Dropout in Psychotherapy for Personality Disorders: A Systematic Review of Predictors

Summary & key facts

Researchers looked through about 2,000 papers and kept 22 that studied why people with personality disorders stop psychotherapy early. They found dropout rates ranged from about 10% to about 60% depending on the type of therapy and the people involved. Younger people, those with a current drug or alcohol problem, trouble handling strong emotions, a history of childhood emotional abuse, and low motivation were more likely to leave treatment early. Things that helped people stay included a strong relationship with the therapist, learning mindfulness skills, and having phone coaching. The review also says that keeping the same therapist, making early efforts to engage people, and improving how care is organized could help reduce dropout, but some findings come from only a few studies and need more research.

Key facts:

• The authors searched three major databases and ended up including 22 studies that looked at predictors of dropout in psychotherapy for personality disorders.
• Dropout rates in these studies ranged from about 10% to about 60%, depending on the treatment and the group of patients.
• Younger age was repeatedly linked to a higher chance of leaving psychotherapy early.
• Having a current substance use disorder (problems with drugs or alcohol) was linked to a higher risk of dropping out.
• Emotional problems like poor regulation of strong feelings and difficulty tolerating distress were associated with higher dropout.
• A history of childhood emotional abuse was found as a predictor of dropout in several studies.
• Therapist turnover — changing therapists during treatment — was associated with more people leaving therapy.
• Stronger therapeutic relationships, learning mindfulness-based skills, and extra supports such as phone coaching were linked to better retention in therapy.
• Low reflective functioning (having trouble understanding thoughts and feelings in oneself or others) was identified as a predictor in only one study, so the evidence for that is limited.
• The reviewers highlight that system-level issues, like how therapy is organized and how care is coordinated, can affect whether people stay in treatment.

Abstract

INTRODUCTION: Dropout in psychotherapy for personality disorders is a major challenge, affecting treatment efficacy and mental health care delivery. Influenced by patient characteristics, therapist factors and treatment dynamics, dropout remains prevalent. This systematic review identifies predictors of psychotherapy dropout in individuals with personality disorders to inform strategies that enhance treatment engagement. METHOD: A systematic search in PsycINFO, PubMed and Scopus identified 22 studies from 1976 articles. Inclusion criteria required DSM/ICD-based personality disorder assessments and dropout predictors in psychotherapy. Non-English or non-peer-reviewed studies were excluded. Screening followed PRISMA guidelines using Rayyan, and study quality was assessed with the Newcastle-Ottawa Scale (NOS). RESULTS: Dropout rates ranged from 10.4% to 58%, depending on treatment modality and patient characteristics. Younger age, comorbid substance use disorders, emotional dysregulation, distress tolerance difficulties, childhood emotional abuse, therapist turnover and low motivation were significant predictors of dropout. Conversely, strong therapeutic alliances, mindfulness-based skills and engagement in phone coaching were associated with improved retention. Other relevant factors included low reflective functioning, lower education levels and socio-economic adversity, such as receiving disability benefits. Only one study identified low reflective functioning as a dropout predictor. Systemic factors, including treatment organization and care coordination, also played a crucial role. CONCLUSIONS: Addressing dropout requires early engagement strategies, therapist continuity and treatment flexibility. Enhancing therapeutic alliance and reflective functioning may be particularly effective in reducing dropout. Systemic improvements, such as better care coordination and accessibility, are crucial for sustaining engagement and improving psychotherapy outcomes for individuals with personality disorders. REGISTRATION: PROSPERO number: CRD42024509283.

Topics

Digital Mental Health Interventions Personality Disorders and Psychopathology Psychotherapy Techniques and Applications

Categories

Clinical Psychology Psychology Social Sciences

Tags

Borderline personality disorder Clinical psychology Computer science Dropout (neural networks) Law Machine learning MEDLINE Mental health Personality Personality disorders Political science Psychology Psychotherapist PsycINFO Social psychology

Substances

Other

Conditions & symptoms

Substance abuse disorder Addiction or harmful habbits Feeling disconnected from others Lack of energy or motivation