Failure to respond to the patient’s coaching: a case study of premature termination in psychodynamic psychotherapy

ABSTRACT

One factor that may help avoid treatment failure by premature termination is the therapist’s responsiveness to the patient’s coaching. Coaching refers to the patient’s efforts to inform and guide the therapist about the kinds of therapist behaviors, attitudes, and interventions that would advance the therapy. The case of Barb, from a naturalistic study of time-limited psychotherapy, was examined as a failed treatment due to premature termination. Using a case study approach, descriptive analysis of the therapy process, along with quantitative ratings of coaching and responsiveness, was employed to examine instances of patient coaching with corresponding therapist responsiveness. Analysis indicated that the patient attempted to coach the therapist throughout each session about her plan for treatment and the responses she sought from the therapist. The therapist’s responses were only partially aligned––and in some instances not at all aligned––with the patient’s coaching. The disparity between the patient’s coaching and the therapist’s responsiveness was widest in the two sessions immediately prior to termination. This case study indicates that patients may coach therapists in order to avoid treatment failure. Therapists who attend to patient coaching and modify their responsiveness may be better able to sustain treatment and help patients achieve therapeutic goals.

KEYWORDS:

• Treatment failure
• premature termination
• drop-out
• psychotherapy process
• therapeutic relationship
• control-mastery theory

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. Pre-consensus ratings of patient coaching, therapist receptivity, and post-coaching plan compatibility were examined for reliability across two randomly selected sessions, with average ICCs of .73, .80, and .81, respectively.

Additional information

Funding

Preparation of this manuscript was supported by a Scholar Award, Michael Smith Foundation for Health Research Scholar Award 18317, awarded to the first author by the Michael Smith Foundation for Health Research.

Notes on contributors

David Kealy

David Kealy, Ph.D. is an Assistant Professor in the Psychotherapy Program at the Department of Psychiatry, University of British Columbia. In addition to teaching and researching psychotherapy and mental health concerns, he maintains a private practice in Vancouver, Canada

James McCollum

James McCollum, Ph.D. is an educator and researcher with the San Francisco Psychotherapy Research Group. He is in private practice in San Francisco, California.

John T. Curtis

John T. Curtis, Ph.D. is a psychologist and Clinical Professor in Psychiatry at the University of California, San Francisco School of Medicine, and Treasurer of the San Francisco Psychotherapy Research Group. He is actively involved in psychotherapy research and teaching while maintaining a private practice in San Francisco.

George Silberschatz

George Silberschatz, Ph.D. is a psychologist and Clinical Professor in Psychiatry at the University of California, San Francisco School of Medicine, president of the San Francisco Psychotherapy Research Group, and a past president of the international Society for Psychotherapy Research. In addition to his research and teaching activities he maintains a private practice in San Francisco.

Aafjes Katie

Dr. Katie Aafjes-van Doorn is a licensed Clinical Psychologist and Assistant Professor of Clinical Psychology at Ferkauf Graduate School of Psychology, Yeshiva University. Her research program focuses on the measurement of psychotherapy research and training, including the use of videorecording and routine outcome monitoring. She is currently associate editor of the journal Clinical Psychology: Science & Practice.

Xiaochen Luo

Xiaochen Luo is an assistant professor in the Department of Counseling Psychology at Santa Clara University. She obtained a Ph.D. in clinical psychology from Michigan State University and is a licensed psychologist. Her research work focuses on understanding psychotherapy process and outcomes.