of the therapist. This included patients who indicated a variety of excuses for ending therapy such as time, money, and other priorities. A case was coded as not premature termination when the patient attended therapy until the end of treatment (e.g., the therapist and patient agreed to terminate, the therapist initiated termination, or it was very clear that the patient had some external reason such as moving, loss of job, divorce that made it necessary for them to terminate). Premature termination ratings were determined by the patients’ therapists directly or, in some cases, gleaned from a retrospective review of the termination summary, which also contained this information. Severity of symptoms at screening. Global Assessment of Functioning (GAF) Scale (American Psychiatric Association, 1994) ratings were made for each patient at the time of the screening interview. GAF scores ranged from 0 to 100, with higher numbers indicating better global functioning and minimal symptom severity. Previous studies (Friis, Melle, Opjordsmoen, & Retterstol, 1993; Moos, McCoy, & Moos, 2000) have indicated that these ratings are reliably associated with clinical diagnosis and psychiatric symptoms, as well as other ratings of clinical outcome. The reliability and concurrent validity of these kinds of ratings in our clinic has been supported; for example, good interrater agreement (␣ ⫽ .84) with a masked second rater’s ratings has been demonstrated (Lyons-Reardon, Cukrowicz, Reeves, & Joiner, 2002). The GAF is a useful index of outcome in situations, like the one in the present study, in which outcome is evaluated across various diagnoses and clinical presentations.
Results Preliminary Analyses There were 21 missing values for GAF at screening. Missing values were replaced with the GAF scores at intake where applicable (n ⫽ 19 or the mean of the GAF scores at screening (GAF ⫽ 61; n ⫽ 2) to preserve the data of interest. Other variables with missing values were potential moderators: 1 missing value for age, 11 missing values for ethnicity, and 76 missing values for personality disorder
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Table 1 Descriptive Statistics for Therapy Attendance Attended Therapy (n ⫽ 245) Variable
Did Not Attend Therapy (n ⫽ 68)
Combined (N ⫽ 313)
M
SD
M
SD
M
SD
GAF at screening Days to assignment Number of sessions Age
61.29 9.56 10.5 27.32
11.45 10.81 11.75 9.53
62.43 15.16 0 27.24
12.19 16.93 0 10.35
61.54 10.78 — 27.3
11.61 12.58 — 9.70
n
n
n
Gender Presence of PD diagnosis
117 males 55 patients (22.45%)
25 males n/a
142 males n/a
Ethnicity
Native American ⫽ 2 Asian ⫽ 8 African American ⫽ 23 Hispanic ⫽ 16 Caucasian ⫽ 187 Unknown ⫽ 9
Native American ⫽ 0 Asian ⫽ 0 African American ⫽ 8 Hispanic ⫽ 3 Caucasian ⫽ 55 Unknown ⫽ 2
Native American ⫽ 2 Asian ⫽ 8 African American ⫽ 31 Hispanic ⫽ 19 Caucasian ⫽ 242 Unknown ⫽ 11
129 patients
n/a
n/a
Terminated prematurely
diagnosis status (this was expected, as many did not attend the diagnostic intake). Missing values for these variables were maintained; however, we performed separate logistic regressions to test the moderators to allow for the greatest preservation of data. A scatterplot of the timeliness of case assignment variable was examined for outliers. Four univariate outliers were detected and deleted, resulting in an acceptable skewness value (2.04 from 9.09).
Main Analyses The descriptive statistics for the variables of interest are located in Table 1 (by therapy attendance) and Table 2 (by termination type). We used a binary logistic regression to test the relationship between the timeliness of case assignment and patient nonattendance to therapy. The screening GAF score was entered into the first block of the equation.3 Timeliness of case assignment was entered into the second block of the equation, with significant results, 2(1, N ⫽ 313) ⫽ 9.08, p ⫽ .003. The Hosmer– Lemeshow test indicated a good-fitting model, 2(8, N ⫽ 313) ⫽ 4.96, ns. Timeliness of case assignment predicted attendance to therapy, z ⫽ 9.24, p ⫽ .002: As the time until the case was assigned increased, the likelihood of the
patient attending therapy decreased, B ⫽ ⫺.03, Exp(B) ⫽ .97. Next, we examined the relationship between the timeliness of case assignment and premature termination from therapy for those who attended at least one session of therapy (and/or intake). Severity of symptoms at screening was entered in the first block of the binary logistic regression equation and timeliness of case assignment in the second. Results were not significant, [2(1, n ⫽ 245)] ⫽ 2.93, ns, and did not support that timeliness of case assignment influenced premature termination from therapy. Potential moderating variables were tested for their influence on the relationships of interest. In all cases, screening GAF was entered in the first block, with the respective moderator variable (e.g., patient ethnicity, patient age, patient gender, and whether the patient had a personality disorder diagnosis) and timeliness of case assignment entered in the second block and the interaction entered in the final block. Results were nonsignificant in all cases. Finally, analyses examining screening GAF 3 All analyses were also conducted without controlling for severity of symptoms at intake and the pattern of results was unchanged.
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Table 2 Descriptive Statistics for Premature Termination Prematurely Terminated (n ⫽ 129) Variable
Did Not Terminate Prematurely (n ⫽ 116)
Combined (n ⫽ 245)
M
SD
M
SD
M
SD
GAF at screening Days to assignment Number of sessions Age
60.75 8.4 7.71 27.49
11.87 9.85 7.99 9.99
61.89 10.85 13.61 27.13
10.99 11.69 14.26 9.03
61.29 9.56 10.5 27.32
11.45 10.81 11.75 9.53
n
n
n
Gender Presence of PD diagnosis
63 males 31 patients (24.03%)
54 males 24 patients (20.69%)
117 males 55 patients (22.45%)
Ethnicity
Native American ⫽ 1 Asian ⫽ 6 African American ⫽ 14 Hispanic ⫽ 6 Caucasian ⫽ 97 Unknown ⫽ 5
Native American ⫽ 1 Asian ⫽ 2 African American ⫽ 9 Hispanic ⫽ 10 Caucasian ⫽ 90 Unknown ⫽ 4
Native American ⫽ 2 Asian ⫽ 8 African American ⫽ 23 Hispanic ⫽ 16 Caucasian ⫽ 187 Unknown ⫽ 9
as a moderator for the effect of timeliness of case assignment on therapy nonattendance and premature termination, respectively, were also nonsignificant.
Discussion Timeliness of case assignment is a concrete and changeable variable; as such, any association between it and very important parameters like therapy attendance and dropout would inform service provision. Moreover, whether timeliness in assignment affects attendance in the first place versus termination after attendance further informs allocation of administrative effort in service provision settings. Further still, examination of potential moderator variables delineates conditions under which timeliness of assignment does and does not wield influence. The significance of the present study lies in the fact that each of these issues is thoroughly addressed in a large sample of outpatients in a reasonably representative service provision setting. Results indicated that timeliness of case assignment predicted intake attendance. After controlling for initial illness severity, we found that, as hypothesized, patients experiencing longer case assignment delays were more likely to drop out. We speculated that notification of case assignment made concrete and salient the
expectation for help and relief, and this, coupled with increased self-efficacy from achieving a timely result, helped to account for the relationship between relatively quick case assignment and the greater likelihood of therapy attendance. Expectations of a positive resource may serve the same function as the resource itself (Aspinwall et al., 1999; Reitzel et al., 2004), and expectation that therapy would begin soon might also conform to this pattern. Other research supports the prompt assignment of a therapist is more important to patients than the actual date of the first contact (cf. May, 1991), and previous studies have speculated about a connection between perceived patient efficacy and attrition (cf. Mennicke et al., 1988). It was hypothesized that severity of symptoms at screening may moderate the relationship between case assignment delay and therapy nonattendance, so that timely case assignment would lead to lower attrition rates for those with greater symptom severity. As previous research found that patients with more urgent concerns are more affected by a wait until case assignment (cf. Archer, 1984), those with greater symptom severity might particularly benefit from any increase in self-efficacy that timely case assignment might provide. This pattern of results, however, was not supported. Perhaps, in this sample, patients with greater symptom severity either (a) were no more likely than other
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patients to experience enhanced self-efficacy with the timely assignment of their case or (b) did not attribute a timely case assignment to their own efforts. Timeliness of case assignment did not predict premature termination from therapy. This is consistent with the suggestion of Rapaport, Rodolfo, and Lee (1985) that administrative variables such as wait time until intake scheduling play a larger role in dropout than premature termination. Perhaps timeliness of case assignment is predictive of premature termination only in the presence of other factors not assessed in this study (e.g., dissatisfaction with quality of care, ineffective techniques, lack of observable progress). Consistent with previous recommendations in the literature (Hatchett & Park, 2003; Kokotovic & Tracey, 1987), this result also supports that types of patient attrition should be examined separately, as results vary based on how patient attrition is defined. Results of this study did not support that patients’ ethnicity, age, gender, personality disorder diagnosis, or severity of symptoms at initial contact moderated the relationship between timeliness of case assignment and therapy nonattendance and premature termination, respectively. This was unexpected, given previous research results supporting the role of these variables (e.g., Christensen, 1977). Perhaps these variables exert more of an influence in settings other than community mental health clinics, which could account for the mixed results in the literature. The results of this study lead to some practical considerations for clinicians or clinic administrators regarding case assignment procedures. In this study, the mean number of days to case assignment was approximately 9.5 days for patients who attended therapy, compared with a mean of approximately 15 days for those who were dropouts. Although these results do not allow us to predict the critical point at which clinic administrators should make case assignments, we can conclude that waiting 15 days or more increases the likelihood of patient attrition. Thus, clinic administrators who routinely have delays of 15 days or more before case assignment might explore options to increase the speediness with which cases assigned to therapists. If therapists are available, case assignment should proceed immediately after screening— holding cases aside for assignment
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at bimonthly staff meetings, for example, might increase the likelihood of nonattendance. Other strategies to prevent patient attrition before intake could include keeping in regular, empathic contact with unassigned patients so that they might remain informed about their status on the waiting list. If positive resource expectation is important for patients in following through and attending the first session, this regular contact might be an alternative way to achieve the benefits of resource expectation in lieu of immediate case assignment. In this study, the dropout rate was 22%, less than the average of 30% reported in previous literature (Issakidis & Andrews, 2004) and perhaps influenced by the regular contact that was kept with wait-list patients. Service providers might also consider increasing group services so more patients can be provided quick “assignment” to treatment while waiting for an individual therapist. Finally, clinic administrators might consider the provision of an in-house crisis hotline number to patients awaiting case assignment. Access to a clinic-affiliated immediate resource might serve as a stand-in for therapist availability (tapping into resource expectation theory), promote patients’ self-efficacy for securing help, and reduce dropout. Although information about the purpose of the hotline and guidelines for appropriate use would need to be provided, previous research suggests that patients make use of emergency contact resources less often than expected (cf. Reitzel et al., 2005). In some settings, such as inpatient Veterans Administration clinics or prisons, patient attrition might be less of a problem as patients are housed at the treatment facility. However, waiting lists for services in these settings are not uncommon, especially in light of recent budget cuts and staff displacements resulting in unfilled positions. Although these settings may not encounter frequent dropouts, the consequences of delaying therapeutic contact could include an increase in symptom severity or distress, an increase in undesirable behaviors such as selfharm or behavioral acting out, or an increase in cynicism about therapy and a decrease in hopefulness that therapy would be helpful, resulting in a failure to engage in therapy once it is provided. Service providers in these settings may want to consider earlier engagement in treatment through methods suggested earlier (e.g., group involvement) or by providing reg-
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ular, brief contacts to assess mental status and provide wait-list status updates. The wait-list patient could also complete standard screening measures not requiring therapist administration or scoring. The benefit of this strategy could include symptom amelioration as consistent with the treatment utility of assessment literature, as well as knowledge of the patient’s treatment needs before the intake session. Results of this study should be interpreted in light of potential limitations. The time between a patient’s scheduling of a screening interview and the actual interview was not recorded, and differences may exist between those who attended the screening interview (and were included in the present research) and those who did not based on timeliness of scheduling issues. Also, delays in scheduling intake appointments were not investigated in the present article. In other words, waiting time for patients not only included timeliness of case assignment, but delays for the screening interview and delays in scheduling contact with the patient once the case was assigned. Of note was that patients were called before the screening appointment as a reminder to attend. This practice might have helped to attenuate any temporally related forgetting of the screening appointment, which otherwise might have led to more no shows for those with longer waiting periods. All patients in the present study attended an initial screening interview in which we gathered background and current information to assess clinical status and to screen for patient suicidality and dangerousness. Given the nature of such interviews, the extent to which initial patient expectations were met could have influenced the decision to pursue therapy (e.g., attend the intake session). This variable could not be controlled for and represents a weakness of this study. In summary, the present study contributes to the existing body of research in the area of patient attrition from therapy. It is unique in its simultaneous investigation of two types of patient attrition: nonattendance before intake session and the discontinuation of services once therapy had begun. It is also unique for its methodological control of symptom severity in the investigation of timely case assignment and patient attrition and its exploration of a number of moderator variables. Results indicated that, after we controlled for initial patient severity,
timeliness of case assignment significantly predicted patient nonattendance before the intake session but did not once patients had engaged in therapeutic services. This pattern of results suggested that delays in case assignment were a better predictor of a specific type of premature attrition; mixed findings in this literature may reflect inattention to different types of patient-initiated termination. Finally, the present results emphasize the need to continue researching factors involved in patient attrition from therapy, as resolving these potential administrative factors could have important implications for improving service delivery. If attrition rates can be reduced, the effects will be beneficial not only to the patients themselves, but also to the service providers who will be able to make more efficient use of their resources.
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Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190 –195. Received May 15, 2005 Revision received October 25, 2005 Accepted November 18, 2005 䡲
