The relationship between social deprivation and unilateral termination (attrition) from psychotherapy at various stages of the health care pathway

The relationship between social deprivation and attrition from psychotherapy was examined at various stages of the health care pathway. Data providing information on service users' discharge status gave a measure of attrition at different stages along this pathway. On the basis of their postcode, service users were allocated a Townsend deprivation score, which is a measure of social deprivation. Of the sample, 60% terminated therapy prior to agreed discharge at various pathway stages. Service users who failed to attend their first appointment had significantly higher social deprivation scores than those who completed therapy. Early terminators, who stopped attending before their fifth session, had a significantly higher level of social deprivation than the late terminators, and those who completed therapy. The late terminators did not significantly differ from completers on social deprivation. These results support earlier findings showing that socio-economic status influences attrition from therapy. However, socioeconomic status only affects two stages of the pathway - attendance at the first appointment, and the early stage of attending therapy. It does not affect earlier or later stages of the pathway. Applying the health action process approach (HAPA) model to the results, the action/maintenance stage can be represented by attendance for therapy. Socio-economic status influences this stage of the model, because social support and resources are important determinants for compliance. Earlier stages, characterized by HAPA as a decisional/motivation stage thought to be influenced by beliefs, was not affected by social deprivation. It is concluded that attrition from therapy should be studied separately for each pathway stage. Earlier conflicting findings on causes of attrition may have resulted from studying different combinations of pathway stages. Furthermore, high rates of attrition related to socio-economic status raises serious questions about the external validity of therapy trials where these factors are not routinely reported, and the ecological validity of current service delivery models.