Psychotherapy 101: Check your client feels validated to reduce drop-out
This week’s study comes from Howard and colleagues (2019) who looked at whether validation was related to therapy drop-out. They asked 50 clients and their Doctoral student therapists to rate how much the therapists validated their clients during sessions 3 to 7. Client-therapist combinations were drawn from a general Cognitive Behaviour Therapy clinic, a stress and anxiety disorders clinic and a Dialectical Behaviour Therapy clinic. A case was considered to have dropped out if the client had decided to end therapy without their therapist’s agreement before the protocol was completed or if they missed 4 consecutive weeks within the first 6 months of DBT. The clients in this study on average experienced moderate anxiety, moderate depression and borderline personality disorder symptoms below diagnostic threshold levels.
The drop-out rate overall was 36%. Validation as reported by clients, early in treatment, predicted reduced drop-out rates: for every 1-point increase in the validation scale (see below) total, the likelihood of dropping out of therapy reduced by 22%. Importantly, there was no correlation between the therapist’s and the client’s validation ratings! The client’s perception was predictive of drop out; the therapist’s perception was not. Interestingly, this whole relationship was moderated by therapist experience. There was no early validation-drop out relationship for therapists with above-average experience (meaning 609 hours), whereas there was an 87% increase in drop-out for therapists with below-average experience (meaning students seeing clients for the first time). Severity of symptoms (anxiety, depression or borderline) was not related to drop-out.
Self-reported Validation and Invalidation Scale (SRVIS)
Although Howard et al (2019) did not include the exact version of the SRVIS used in this study, Stigen‘s (2011) Master’s thesis includes a similar version which has been adapted here to refer a therapist rather than an experimenter:
0=never; 1=rarely; 2=sometimes; 3=often; 4=almost always/always
Was your therapist paying attention to you?
Was your therapist interested in what you had to say?
Did your therapist take your responses seriously?
How well were you understood by your therapist?
Was your therapist responsive to your emotions?
Did your therapist tell you what you should think and feel?
Did your therapist see your responses as abnormal or inaccurate?
Did your therapist increase your negative feelings?
Was your therapist condescending or contemptuous toward you?
Did your therapist see you as more fragile than you really are?
Take home: Clinical Implications
The SRVIS provides ideas for a range of generic questions a therapist could simply ask verbally at the end of session to get the client’s feedback on the working alliance. There are many examples of questions that could be asked to obtain feedback but many have not demonstrated clinical predictive validity.
Psychology registrars and other non-doctoral level mental health workers probably have a similar level of experience to many of the therapists in this study. They may want to use a structured feedback form like the SRVIS to help them check their client’s perceptions of sessions until they learn what they need to attune to.
Supervisors may also want their supervisees to administer a measure like the SRVIS – at least in the early stages of therapy – to hear a perspective their supervisees may not be able to give them yet.
Consumer perceptions of their therapist’s behaviour remains an important and understudied area – see the ad for Bianca’s study above!
This article is currently in press at Behavioural and Cognitive Psychotherapy. Go to https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/validation-predicting-premature-dropout-from-treatment-provided-in-training-clinics/A78FD27E9E59187A55570FA2FC168D0A/core-reader for the full article.
References
Howard, K.P., Altenburger, E.M., & Cheavens, J.S. (2019). Validation predicting premature drop-out from treatment provided in training clinics. Behavioural and Cognitive Psychotherapy, 1-9.
Stigen, C.L. (2011). The impact of validation and invalidation on affect and learning task performance. Master of Arts thesis. Ohio State University.