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Introduction
Mental health problems in children and adolescents have been the focus of attention worldwide [1] due to its high prevalence and gradual increase in Latin America [2]. This makes it necessary to understand and optimize the interventions and treatments offered to this population [3]. It is relevant to know why this type of treatment is terminated and the elements related to such decision [4]. This is a central issue since evidence shows that there are few children and adolescents who receive specialized help for their emotional needs, and even less children who complete their treatment [5].
Studies show that there are different ways of terminating psychotherapy, understood as the termination of patient-therapist sessions [6,7]. Among them, the most referenced ways are by mutual agreement, by request of one of the participants, and by dropout. Termination of therapy does not necessarily occur because of the achievement of goals. Termination also occurs prematurely, and the factors associated with each type are different [8].
Termination by mutual agreement between therapist and patient usually occurs when the goals agreed upon in the process have been achieved [9]. In the case of child and adolescent psychotherapy, this occurs when the therapist, the child, and their parents agree to conclude the process [10]. In this agreement, parents or legal guardians have an important and active role [11] because they usually seek help, support the definition of goals, and pay for the process [12].
When a patient, therapist, or contextual factor limits the process, such termination may occur with partial achievement of the goals [13]. Therefore, the negotiation of the therapeutic alliance and of the termination of therapy is related to the achievement of goals and to the possibilities and limitations of the participants [14].
Furthermore, unilateral termination by the therapist is associated with personal conditions (e.g., end of practice, change of job, etc.) or with the achievement of the goals established [7,15,16]. In this type of termination, the patient’s clinical conditions must be considered in order to face the termination of the therapeutic relationship and the need to make referrals to continue with the process, when required [7].
Finally, dropout is understood as the unilateral termination of treatment by the patient due to lack of motivation for the process or due to some limitation that makes it impossible to continue [5,11]. In child and adolescent psychotherapy, dropout is a major challenge, as it occurs in between 20% and 60% of cases, and there are not many studies on the aspects related to this type of termination [16,5].
Research on this topic has focused on premature termination and dropout, associating it with patient factors such as personality, type of problem, severity of symptoms [17], or ethnicity [12]. Other associated factors include elements of the family context, such as the attitude of the parents or guardians towards the treatment [18], the diagnosis and their expectations [12,19]. Added to this are factors such as unsatisfaction with the process and ruptures in the therapeutic alliance [20]. Finally, some studies show that the decision to terminate treatment may be an interaction of second-order factors [13] such as financial difficulties [21] or modification of extra-therapeutic factors that changes the needs of psychotherapy [22].
In this perspective, dropout is not a sign of unachieved goals, and mutual termination does not guarantee the achievement of these goals [8]. Another point to consider is that, in child and adolescent psychotherapy, the decision to attend is often made by the caregivers or guardians. Considering this, it is important to develop motivation and to agree on therapeutic goals integrating the perspectives of all involved [10].
Additionally, the specific characteristics of the institutional context must be taken into consideration, such as the number of appointments, access to treatment, flexibility of schedules and professional rotation [23,24]. These aspects may affect the continuity of treatment [25].
Understanding the factors related to the termination of psychotherapy with children and adolescents allows therapists to identify elements connected to premature termination [5]. At the institutional level, it is essential to know the reasons associated with the termination of therapy, because this makes it possible to develop strategies to improve adherence, guide work teams, build intervention modalities, and optimize treatments for greater effectiveness.
Considering the above, the present study aims to know the forms of psychotherapy termination in child and adolescent psychotherapy and their associated factors in two university psychological care centers in Antioquia (Colombia). This makes it possible to improve interventions, identify specific elements of this context, and develop treatments closer to the patients.
Method
This study has a quantitative, exploratory, cross-sectional research design with a descriptive and association scope. The research was conducted during 2020-2021 in two psychological care centers: IPS CES Sabaneta - Universidad CES (CES) and Consultorio Psicológico Popular - Universidad de San Buenaventura (USB).
Participants
A random sampling stratified by age group was carried out. One hundred patients who had terminated therapy in the last four months (48 children and 52 adolescents) were included in the study. The children included 33 females and 15 males between the age of 5 and 12 (age X = 9.14; SD = 2.2). Among adolescents, there were 35 females and 17 males between the ages of 13 and 18 (age X = 15.82; SD = 1.64).
The inclusion criteria were: to have been in psychotherapy for at least three sessions, to be between the ages of 5 and 18, and to agree to participate by means of informed consent approved by the bioethics committees of both institutions. Patients with a diagnosis of organic brain damage or cognitive disability were excluded. The inclusion criteria of considering patients with at least three sessions was adopted because some studies show that in these sessions the preliminary evaluation and therapeutic setting are carried out and the basis of the therapeutic alliance are consolidated [26].
Variables, instruments, and data collection
A survey was conducted with questions on sociodemographic aspects of the patient, rating of psychotherapy, and reasons for terminating therapy. An expert group based on a desk review constructed the survey and defined the thematic domains and items. A pilot test of the questionnaire was conducted to determine that responses were clear and understood by the patients (see Table 1). The interviews were conducted by telephone, audio-recorded and recorded in a database for analysis.
Table 1 Variables Included in the Analyzes.
| Variable group | Variables | Values | Variable Type |
|---|---|---|---|
| Sociodemographic variables | Age group | Child-Adolescent | Dichotomous |
| Gender | Male-Female | Dichotomous | |
| Socio-economic level | Low (1-2) | Ordinary | |
| Medium (3-4) | |||
| High (5-6) | |||
| Therapy rating | Motivation | Low-Medium-High | Ordinary |
| Therapeutic actions | |||
| Therapeutic relationship | |||
| Therapeutic progress | |||
| Recommend | |||
| Satisfaction | |||
| Variable group | Variables | Values | Variable type |
| Variables of external factors that influence the completion of psychotherapy | Socioeconomic factors | Economic aspects - Academic aspects - Social aspects | Nominal |
| Institutional Factors | Location - Hours and/or availability of appointments - EPS Authorizations | Nominal | |
| End of Therapy Variables | Type of therapy termination | Open responses | Nominal |
| Reason for termination | |||
| Who decided to terminate psychotherapy |
Procedure
Initially, patients who met the study criteria were selected from institutional care records. Subsequently, parents were invited and, if they accepted the ethical conditions, the interview was carried out. The open-ended responses were then categorized, and each therapy was classified according to a main form of termination. Finally, descriptive and association analyses were performed.
Data analysis
Descriptive statistics were calculated considering frequencies, percentages, means and standard deviations according to the type of variable. Percentages were reported because standardization of the data allows for the interpretation of trends in the information. Subsequently, chi2 analysis was performed to establish the levels of association between “types of termination of therapy” and sociodemographic variables, “rating therapy” and “who decided to terminate psychotherapy”. Analyses were performed with IBM SPSS Statistics 24 software.
Results
Four types of therapy termination reported by parents were identified in the results: related to external factors (F=25), institutional or therapist aspects (F=39), attributed to patient unsatisfaction (F=17), and achievement of goals (F=19). Among these, the most frequent reasons for terminating the processes were achievement with goals (F=19), change of psychologist (F=15), and psychologist’s suggestion (F=10) (see Table 2).
Table 2 Frequency of types and reasons for terminating therapy in children and adolescents.
| Types of therapy termination | Reasons for termination | Children | Adolescents | General | |||
|---|---|---|---|---|---|---|---|
| F | % | F | % | F | % | ||
| 1. Due to factors external to psychotherapy | Time incompatibility | 2 | 4,2 | 2 | 3,8 | 4 | 4 |
| Economic difficulties | 5 | 10,4 | 5 | 5 | |||
| Location | 2 | 4,2 | 1 | 1,9 | 3 | 3 | |
| Modification of the school's requirement | 1 | 2,1 | 1 | 1 | |||
| Parental divorce | 1 | 2,1 | 1 | 1 | |||
| Pandemic | 1 | 2,1 | 3 | 5,8 | 4 | 4 | |
| Prioritize another activity (travel, work, another process, or institution ) | 3 | 6,3 | 3 | 5,8 | 6 | 6 | |
| Appointments in another institution | 1 | 2,1 | 1 | 1 | |||
| 2. Due to institutional and/or therapist factors | Change of psychologist | 6 | 12,5 | 9 | 17,3 | 15 | 15 |
| Change in institutional procedures | 1 | 2,1 | 2 | 3,8 | 3 | 3 | |
| Remission | 2 | 4,2 | 1 | 1,9 | 3 | 3 | |
| Health system processes | 1 | 1,9 | 1 | 1 | |||
| Appointment availability | 4 | 8,3 | 4 | 7,7 | 8 | 8 | |
| Psychologist decision | 4 | 8,3 | 5 | 9,6 | 9 | 9 | |
| 3. Due to patient dissatisfaction | With the professional | 4 | 8,3 | 3 | 5,8 | 7 | 7 |
| With the progress of therapy | 3 | 6,3 | 1 | 1,9 | 4 | 4 | |
| With therapy | 1 | 1,9 | 1 | 1 | |||
| Lack of motivation | 5 | 9,6 | 5 | 5 | |||
| 4. Due to achievement of goals | Achievement of goals | 8 | 16,7 | 11 | 21,2 | 19 | 19 |
| Total | 48 | 100 | 52 | 100 | 100 | 100 | |
In addition to this, 46% of the processes were terminated by parental decision (31 children and 15 adolescents), 25% by the patients (3 children and 22 adolescents), 24% by the psychologist (12 children and 12 adolescents), 4% by mutual agreement between therapist, parents, and patients (1 child and 3 adolescents), and 1% by the health insurance provider (1 child).
Regarding the external factors that influenced psychotherapy termination, 22% attributed it to economic reasons, 12% to labor or academic elements, and 3% to social aspects related to affray. In addition, institutional factors such as location (13%), schedules and appointment availability (13%), and authorizations from insurance companies (3%) were also found. As Table 3 shows, there are no descriptive differences between children and adolescents.
Table 3 Factors influencing the termination of therapy.
| Factors Influencing Termination | Children | Adolescent | Total |
|---|---|---|---|
| (F - %) | (F - %) | (F) | |
| Socioeconomic factors | |||
| Economic aspects | 12 - 25% | 10 - 19% | 22 |
| Labor aspects - Academics | 6 - 12,5% | 6 - 11,5% | 12 |
| Social aspects (Affray) | 1 - 2% | 2 - 4% | 3 |
| Institutional Factors | |||
| Location | 9 - 19% | 4 - 8% | 13 |
| Hours and/or availability of appointments | 5 - 10,5% | 8 - 15% | 13 |
| Health system authorizations | 1 - 2% | 3 - 6% | 4 |
Furthermore, when parents were asked to rate the psychotherapy, they reported a high rating of the service in general (90%), of the therapeutic relationship (84%), of the activities carried out in therapy (76%), and 83% would return or recommend the service. The dimensions related to motivation (68%) and therapy progress (59%) were those with the lowest percentage of positive ratings. The descriptive distribution of these dimensions was similar in children and adolescents (see Table 4).
Table 4 Rating dimensions associated with psychotherapy.
| Rating dimensions of therapy | Low | Medium | High | Did not report | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| N | A | T | N | A | T | N | A | T | ||
| Motivation for therapy | 6 | 7 | 13 | 7 | 9 | 16 | 33 | 35 | 68 | 3 |
| Therapeutic actions | 8 | 4 | 12 | 4 | 5 | 9 | 36 | 40 | 76 | 3 |
| Therapeutic relationship | 3 | 4 | 7 | 4 | 3 | 7 | 41 | 43 | 84 | 2 |
| Therapy progress | 11 | 9 | 20 | 7 | 12 | 19 | 30 | 29 | 59 | 2 |
| Would recommend the institution | 5 | 3 | 8 | 2 | 7 | 9 | 41 | 42 | 83 | 0 |
| Satisfaction with the service | 2 | 2 | 4 | 3 | 2 | 5 | 42 | 48 | 90 | 1 |
Note: N=Child frequency, A=Adolescent frequency, T=Total frequency, Valuation levels = Low: Answers 1 and 2, Medium: Answer 3, and High: Answers 4 and 5.
In the analysis of variable association among the four types of psychotherapy termination identified in the study and the sociodemographic variables, a significant result was found between the termination due to goal achievement and socioeconomic level (X2: 6.824, DoF:1, p.0.009), with a higher percentage in middle-class patients (15%) compared to low-class (4%).
Significant associations were also found between patients who terminated therapy due to dissatisfaction and the following variables: motivation in therapy (X2: 31,041, DoF:2, p.0.000 ), actions rating (X2: 26.481, DoF:2, p.0.000), therapeutic relationship (X2: 25.597, DoF:2, p.0.000), progress perception (X2: 17.920, DoF:2, p.0.000), and satisfaction in therapy (X2: 18.844, DoF:2, p.0.000). Based on these results, the therapy rating tends to be lower when therapy ends due to dissatisfaction (See Table 5).
Table 5 Significant associations among types of termination and sociodemographic and therapy variables.
| Types of termination | Variables with significant association | Descriptive Data | X2 | DoF | p |
|---|---|---|---|---|---|
| 1. Due to factors external to psychotherapy (25) | Therapy progress rating | Low: 9 | 11,892 | 2 | 0,003 |
| High: 15 | |||||
| Caregiver decides to terminate | No: 7 | 9,071 | 1 | 0,003 | |
| Yes: 18 | |||||
| Therapist decides to terminate | No: 24 | 7,31 | 1 | 0,007 | |
| Yes: 1 | |||||
| 2. Due to institutional and/or therapist factors (39) | Therapist decides to terminate | No: 24 | 7,331 | 1 | 0,007 |
| Yes: 15 | |||||
| 3. Due to patient dissatisfaction (17) | Motivation for therapy | Low: 9 | 31,041 | 2 | 0 |
| Medium: 4 | |||||
| High: 4 | |||||
| Therapeutic actions rating | Low: 8 | 26,481 | 2 | 0 | |
| Medium: 3 | |||||
| High: 6 | |||||
| Therapeutic relationship rating | Low: 5 | 25,597 | 2 | 0 | |
| Medium: 4 | |||||
| High: 8 | |||||
| Therapy progress rating | Low: 9 | 17,92 | 2 | 0 | |
| Medium: 5 | |||||
| High: 3 | |||||
| Satisfaction with the service | Low: 4 | 18,844 | 2 | 0 | |
| Medium: 5 | |||||
| High: 8 | |||||
| 4. Due to achievement of objectives (19) | Socio-economic level | Low: 4 | 6,824 | 1 | 0,009 |
| Medium: 15 | |||||
| Caregiver decides to terminate | No: 15 | 5,877 | 1 | 0,015 | |
| Yes: 4 |
Additionally, a significant association was found between psychotherapies that end due to external factors and the perception of progress rating (X2: 11.892, DoF:2, p.0.003). Thus, a higher progress rating tends to be found in this type of termination.
Finally, when calculating the association between the types of termination and “who decided to terminate the processes,” some significant results were found. An association was found among all types of termination and parental decision: by external factors (X2: 8.926a, DoF:1, p.0.003); by institutional aspects and/or therapist (X2: 6.305, DoF:1, p.0.012); by dissatisfaction (X2: 4.494a, DoF:1, p.0.034); by achievement with goals (X2: 6.576a, DoF:1, p.0.010). Also, an association was found between the therapist’s decision and termination by institutional aspects (X2: 8,000a, DoF:1, p.0.005) and by external aspects of therapy (X2: 6,831, DoF:1, p.0.009). According to these analyses, in termination due to factors external to the therapy, the decision tends to be made more by the parents, and in institutional termination by the therapists. In the case of dissatisfaction there is a higher percentage of parents who decide, while in the case of achievement with goals there is less parental involvement (see Table 5). As can be seen, in children there is greater influence of parents and therapists on the termination. In adolescents, only a positive association was found between termination due to dissatisfaction and the patient’s decision (X2: 3.890a, DoF:1, p.0.049).
Discussion
The results of this study show four types of termination of child and adolescent psychotherapy: due to institutional and/or therapist factors, attributed to external treatment factors, due to user dissatisfaction, and due to goal achievement. Within each of these types of termination, multiple reasons and associated factors are identified.
The type of termination most referred by users of child and adolescent psychotherapy was related to institutional and/or therapist factors, considering aspects such as frequent changes of psychologists, limited availability of appointments, and the decision by the psychologist to end the process. Psychotherapy requires the establishment of a therapeutic relationship, which is sensitive to professional rotation and is frequent in teaching-service institutions. Some authors have pointed out that patients treated at these centers are affected by therapist discontinuity [25] and by conclusion of academic periods for training staff [7]. This reveals the importance of improving the therapeutic frame with users at the beginning of treatment, promoting the consolidation of a patient-institution alliance that supports the user in the face of staff rotation, by creating a triage system and case assignment that takes into account the particularities of each case and by improving the process of transferring the therapy from one therapist to another.
Simultaneously, the results show how institutions and therapists have various conditions that can become barriers to treatment, such as appointment availability and timeliness in their allocation [25], as well as administrative processes within the healthcare system [23,24], which becomes a challenge for treatment continuity.
In this type of termination, it is interesting that some psychologists unilaterally decide to end the process, although some parents express that the goals were not achieved or that they did not understand the decision made in these cases. This termination may be due to the limitations that professionals have in addressing complex problems and the absence of feedback to parents [27] Considering this, it is recommended that parents be involved in the treatment through psychoeducation processes and systematic feedback on progress. This supports their perception of the advances [28] and the acceptance of the professional’s evaluation [29].
Secondly, there is terminating treatment due to external factors to the treatment, which are related to economic conditions and the prioritization of other activities. Numerous studies have shown how economic conditions are one of the factors most associated with the risk of dropout [12,21,30] and how the therapist should consider the patient’s and their family’s living conditions, other treatments and activities they perform, as elements that can contribute to therapy or that can affect treatment continuity [31].
This type of termination is also associated with a better perception of progress in psychotherapy, which allows us to hypothesize that, as discomfort decreases, external factors or user activities become relevant and prioritized [13,32], making the therapeutic process dispensable [30]. In this sense, it is important for therapists to anticipate that certain improvements may be associated with premature termination of the process, which should be taken into account in therapy setting and planning [22,31].
Thirdly, termination due to patient dissatisfaction, there is discontent with different aspects of therapy, such as the therapist or the perception of progress. This type of termination has been associated with therapeutic alliance failure [33,34], parental disagreement with treatment [19] and diagnosis [35]. Therefore, the importance of parental involvement in therapy is highlighted in some studies [29,36,37].
In the case of adolescents, the literature reports in the same direction as this study that, when they feel dissatisfied, it is they who decide to terminate therapy [28]. Studies have reported that when adolescents perceive collaborative sessions and less pressure to talk, they have a stronger therapeutic alliance [38,39]; therefore, it is recommended to consider the characteristics of life cycle to achieve adherence [38].
Furthermore, this type of termination highlights the importance of addressing and modulating the expectations of those seeking therapy in the therapeutic context, clarifying the reach of the treatment. It becomes important to support parents in building expectations that align with the patient’s needs [28], as well as the therapist’s and institution’s possibilities. We recommend establishing, for the initiation of child and adolescent therapy, processes that guide caregivers regarding the reach, procedures and limitations of psychotherapy based on the evaluation of the child or adolescent.
Lastly, termination due to attainment of objectives refers to therapies in which treatment goals are achieved. At this level, parents tend to participate less in the decision to end the process. However, some studies show that this type of termination does not necessarily imply closure and can occur unilaterally when significant progress is evident [8]. This is related to some studies that explain a relationship between satisfaction with the process, symptomatic improvement, and a decrease in the need for support [6,31].
This type of termination was more common among adolescents from middle socioeconomic backgrounds, with the clarification that the treatment centers referred to in this research primarily serve low and middle socioeconomic populations. Some authors point out the positive impact that social conditions and developmental stage have on adherence and treatment outcomes [12,21]. Additionally, adolescents from middle socioeconomic backgrounds experience fewer psychosocial problems, which promotes their reflective function [40-43].
The present study has limitations, such as the small sample size, which restricts the possibility of conducting other types of analysis. However, given its exploratory and associative nature, it allows for the identification of important trends and hypotheses for future studies in this research field. Furthermore, it is crucial to achieve a broader understanding of the termination of child and adolescent treatments by conducting new studies that consider and relate the perspectives of other therapy participants, such as patients, psychotherapists, and other institutional actors.
Based on the findings of this research, it is recommended to expand the technical approach to parents or caregivers in the training of psychologists. They play a crucial role in the continuity of therapy processes, and their expectations, level of participation, and satisfaction with therapy should be taken into account. Additionally, it is important to establish an induction or framing process for therapy in institutional settings that clarifies the reach of the intervention and the level of parental participation in the process. This can also help adjust the expectations of both patients and their parents.
In addition, institutional factors should be considered as aspects of the process with children and adolescents, not only as a logistical dimension, but as an actor that, although external to the patient-parent-therapist triad, has the effect of facilitating or hindering adherence to psychotherapy. In this sense, the patient-institution relationship must be worked on, since a proper alliance with it can mitigate the effect of institutional situations, such as professional rotation.
Conclusions
The findings of this research allow us to conclude important elements for psychotherapists, mental health institutions, and formative practice processes that contribute to the reflection on child and adolescent psychotherapy. It is advisable for university psychological care centers to have triage and referral processes to evaluate the pertinence of care by a practitioner or professional, thus providing timely attention according to the needs and characteristics of patients. In this respect, it is important for institutions to be aware of the implications of the teaching-service model and its impact on the patient’s process. They should also consider emphasizing the training of psychologists in culturally and contextually informed therapies, enabling them to develop tools for working with vulnerable populations and in coordination with the healthcare system.
The psychotherapist should work on developing and modulating patient and caregiver expectations to make them more realistic and help the therapist manage identified expectations within the process, ensuring they are aligned with those of the patient. This implies considering some of the barriers or temporal limitations of the process within the setting and how they can be overcome, articulating with different support networks for patients.
On the other hand, it is advisable to make use of monitoring tools for assessing patient conditions in formulating, planning, and monitoring cases, allowing necessary and timely adjustments in the process. In addition to implementing routine monitoring of interventions with process and outcome variables to enhance intervention quality and overall service.
Finally, it is an invitation to continue with this type of research, considering the limitations of this study and how they can be overcome in future research with a larger sample size and involvement of other actors in the therapeutic process within institutional contexts. Furthermore, consider incorporating more variables related to experience level, context, culture, and therapeutic process that influence therapy termination in research. This study provides initial foundations for understanding types of therapy termination in children and adolescents, as well as associated process factors within an institutional context. Continued research in this area will contribute to therapy with children and adolescents.
