A Model of the Early Therapeutic Environment: Predicting Client Attrition

How can clinicians predict who is more likely to drop out of therapy during initial sessions? Studies indicate that many clients in early sessions (a) quickly reach a threshold where they establish an alliance with their therapists, (b) report large decreases in distress after completing only one session of therapy, and (c) attend only one to three sessions before prematurely terminating. Based on these findings, this article describes a model of an early therapeutic environment that predicts that clients are likely to terminate prematurely if (a) clients fail to establish what they experience as a holistic connection with the therapist, (b) client distress remains too high or too low, and (c) clients lack efficacy and outcome expectations appropriate for initiating therapy. With suitable levels of alliance, distress, and expectations, however, clients are more likely to remain in therapy. Recommendations for future research include examination of the interactive effects of alliance, distress, and expectations on attrition; development of new measures of the working alliance and self-efficacy for therapy-related behaviors; and further evaluation of the construct validity of distress-related measures. Public Health Significance Statement How can clinicians predict who is more likely to drop out of therapy versus engage in psychosocial interventions? Research indicates that in initial sessions, many clients (a) quickly reach a threshold where they establish an alliance with their therapist, (b) report large decreases in distress after completing only one session of therapy, and (c) attend only one to three sessions before prematurely terminating. This article interprets these findings through the development of a model of the early therapeutic environment (ETE) that describes relations among alliance, distress, and attrition. More research is needed to test the predictions of the ETE model regarding the interactive effects of alliance and distress on attrition.