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Drop-out is an important issue in psychotherapy, but it is generally understudied, and published work varies widely depending on how it is defined (Bados et al., 2007; Wierzbicki & Pekarik, 1993). Typically, dropout rates range from 35% to 55% (Barkham et al., 2006) and the median treatment dropout rate in a recent meta-analysis of 152 studies was 21.9% (Swift et al., 2017). In turn, dropout rates vary depending on what is considered dropout; for example, in controlled trials, dropout is defined as non-attendance at a programmed session, where rates drop to around 25% (Swift et al., 2017; Swift & Greenberg 2014).
In general, it has been reported that dropout rates do not vary significantly according to the theoretical treatment model used (e.g., cognitive-behavioral, humanistic, or psychodynamic therapy) (Leichsenring et al., 2019; Linardon et al., 2019; Swift & Greenberg 2014), nor according to the type of diagnosis of the participants, except for borderline personality disorder and eating disorders (Campbell, 2009; Leichsenring et al., 2019). In contrast, several studies have associated treatment dropout with socio-demographic variables such as low educational attainment, unemployment, and younger age (Bennemann et al., 2022; Gersh et al., 2017; Jensen et al., 2014).
Premature treatment dropout is associated with several disadvantages for patients, therapists, and the health care system. On the one hand, patients who drop out of treatment have a lower likelihood of self-reversal of their symptomatology and a higher probability of poor long-term outcomes (Campbell, 2009). In turn, it increases demoralization and frustration in both patients and therapists and is linked to ineffective use and expense of public health (Berghofer et al., 2002). Treatment dropout may also result in biases in study samples, affecting their validity and generability (Mahon, 2000).
In our country at the moment, there are no studies on treatment dropout in cognitive-behavioral therapy for emotional disorders and in general in the world, there are few studies on the experience of patients who drop out of treatment, especially in the online modality (Weinberg, 2020). Since the exact variables involved and the perspective of patients who drop out of treatment are not yet known (among other reasons because it is difficult to contact them for follow-ups), previous studies suggest using a qualitative approach based on individual interviews to explore the variables possibly involved (Leichsenring et al., 2019). The present study aimed to explore the experiences and perspectives of patients who have dropped out of a therapeutic group, administered remotely (online), and conducted in the context of a research study in Argentina. To this end, three key research questions have been posed: 1) What is the experience of patients who drop out of treatment? 2) What is/are the reason(s) for dropout? and 3) What can be done to reduce future dropout in our population?
METHODS
STUDY DESIGN AND CONTEXT
The present work consisted of a qualitative design according to the classification proposed by Maxwell (2021). This method was chosen for this study because of the humanistic nature of internal experiences in psychotherapy (McLeod, 2011).
The research was carried out with a sample obtained in the context of an ongoing randomized controlled trial (Celleri et al., 2023) that aims to evaluate the effectiveness of the Unified Protocol (UP) in group and online formats. So far, four therapy groups have been conducted throughout 2022 and 2023.
ETHICAL CONSIDERATIONS AND INFORMED CONSENT
This study is part of the UBACYT research project “Aspectos culturales de una intervención psicológica transdiagnóstica basada en internet: percepción de usuarios del sistema de salud argentino”, approved by the University of Buenos Aires .and directed by the last author of the article. The project has been approved by the Committee on Responsible Behaviour in Research of the Faculty of Psychology of the University of Buenos Aires.
By registering to participate, all participants have read and accepted the informed consent form, which explains their voluntary participation in the study and their right to withdraw from the study at any time during their participation. This consent is by the Declaration of Helsinki and the Argentine Law on Patient Rights and Informed Consent (No. 25.529) of the Republic of Argentina.
TREATMENT
Study participants received 10 sessions of 120 minutes each, based on the UP (Barlow et al., 2011). The UP is a transdiagnostic intervention focusing on emotion regulation in emotional disorders. The UP aims to teach clients, through eight treatment modules, adaptive strategies to regulate their own emotions, as research has shown that people with emotion disorders tend to view their own emotions negatively and therefore wish to avoid them (Bullis et al., 2019). Research has highlighted the role of dysfunctional emotion regulation strategies, focusing on suppression and avoidance as the main maintenance mechanism of ET (Campbell-Sills et al., 2006). It becomes a more efficient intervention than specific protocols by saving resources as a transdiagnostic intervention applied in a group setting.
The sessions were delivered virtually, online, synchronously, and in groups. Groups consisted of 4-7 members each. More information about the content of the sessions, the structure of the treatment, and the criteria for inclusion and exclusion of the sample can be found in the study protocol (Celleri et al., 2023).
SAMPLE AND DATA COLLECTION
The study sample consists of three patients who participated in one of the groups held during the years 2022 and 2023. Two of them are identified as female and one as male. The level of education of the participants in this study is secondary school. None of them were under psychopharmacological treatment. Table 1 presents the socio-demographic characteristics of the participants.
Table 1 Participants’ socio-demographic data
| Patient | Age | Residence | Drop-out |
|---|---|---|---|
| Patient 1 | 36 | Córdoba | Session 10 |
| Patient 2 | 33 | Buenos Aires | Session 4 |
| Patient 3 | 23 | Santa Fe | Session 3 |
To date, N=25 participants have started one of the 2022-2023 groups. Of these, n=7 participants have dropped out of the group. These n=7 participants were contacted by email and telephone in September/October 2023 to invite them to participate in this study. Of the n=7 participants contacted, n=3 responded and agreed to participate in the study (the remaining n=4 did not respond to the emails and phone calls).
Data were collected through telephone interviews lasting approximately 20 minutes with those participants who could be contacted and were willing to participate. Interviews were conducted by two members of the team. Once informed consent for the recording of the interview had been obtained, the interview began.
A semi-directed interview was designed to explore the experiences of each participant in the group and the difficulties that led to drop-out. The guidelines suggested by Krueger (2014) were followed for the preparation of the interview. The interview consisted of 24 questions divided into five sections. Each of the sections and examples of the questions asked for each topic can be found in Table 2. The interviews were then transcribed for thematic analysis.
Table 2 Semi-structured interview
| Section | Topic | Example of question |
|---|---|---|
| Phenomenological exploration | ||
| Openness and general experience with the group | How was your experience with group therapy? | |
| Format and structure of the treatment | ||
| Virtual format | What do you think about this format? | |
| Homework | What assessment can they make about the usefulness of the homework? | |
| Relationship with others | ||
| Therapeutic alliance | What has the relationship with the therapists been like? | |
| Partnership with partners | Could you describe what the relationship with your partners was like? | |
| Treatment barriers | ||
| Drop-out | What was the reason for dropping out of therapy? | |
| Difficulties | What difficulties did you encounter in carrying out the treatment? | |
| Proposed changes | What changes would have caused them to continue therapy? | |
| Closing and final suggestions | What suggestions do you have for improving the next groups? | |
DATA ANALYSIS
To analyze the data, a qualitative thematic analysis (Schreier, 2012) of the content of the interviews was carried out by inductively forming the categories based on segments of meaning within the framework of Qualitative Content Analysis (Roller, 2019). The process of forming and analyzing the thematic categories in the dataset was carried out independently by two of the authors of the article and then agreed upon according to their level of saturation. According to this analysis, the themes that emerge are those most frequently and intensely mentioned by the participants.
RESULTS
A total of 5 themes emerged from the analysis, divided into 11 sub-themes: (1) General experience, which was divided into three sub-themes: a) overall experience with the group, b) length and structure of sessions, c) therapeutic alliance, (2) Reason for drop-out, (3) Patient manual and homework between sessions, which was divided into two sub-themes: a) difficulties and b) benefits, (4) Groupness, which was divided into: a) virtual format, b) shared experiences (normalization), c) understanding one’s own experiences, and d) difficulties in the group. Finally, (5) changes to reduce drop-out, which was divided into: a) increased flexibility, extension, and modality, and b) structure (tasks/group size). Each theme and sub-theme are described below and examples of quotes from the meaning-making segments are included. Figure 1 included a mapping of the composition of the themes and sub-themes.
GENERAL EXPERIENCE
In this theme, the participants referred to general questions about the experience of participating in the therapy group. All participants reported that overall, they found the experience positive.
Overall experience with the group. In terms of the overall experience of the group, participants report a positive experience, highlighting the diversity, for example in terms of age and gender. They also say that they liked the methodology used during the meetings (experiential exercises, skills practice).
“I liked the different age groups, the fact that there were men and women” (Participant 3).
“I thought it was very good. In fact, I am grateful for the methodology, it was good” (Patient 1, personal communication, September 2023).
Length and structure of sessions. Regarding the length of the sessions and the structure of the treatment, the participants generally felt that on the one hand, the length of the sessions and the duration of the treatment were appropriate, highlighting the participation of everyone and the availability of time for each person to talk.
“The length of the sessions was good and the time between sessions was also good” (Patient 2, personal communication, September 2023).
“We were given time for everyone so we could all express ourselves” (Patient 3, personal communication, September 2023).
However, some of the participants point out that the time they had to speak was not enough, given the composition of the group they were in, or the time they would have liked to have had to express themselves.
“Not enough time for everyone to speak” (Patient 1, personal communication, September 2023).
“I understand that, let’s say, it was a study, so we couldn’t take so much time” (Patient 2, personal communication, September 2023).
Therapeutic alliance. Regarding the therapeutic alliance, which is considered an important non-specific factor concerning therapy, participants report that the alliance formed with the therapists who coordinated the sessions was positive. They describe the bond as warm and empathic on the part of the therapists, which resulted in the participants being able to interact, be interested and feel understood.
“They were kind, friendly, nice, pleasant, empathetic, firm as well. And I can’t say anything negative” (Patient 2, personal communication, September 2023).
“The psychologists were very nice, very sweet. They talked, people interacted, they were interested” (Patient 1, personal communication, September 2023).
REASON FOR DROP-OUT
The main reason for dropout was that participants reported difficulties in attending some of the sessions. As they were only allowed to miss one session during the ten sessions, those who missed a second session were not allowed to continue. Difficulties reported included medical problems, work problems, or unforeseen circumstances that prevented them from attending the session.
“I didn’t attend too much because my schedule got complicated because of a work problem and that limited my participation” (Patient 3, personal communication, September 2023).
“Yes, there was a limitation, which I understand is a good thing to say, but well, it was complicated for me. If you were absent for more than 2 sessions you were dropped from the group. And for me, because it was complicated because of the timetable, I was left out” (Patient 1, personal communication, September 2023).
PATIENT MANUAL AND HOMEWORK BETWEEN SESSIONS
This category explores patients’ experience of using the patient handbook and completing tasks between sessions. The various difficulties and benefits those patients experienced during treatment were explored.
Difficulties. Among the difficulties reported with the tasks and the reading of the manual, some patients report problems with the interoceptive exposure exercises between sessions (e.g., hyperventilation or turning in place) and difficulties in integrating them into practice. On the other hand, when performing the exercises, they reported that some of the instructions were abstract.
“The only one I couldn’t incorporate was the one about reproducing with the body because it was uncomfortable, it was ugly” (Patient 1, personal communication, September 2023).
“There were some that were a bit abstract in terms of the instructions or a bit vague in terms of the instructions” (Patient 2, personal communication, September 2023).
Benefits. Regarding the use of the patient manual, patients reported that sending them the corresponding chapters of the manual helped them to better understand the skills that had been worked on in the session. In addition, they report that the content of the manual is useful and easy to understand.
“The guide, the book seemed to me to be super, it would be important for us patients to be more aware of this book” (Patient 3, personal communication, September 2023).
“They sent us some notes, some chapters. It’s good, in other words, they kind of gave you a preview of what you were going to see in the session, yes. And it was like content, simple, it wasn’t complex to understand” (Patient 1, personal communication, September 2023).
Groupness
In this category, participants’ experiences of the characteristics of group therapy emerged, where they emphasized the benefits of the virtual format of group therapy, the possibility of normalizing experiences, and the ability to understand their emotions, and also referred to difficulties in group therapy, such as the feeling of incompatibility with the rest of the group for some of them.
Virtual format. Concerning the group format, participants generally reported that this innovative format allowed them to break down barriers of distance and access to treatment, and to overcome difficulties such as being exposed to face-to-face group treatment.
“It broke down barriers in the sense that even though there was distance, you could still connect” (Patient 2, personal communication, September 2023).
“It’s good that it’s virtual because sometimes I think it’s more difficult to be exposed, maybe” (Patient 1, personal communication, September 2023).
Shared experiences (normalization). Patients report that being able to share the sessions with other people who have gone through similar situations or experiences to their own has a normalizing effect on the experience and reduces stigma, mainly because they can see what is happening to them reflected in others and that, although the problems are not exactly the same, they have many features in common.
“With the others, they talked and it was like reproducing what was happening to me, in other words with another person, but it defined me, let’s say” (Patient 2, personal communication, September 2023).
“To be in contact with people who have experienced similar things to me. Maybe not the same, but in many cases yes” (Patient 3, personal communication, September 2023).
Understanding one’s own experiences. Participants reported that the group work with the therapists and the different skills enabled them to understand and validate their own emotional experiences (e.g., to understand what emotion they are feeling). They also reported being able to begin to understand how emotions lead them to engage in impulsive or emotional behaviors, and in turn, begin to modify these behaviors.
“Recognizing emotions, why am I feeling this way, why are you doing this action, and so on, are questions I didn’t ask myself before” (Patient 2, personal communication, September 2023).
“I’m very impulsive, so I can recognize what emotion I’m feeling. If I feel angry if I feel sad and so on” (Patient 3, personal communication, September 2023).
Difficulties in the group. In terms of difficulties with the group, some patients reported that during the meetings or at some point in the meetings they did not feel compatible with the rest of the group or did not understand the problems of others, which led to a decrease in their connection with the group and their participation.
“No, I’m not very sociable, so I felt like there were people who were there because they were bored or something” (Patient 2, personal communication, September 2023).
“I didn’t feel like there was any compatibility, but that’s what I remember” (Patient 3, personal communication, September 2023).
CHANGES TO REDUCE DROP-OUT
In terms of changes that participants felt could be made to reduce the likelihood of dropping out, these fell into two main areas: changes to flexibility, length and modality, and changes to the structure of treatment.
Increased flexibility, extension, and modality. Patients felt that to continue attending the group, it would have been helpful to have more flexibility in the number of absences allowed or in the group’s timetable. On the other hand, they also suggest the possibility of hybrid treatments, in which it would be possible to hold the meetings they cannot attend asynchronously.
“Maybe some flexibility in the timetable” (Patient 2, personal communication, September 2023).
“I don’t even know if some asynchronous mode is possible. Let’s say they don’t all connect at the same time. Maybe that would be weird…a suggestion that can be explored” (Patient 3, personal communication, September 2023).
Structure (tasks/group size). In terms of suggested changes to the structure of the treatment, participants say that more challenging tasks between sessions would help them to improve their engagement with the therapy. At the same time, they suggest a reduction in the number of people in the group, both to allow more time for discussion and to reduce the length of the sessions, which would make them more compatible with the rest of their daily activities.
“Like with more homework and for us patients to be a bit more demanding with it, maybe that” (Patient 2, personal communication, September 2023).
“Smaller groups, so the duration doesn’t have to be so long, and try to encourage communication between people” (Patient 1, personal communication, September 2023).
DISCUSSION
This study aimed to explore the experiences and perspectives of patients who have dropped out of treatment, in this case, transdiagnostic cognitive-behavioral therapy delivered in a group setting and a virtual format (online). To the best of our knowledge, this is the first study in Argentina and the region to qualitatively explore the reasons why patients drop out of treatment.
The result of the analysis of the interviews conducted shows that, in general, the patients’ experience in this treatment format was positive and, as shown in the general experience theme, the participants had a positive experience of their participation, highlighting that the dropout rate of patients in this study is currently similar to that of face-to-face treatments and even slightly lower (28%) compared to previously reported rates (Bennemann et al, 2022), but this could be related to the characteristics of the treatment provided, as previous studies have found that PU has lower dropout rates compared to specific protocols (Barlow et al., 2017), and this could be one of the benefits of its use. The number of sessions and the length of each session were reported to be adequate.
The therapeutic alliance was described as positive, highlighting the therapists’ empathy and ability to generate interest in group participants, as reflected in the sub-theme of therapeutic relationship. This may be consistent with previous literature showing that the quality of the therapeutic alliance can be maintained through teletherapy (Eichenberg et al., 2022) and in this particular case, group therapy, although as teletherapy has recently expanded massively, further research is needed. However, the therapeutic alliance in group therapy does not appear to be as central to treatment outcomes as it is in individual therapy, according to previous literature, and this may be because this bond in the context of group therapy is only one variable in the complex relationships that are established between the group and the therapists and between group members (Rosendahl et al., 2021). In contrast to some previous research suggesting the therapeutic alliance as a mediating factor in treatment dropout, participants do not directly mention specific treatment issues or problems in the therapeutic relationship (Anderson et al., 2019).
Regarding the patient handbook and intersession tasks, participants’ experience of using the handbook was positive, as it was adapted to simple and understandable language, as reported in previous research (Christensen et al., 20-22). In the intersession tasks, a central aspect of the anxiety treatment model (Boettcher & Barlow, 2019), interoceptive exposure, emerges. Some participants commented on difficulties in performing the exercises (‘something uncomfortable, it was ugly’). This is relevant as interoceptive exposure is a key component in the treatment of anxiety disorders. It is inherent in therapy that such reactions occur, but it is also possible that they lead to dropout or poor adherence. Clinically, it requires a great deal of skill on the part of the therapist to propose and make acceptable something that people with emotional disorders are sometimes very explicit about wanting to avoid.
Concerning the virtual format, the experience of the participants was positive, and they appreciated the benefits of digital technologies, such as being able to connect from anywhere in the country and access a treatment that would otherwise not be possible due to physical problems, and as suggested, this allows better and greater access to psychotherapeutic treatments for the population (Wind et al., 2020). In turn, as suggested in the sub-theme of shared experiences (normalization), the group format allows for the normalization of one’s own experiences and the understanding that the symptomatology presented by each patient is not unique to them, but that other people have similar problems, and as previous literature suggests, this normalization of experiences reduces stigma and shame (Weinberg, 2020; Zielinski et al., 2021).
At the same time, participants report that the group context and the activities proposed during the sessions, as reflected in the sub-theme Understanding one’s own experiences, enabled them to understand their own experiences (e.g., to understand, label, and validate their emotions). Not feeling validated or not being able to understand their emotional experiences has recently been studied as a predictor of dropout from psychotherapy (Howard et al., 2020), so therapists need to be attentive to these variables.
Concerning the reasons for dropping out, on the one hand, practical and concrete problems are generally mentioned, such as incompatibility of schedules or being ill at the time of attending some of the meetings, although, as described below, it seems that some of the participants did not feel fully involved in the group. On the other hand, although the participants in the study mentioned that the experience with the group was generally good when it came to difficulties with the group, various difficulties emerged that reduced their participation including not feeling compatible with the other members or not being very “social”. More recently, it has been investigated how certain personality variables (e.g., more negative or antisocial styles) predict dropout in group therapy (Bennemann et al., 2022). These personality styles may affect the so-called group cohesion, a term that refers to the sense of connectedness and closeness of group members and has been shown not only to relate to therapeutic outcomes (Bryde Christensen et al., 2021) but also to represent a similar extent the therapeutic alliance in individual therapy (Rosendahl et al., 2021). Therefore, consistent with previous research (Busmann et al., 2019), it is central to establish a strong therapeutic alliance with these patients in the first sessions and to foster their engagement and participation.
We can hypothesize that for the patient who dropped out in session 10, the reasons were linked to difficulties in attending the sessions specifically, and for the patients who dropped out in the first meetings, the reasons were more linked to compatibility or alliance issues. In turn, in terms of socio-demographic variables, the patients who dropped out in the first sessions were younger, a fact that in previous research has been associated with dropouts.
Some of the strategies suggested by participants to reduce dropout that emerged in the theme of changes to reduce dropout included the possibility of holding some of the meetings asynchronously. Given that in our study, as in the vast majority of controlled studies (Swift et al., 2017; Swift & Greenberg, 2014) the main reason for dropout is difficulty in attending one of the agreed meetings, it is possible that some novel formats, such as internet-based interventions (Andersson et al., 2019; Andersson & Cuijpers, 2009), and especially their recent implementation in a blended format (combining some synchronous and some asynchronous sessions), may lead to a lower dropout rate and higher treatment adherence (Díaz-García et al., 2021; Etzelmueller et al., 2018; Schuster et al., 2020). In this sense, an asynchronous intervention called IUPI is currently being implemented in Spain and it is hoped that future studies will investigate its use and combination with synchronous therapy (Celleri et al., 2023), thus not only improving access to treatment but also reducing the dropout rate.
With the limitations of the present study, it should first be noted that the accessible sample is small and the experiences are unlikely to be fully representative of the entirety of those who have dropped out of treatment. As previous studies have reported, contacting patients who have dropped out of treatment is a difficult task (Leichsenring et al., 2019), and it is suggested that future research should encourage participation in dropout studies to be able to study this phenomenon more rigorously. On the other hand, by conducting interviews that are not coordinated by therapists but by members of the research team, it can be hypothesized that participants may not feel completely comfortable commenting on the difficulties they perceived during treatment, so it is suggested that future studies could have interviews conducted by an external person.
Finally, it is hoped that these findings will improve adherence to psychotherapeutic treatment in our region, motivating the creation of a strong therapeutic alliance that will allow for the commitment of patients to treatment, especially those who seem less compatible with the group. At the same time, the incorporation of technologies such as Internet-based interventions or other ways of increasing the flexibility of a therapeutic group will reduce dropout rates.
