Understanding Non-Response In Psychotherapy: A Meta-Synthesis

Carrington, B., Yeates, R., & Masterson, C. (2024). Understanding non-response in psychotherapy: A meta-synthesis. Clinical Psychology Review, 102489.

Rationale

Previous research has focused on negative outcomes in psychotherapy, but there remains an overlooked population: those who show no response after treatment (Vybíral et al., 2023).

Nonresponse in psychotherapy refers to a lack of meaningful improvement in a client’s symptoms or functioning despite receiving treatment (Linden, 2013).

Nonresponse affects a substantial portion of therapy clients, with one UK study finding 18.8% of clients with planned endings experienced no reliable change following psychotherapy (Stiles et al., 2015).

It occurs when therapy fails to produce significant positive changes, even though the client has engaged in the therapeutic process.

Nonresponse is distinct from deterioration or harm, representing a middle ground where the client’s condition remains largely unchanged after completing a course of psychotherapy.

Understanding nonresponse is crucial for improving therapeutic outcomes and practices.

While quantitative studies have explored nonresponse using standardized measures, there is a growing recognition of the importance of qualitative approaches to capture the complexities of individual change (Hill et al., 2013).

This study aims to synthesize the available qualitative literature on client and therapist experiences of psychotherapy nonresponse, addressing a gap in the current understanding of this phenomenon.

Method

The study employed a qualitative evidence synthesis (QES) using thematic synthesis methodology.

The research team followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework to ensure trustworthiness.

Search strategy and terms:

Seven databases were searched: Medline, PsycINFO, Embase, CINAHL, Web of Science, Scopus, and Social Work Abstracts. Search terms included variations of “therapy,” “non-response,” and “qualitative” (e.g., “talking therap,” “non-improv,” “semi-structured interview*”).

Inclusion criteria:

• Qualitative or mixed-method studies exploring experiences of psychotherapy nonresponse
• Studies focusing on client or therapist perspectives
• Studies with substantial doses of therapy

Exclusion criteria:

• Purely quantitative studies
• Studies unavailable in English
• Studies exploring self-help interventions
• Studies not differentiating nonresponse from other related experiences

Data extraction:

Data extraction was conducted using a form in Microsoft Excel, focusing on results and discussion sections of included studies.

The researchers carefully extracted data related to nonresponse experiences, distinguishing these from experiences of deterioration or harm.

Two independent reviewers screened 20% of the full texts to ensure consistency.

Data synthesis:

The study employed thematic synthesis for data analysis, following the approach outlined by Thomas and Harden (2008).

This involved three iterative processes: line-by-line coding, development of descriptive themes, and development of analytical themes. The researchers used EPPI-Reviewer software to support the coding process.

The synthesis process resulted in 529 initial codes for client perspectives and 311 for therapist perspectives. These were then grouped into descriptive themes, and finally into analytical themes.

The process was iterative, with researchers discussing and refining themes throughout the analysis. Credibility checks were conducted to ensure the themes accurately represented the data.

Results

Client Perspective

1. Hopes and fears:

This theme captures the mixed emotions clients experience when starting therapy. Many clients enter therapy with high hopes for positive change, often seeing it as a “last chance” to alleviate their problems.

However, these hopes are frequently accompanied by significant apprehension and doubt. Clients may fear failure, judgment, or the unknown aspects of the therapeutic process.

Some hold idealized views of therapy as a cure-all, while others are skeptical about its potential benefits. This combination of hope and fear can significantly impact clients’ initial engagement with therapy and set the tone for their therapeutic journey.

“I suppose it would be good if she could have waved a magic wand and that feeling had gone” (Morton, 2019).

2. Difficult task:

This theme highlights the challenging nature of therapy from the client’s perspective. Clients often find therapy emotionally taxing, requiring significant energy and commitment.

Gaining insight into their difficulties can be painful rather than immediately helpful. Practical aspects of therapy, such as learning and maintaining new skills, can also be demanding.

Some clients struggle to apply therapeutic techniques to their everyday lives. The emotional and practical demands of therapy lead some clients to question whether the process is worth the effort.

This theme also encompasses instances where therapy lacks cultural sensitivity or flexibility, making the task even more challenging for some clients.

“It does make you look at it a bit more depth maybe than you’re prepared to… and do I really want to open that can of worms?” (Radcliffe et al., 2018).

3. Disconnected Relationship:

This theme describes the lack of a strong, trusting therapeutic alliance between client and therapist.

Clients often report feeling unable to fully open up or be vulnerable in therapy due to fear of judgment or lack of safety.

There’s frequently a mismatch in understanding therapy goals, focus, or direction between client and therapist, leading to a sense of not being “on the same page.”

Some clients feel unseen or unheard, which increases their reluctance to engage fully.

The theme also includes experiences of poor match with the therapist, lack of cultural sensitivity, and insufficient repair of relationship ruptures. This disconnection significantly impacts the therapeutic process and outcome.

“I didn’t completely open up, nor allow him in completely; I was probably afraid; that is, I think the fear took over, fear of losing control” (Werbart et al., 2015).

4. Staying involved:

This theme explores the factors that keep clients engaged in therapy despite limited therapeutic gains. Some clients experience positive aspects of therapy, such as feeling validated or normalized, particularly in group settings.

These experiences, while not necessarily leading to significant change, provide enough value to maintain engagement. Some clients report positive elements in their relationship with their therapist, even if overall progress is limited.

This highlights that a supportive relational experience, while not sufficient for meaningful change, can be an important engagement factor.

Additionally, some clients persist in therapy out of hope that change will eventually occur, demonstrating a commitment to the process despite the current lack of progress.

“It was nice to see that there are others. Who maybe struggle with … [and] have some of the same feelings…” (Hjeltnes et al., 2018).

5. Therapy was not worth the investment:

This theme encapsulates clients’ feelings of disappointment and regret about their therapy experience.

Many clients feel that despite some benefits, therapy did not produce the meaningful change they sought.

The emotional, time, and sometimes financial investment in therapy is perceived as disproportionate to the outcomes achieved. Some clients describe feeling “stuck,” experiencing a disconnect between their desire for change and their actual progress.

This theme also includes negative self-focused emotions, where clients blame themselves for the lack of improvement, questioning their deservingness of help or even their sanity.

In some cases, clients report feeling worse after therapy, highlighting the potential negative impact of nonresponse.

“Therapy has ended now and once again I’m nowhere, it did not help, and it only cost me money, a lot of time and energy, and why? For nothing” (De Smet et al., 2019).

6. On a Trajectory for Improvement:

This theme reflects the complexity and variability of nonresponse experiences. Some clients view therapy as a starting point for change, acknowledging small improvements or shifts in perspective.

They may anticipate further positive changes over time, even after therapy has ended. Some clients express a desire for more therapy, believing that additional sessions would have led to better outcomes.

This theme also highlights systemic issues in healthcare provision, such as time-limited interventions, which some clients feel hinder their progress.

The varying emphasis on positive experiences within this theme underscores the diverse nature of nonresponse and the potential for future improvement in some cases.

“So life’s definitely getting better as I say, my mood’s still low but I feel as long as I’m hoping then…that’s an improvement” (MacLeod, 2017).

Therapist Perspective

7. High expectations

This theme, from the therapist’s perspective, highlights the unrealistic expectations that both clients and therapists bring to therapy.

Therapists often perceive their clients as having overly high hopes for what therapy can achieve, particularly in terms of symptom relief or rapid change.

Simultaneously, therapists themselves may enter therapy with strong beliefs in their ability to help and feelings of pressure to succeed, driven by both internal and external factors.

Some therapists report an initial strong connection with clients, which can further raise expectations.

Despite early signs of difficulty, many therapists persist with their approach, potentially due to these high expectations for eventual success.

“I think she was hoping that I would somehow unlock a key and she’d never have to feel those feelings again” (Morton, 2019).

8. Experiencing a disconnect:

This theme captures therapists’ experiences of a lack of connection or shared understanding with their clients in nonresponse cases. Therapists often report struggling to establish a genuine connection, sensing a lack of trust from clients.

They perceive clients as emotionally distant or resistant to fully engaging in the therapeutic process.

Therapists also describe a lack of mutual agreement on therapy goals and direction, feeling that they cannot fully understand or address their clients’ difficulties.

This disconnect can lead to frustration and a sense of working at cross-purposes. The theme highlights the challenges in creating a collaborative therapeutic relationship and the impact this has on therapy outcomes.

“From the start I just didn’t feel comfortable with them, and I sensed that they didn’t trust me” (Laszloffy, 2000).

9. Feeling threatened:

This theme explores the emotional challenges therapists face when dealing with nonresponse cases. Therapists often describe the experience as taxing and threatening to their professional identity.

They may find themselves pushing boundaries or trying unconventional approaches out of desperation to help their clients.

As nonresponse becomes apparent, therapists can become self-critical, questioning their competence and feeling inadequate. Some therapists report comparing themselves unfavorably to colleagues, imagining others would have been more successful.

The theme also touches on the difficulty therapists face in discussing these challenging cases in supervision, possibly due to fear of criticism or professional shame.

“I felt inadequacy as a therapist and that I wasn’t getting it right, that I’m not very good at engaging people” (Hopper, 2015).

10. Holding onto hope:

Despite the challenges of nonresponse, this theme illustrates therapists’ persistent optimism and belief in the potential for positive change. Therapists often emphasize small improvements or shifts in client perspectives, even when core problems remain unresolved.

They may view therapy as laying groundwork for future growth, hoping that clients will continue to improve post-therapy using skills gained during treatment.

Some therapists report valuable learning experiences from nonresponse cases, leading to adjustments in their expectations or approach to therapy.

This theme underscores the resilience of therapists and their commitment to finding value and potential for growth even in challenging therapeutic experiences.

“She is much freer than before therapy, she has a better eye on herself, she knows a lot more about her problems” (Werbart, Von Below, et al., 2019).

Insight

This study provides a comprehensive understanding of the nonresponse experience in psychotherapy from both client and therapist perspectives. The findings reveal that nonresponse is not simply an absence of effect but a complex range of experiences that can be potentially harmful, particularly to clients.

The research extends previous studies by synthesizing a larger set of qualitative studies across various therapeutic modalities and settings. It highlights the importance of addressing expectations, therapeutic relationships, and emotional challenges in therapy to prevent nonresponse.

Future research could focus on developing and testing interventions to address the factors identified in this study, such as improving expectation management, enhancing therapeutic relationships, and providing support for both clients and therapists in managing the emotional demands of therapy.

A model of therapy nonresponse

The model of therapy nonresponse, as presented in the study, synthesizes the experiences of both clients and therapists.

This model highlights the complex, interactive nature of nonresponse, emphasizing the parallel processes experienced by clients and therapists throughout the therapeutic journey.

1. Initial expectations: Both clients and therapists often begin therapy with high expectations. Clients may see therapy as a last resort or cure, while therapists feel pressure to succeed.
2. Early uncertainty: As therapy progresses, both parties may experience uncertainty. Clients find therapy different from what they expected, and therapists recognize early challenges.
3. Disconnected relationship: A lack of trust and genuine connection develops between client and therapist. This leads to difficulties in open communication and collaboration.
4. Holding back: Both clients and therapists may withhold information or feelings. Clients fear judgment, while therapists may avoid discussing difficulties in supervision.
5. Emotional challenges: Therapy becomes emotionally taxing for both parties. Clients question if it’s worth the effort, while therapists struggle with feelings of inadequacy.
6. Misaligned focus: There’s often a lack of agreement on therapy goals and direction, leading to frustration on both sides.
7. Coping mechanisms: Clients may stay involved due to some positive aspects, while therapists hold onto hope for change.
8. Mixed outcomes: Some clients experience minor improvements but overall feel therapy wasn’t worth the investment. Therapists may see small gains as signs of potential future improvement.
9. Self-reflection: Both clients and therapists may engage in self-blame or criticism as a result of the nonresponse experience.
10. Learning and adaptation: Some therapists report gaining insights from nonresponse cases, potentially influencing their future practice.

Strengths

1. Comprehensive synthesis of qualitative studies on nonresponse
2. Inclusion of both client and therapist perspectives
3. Use of established guidelines (PRISMA and ENTREQ) for systematic review and reporting
4. Rigorous quality assessment of included studies
5. Development of a conceptual model of nonresponse

Limitations

1. Broad definition of nonresponse, potentially including varied experiences
2. Inclusion of only English-language studies
3. Potential tensions due to varying methodologies in primary studies
4. Limited exploration of cultural factors in nonresponse experiences

These limitations may affect the generalizability of findings and highlight the need for further research in diverse cultural contexts and with more specific definitions of nonresponse.

Clinical Implications

The findings have significant implications for clinical psychology practice:

1. Expectation management: Therapists should assess and address client expectations throughout therapy to ensure alignment with realistic outcomes.
2. Therapeutic relationship: Emphasis on building trust and collaboration is crucial for preventing nonresponse.
3. Emotional support: Both clients and therapists need strategies to manage the emotional demands of therapy.
4. Cultural sensitivity: Therapists should be aware of and responsive to cultural factors that may influence the therapeutic process.
5. Supervision and training: The study highlights the importance of addressing nonresponse cases in clinical supervision and therapist training programs.
6. Outcome measurement: Incorporating qualitative elements in outcome assessment may provide a more comprehensive understanding of therapeutic experiences.

References

Primary reference

Carrington, B., Yeates, R., & Masterson, C. (2024). Understanding non-response in psychotherapy: A meta-synthesis. Clinical Psychology Review, 102489.

Other references

De Smet, M. M., Meganck, R., Van Nieuwenhove, K., Truijens, F. L., & Desmet, M. (2019).
No change? A grounded theory analysis of depressed Patients’ perspectives on non-improvement in psychotherapy. Frontiers in Psychology, 10.

Hill, C. E., Chui, H., & Baumann, E. (2013). Revisiting and reenvisioning the outcome problem in psychotherapy: An argument to include individualized and qualitative measurement. Psychotherapy, 50(1), 68-76.

Hjeltnes, A., Moltu, C., Schanche, E., Jansen, Y., & Binder, P.-E. (2018). Both sides of the story: Exploring how improved and less-improved participants experience mindfulness-based stress reduction for social anxiety disorder. Psychotherapy Research, 28(1), 106–122

Hopper, S. A. R. (2015). The therapist experience of client nonresponse. Doctoral dissertation. University of Leeds. White Rose eTheses Online https://etheses.whiterose.ac.uk/10725/1/Final_Thesis_WREO.pdf.

Laszloffy, T. A. (2000). The implications of client satisfaction feedback for beginning family therapists: Back to the basics. Journal of Marital and Family Therapy, 26(3), 391–397

Linden, M. (2013). How to define, find and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions. Clinical Psychology & Psychotherapy, 20(4), 286-296.

McLeod, J. O. H. N., Stiles, W. B., & Levitt, H. (2021). Qualitative research: Contributions to psychotherapy practice, theory and policy. Bergin & Garfield’s handbook of psychotherapy and behavior change, 51-86.

Morton, C. E. (2019). Experiences of non-improvement in psychological therapy: A qualitative
study of client-therapist dyads. Doctoral dissertation. University of Leeds. White Rose eTheses Online. https://etheses.whiterose.ac.uk/25052/

Radcliffe, K., Masterson, C., & Martin, C. (2018). Clients’ experience of non-response to
psychological therapy: A qualitative analysis. Counselling and Psychotherapy Research, 18(2), 220–229.

Stiles, W. B., Barkham, M., & Wheeler, S. (2015). Duration of psychological therapy: Relation to recovery and improvement rates in UK routine practice. British Journal of Psychiatry, 207(2), 115-122.

Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8(1), 45.

Tong, A., Flemming, K., McInnes, E., Oliver, S., & Craig, J. (2012). Enhancing transparency in reporting the synthesis of qualitative research: Entreq. BMC Medical Research Methodology, 12(1)

Vybíral, Z., Ogles, B. M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023). Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis. Psychotherapy Research, 1-14.

Werbart, A., Von Below, C., Engqvist, K., & Lind, S. (2019). “It was like having half of the patient in therapy”: Therapists of nonimproved patients looking back on their work. Psychotherapy Research, 29(7), 894–907.

Keep Learning

1. How might therapists balance addressing client expectations while maintaining hope for positive change?
2. In what ways could therapists improve their ability to identify and address nonresponse earlier in the therapeutic process?
3. How might cultural factors influence the experience of nonresponse, and how can therapists better account for these differences?
4. What role could technology play in monitoring and preventing nonresponse in psychotherapy?
5. How can the findings of this study inform the development of more effective therapist training programs?