Case Conceptualization: Interventions and Evaluation

BRIEF REPORT

‘No-Show’: Therapist Racial/Ethnic Disparities in Client
Unilateral Termination

Jesse Owen
University of Louisville

Zac Imel
University of Utah

Jill Adelson
University of Louisville

Emil Rodolfa
University of California, Davis

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in
unilateral termination (i.e., the client ending therapy without informing the therapist)—a form of dropout
that is associated with poor alliance and outcome. First, the authors tested whether some therapists were
more likely to have clients who reported unilaterally terminating as compared with other therapists. Next,
the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a)
that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other
components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are
specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral
termination with REM clients as compared with White clients. The sample included 155 REM clients and
177 White clients who were treated by 44 therapists at a university counseling center. The results showed
that therapists accounted for a significant proportion of the variation in clients’ unilateral termination, and
REM clients were more likely to report they unilaterally terminated from therapy as compared with
White clients. Furthermore, racial/ethnic disparities in clients’ report of unilateral termination varied
across therapists’ caseloads. These results suggest that therapists have a central role in their clients’
unilateral termination and have implications for understanding racial/ethnic mental health disparities.

Keywords: unilateral termination, race/ethnicity, mental health disparities, therapist effects

Every therapist has had the experience of a client dropping out
of psychotherapy. Unfortunately, this experience is extremely
common. Approximately one third of adults who begin psycho-
therapy do not return for a second session (Hamilton, Moore,
Crane, & Payne, 2011; Simon & Ludman, 2010), and 40%– 60%
of all clients drop out of psychotherapy (Clarkin & Levy, 2004;
Wierzbicki & Pekarik, 1993). The situation is even more concern-
ing for racial/ethnic minority (REM) clients 1 (e.g., Institute of
Medicine, 2002; Kales, Blow, Bingham, Copeland, & Mellow,
2000; U.S. Surgeon General, 2001; van Ryn, 2002). Specifically,
REM clients receive fewer services and drop out more often than
White clients (Whaley & Davis, 2007; Wierzbicki & Pekarik,

1993). Several reasons for these disparities have been proposed,
such as stigma associated with seeking mental health treatment and
the failure of treatment to meet the unique needs of REM clients
(Breaux & Ryujin, 1999; Leong, Wagner, & Tata, 1995). These
mental health disparities have fueled the call for therapists to
increase their cultural competence (American Psychological As-
sociation, 2003; Arrendondo & Toporek, 2004).

To understand racial/ethnic disparities, it is important to clarify
the definition of dropping out of psychotherapy (Hatchett & Parks,
2003). In clinical trials, the definition of dropout is typically
defined by the failure to complete a prescribed dose of treatment
(e.g., not attending at least five sessions or not completing the full
treatment protocol). Although defining dropout based on the num-
ber of sessions has intuitive appeal and avoids the need for sub-
jective assessments (i.e., therapist or client judgment), this defini-
tion may unintentionally classify clients who were treated

1 Ethnicity typically refers to a group of people who share a common
cultural heritage, values, attitudes, and behaviors, whereas race is typically
defined by physical attributes (e.g., skin color) that are shared by a group
of people (Quintana, 2007). We have opted to use a hybrid definition that
integrates both race and ethnicity, which appears to be most consistent with
clients’ experience in therapy, as therapists are reacting to both the clients’
race and ethnicity.

This article was published Online First February 20, 2012.
Jesse Owen, Department of Educational and Counseling Psychology,

College of Education and Human Development, University of Louisville;
Zac Imel, Department of Educational Psychology, Counseling and Coun-
seling Psychology Program, University of Utah; Jill Adelson, Department
of Educational and Counseling Psychology, College of Education and
Human Development, University of Louisville; Emil Rodolfa, Counseling
and Psychological Services, University of California, Davis.

Correspondence concerning this article should be addressed to Jesse
Owen, Department of Educational and Counseling Psychology, University
of Louisville, Louisville, KY 40092. E-mail: [email protected]

Journal of Counseling Psychology © 2012 American Psychological Association
2012, Vol. 59, No. 2, 314 –320 0022-0167/12/$12.00 DOI: 10.1037/a0027091

314

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successfully as failures (Lester, Resick, Young-Xu, & Artz, 2010).
This definition is especially problematic in community settings,
where the dose of treatment is not prescribed. For example, in a
study comparing the dose-response model of psychotherapy (i.e.,
more treatment is better) with the good-enough model (i.e., clients
participate in enough treatment to meet their needs and then stop),
Baldwin et al. (2009) found that clients who received the lowest
dose of treatment benefited the most and progressed most rapidly.
In another study, clients who failed to return for second psycho-
therapy session were just as likely to report symptom improve-
ment, a quality working alliance, and treatment satisfaction as
those who did return (Simon et al., 2010; see also Pekarik, 1992).

An alternative approach to defining dropout is to ask therapists
or clients directly. Therapist ratings, although useful in many
regards, can be biased, especially for clients who are not benefiting
from therapy (e.g., Garb, 1998; Hannan et al., 2005). In studies
relying on client perspective, therapy dropout typically has been
defined as unilateral termination, or ending therapy without dis-
cussing termination with the therapist (e.g., Callahan, Aubuchon-
Endsley, Borja, & Swift, 2009; Masson, Perlman, Ross, & Gates,
2007; Owen, in press; Vandereycken & Vansteenkiste, 2009).
Clients who unilaterally terminate report lower quality alliances
with their therapists and have worse therapy outcomes, perhaps
indicating that the end of treatment was unplanned or premature
(Daughters et al., 2005; Masson et al., 2007; Owen, in press;
Owen, Smith, & Rodolfa, 2009; Vandereycken & Vansteenkiste,
2009). In the present study, we used clients’ ratings of whether
they ended therapy unilaterally.

Over the years, researchers have examined several factors as-
sociated with unilateral termination, such as client diagnosis/
severity, client–therapist racial/ethnic match, and alliance (e.g.,
Maramba & Nagayama Hall, 2002; Sharf, Primavera, & Diener,
2010; Wierzbicki & Pekarik, 1993). However, there are no known
studies examining whether therapists’ differ, on average, in their
clients’ unilateral termination rates. Given that therapists have
been found to account for approximately 3%–10% of the variance
in their client outcomes (e.g., Baldwin & Imel, 2011; Wampold &
Brown, 2005), it stands to reason that therapists would also vary in
the extent to which their clients unilaterally terminate from ther-
apy. Therapists’ variability in their clients’ unilateral termination
provides an empirical estimation of therapists’ general competency
based on actual therapy outcomes (Wampold & Brown, 2005) and,
in this case, therapists’ general competency related to unilateral
termination.

Extending this approach to racial/ethnic disparities, it may be
that disparities in unilateral termination could be consistent across
therapists (general disparity) or vary across therapists (therapist-
specific disparity). For instance, although there may be differences
between REM and White clients in rates of unilateral termination
generally, these differences would be the same within each ther-
apists’ caseload. This would be evidence of a general racial/ethnic
disparity and would suggest that other aspects of treatment apart
from therapist-specific factors, potentially including stigma for
attending therapy, influence REM clients’ decision to stay in
therapy as compared with White clients. In contrast, if disparities
vary across therapists (e.g., some therapists have higher rates of
REM clients terminating unilaterally than other therapists), then
this would be evidence of a therapist-specific racial/ethnic dispar-
ity. This finding may suggest that some therapists do not have the

skills to engage REM (or White) clients in the therapy process.
Disentangling general versus therapist-specific effects for mental
health, racial/ethnic disparities is an important step for building
appropriate interventions to reduce these disparities.

Imel et al. (2011) examined general and therapist-specific dis-
parities in therapy outcomes with a diverse sample of 582 adoles-
cents who were treated for cannabis abuse/dependence by one of
13 therapists. They found that therapists differed both in their
clients’ outcomes generally and that racial/ethnic disparities in
outcomes varied across therapists. Specifically, some therapists
were equally effective with White and REM clients, whereasothers
were not. These results provide initial evidence that some compo-
nent of therapist behavior contributes to mental health racial/ethnic
disparities. These findings are in contrast to large correlations
between clients’ reports of their therapists’ general and multicul-
tural competencies (rs ranging from .50 to .80; Coleman, 1998;
Constantine, 2002, 2007). Although there may be therapist-
specific disparities in unilateral termination, we do not know of
any studies in which this issue has been examined.

Therapists’ role in unilateral termination disparities may be
understood within the context of forming a quality working alli-
ance. In particular, a recent meta-analysis demonstrated that clients
who have a strong working alliance with their therapists are less
likely to unilaterally terminate (d � 0.55; Sharf et al., 2010). The
alliance captures the degree to which clients and therapists are
“engaged in collaborative, purposeful work” (Hatcher & Barends,
2006, p. 293). Accordingly, clients who are actively involved in
the therapy process with a strong connection with their therapists
may consequently be less likely to unilaterally terminate. Given
the association between alliance and unilateral termination, it is
important to consider the role of working alliance when testing
therapists’ differences in racial/ethnic disparities in unilateral ter-
mination.

In the present study, we examined the therapist as a source of
racial/ethnic disparities in clients’ unilateral termination. First, we
posited that therapists would differ in the rate of client unilateral
termination (Hypothesis 1). That is, some therapists will be more
likely to have clients who report they ended therapy unilaterally as
compared with other therapists. Second, we predicted that REM
clients would be more likely to unilaterally terminate therapy as
compared with White clients (i.e., there is a health disparity;
Hypothesis 2). Third, we expected that the disparity in unilateral
termination between REM and White clients would vary across
therapists (therapist-specific disparities), after controlling for alli-
ance, psychological well-being, number of sessions, and the pro-
portion of White to REM clients treated by the therapist (Hypoth-
esis 3).

Method

Participants

Clients. The sample were 332 clients from a large university
counseling center. All clients in this study had ended therapy. Of
the 332 clients, 177 (53.3%) identified as White, and 155 (46.7%)
identified as REM. Of those who identified as REM, 37.7%
identified as Asian American, 22.4% identified as multiracial/
ethnic (of which 84.3% identified as White and Asian American),
21.9% identified as Hispanic/Latino(a), 9.3% identified as African

315TERMINATION STATUS AND RACIAL/ETHNIC DISPARITIES

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American, 8.0% identified as Middle Eastern, and 0.7% identified
as Native American. Given the low number of clients in some of
the REM statuses, the decision was made to dichotomize racial/
ethnic status into White and REM. The majority of clients were
women (n � 246, 73.4%). Clients reported their median number of
sessions attended was 5.0 (M � 6.73, SD � 5.48, range � 1–21).
Formal diagnoses were not provided at this counseling center,
however, based on clients’ reports there were a wide range of
presenting concerns, such as depression, dis eating, anxiety,
adjustment issues, anger, alcohol use, and relationship difficulties.

Therapists. Forty-four therapists treated the 332 clients in the
present study, an average of 7.54 (range � 3–21) clients per
therapist. For purpose of this study, only therapists who treated at
least one White and one REM client were included. Thirteen of the
therapists self-identified as REM, and 31 self-identified as White.
Ten therapists were men and 34 were women. The therapists were
predoctoral interns, postdoctoral fellows, staff psychologists, and
staff therapists. In prior assessments at this counseling center,
100% of the therapists reported that they practiced some form of
integrative therapy (e.g., psychodynamic/cognitive-behavioral, re-
lational/systems/cultural; Owen, Quirk, Hilsenroth, & Rodolfa,
2011). This counseling center generally provides brief therapy (six
to 10 sessions). Additionally, it is common practice at this coun-
seling center for the therapist who conducted the intake to continue
to see the client for therapy.

Measures

Client-defined termination status (Owen et al., 2009). Cli-
ents were asked how therapy ended through a multiple-choice
format, which resulted in five different categories: (a) client initi-
ated the end of therapy without talking with the therapist (unilat-
eral termination; n � 101, 30.4%), (b) client initiated the end of
therapy after talking with the therapist (n � 64, 19.1%), (c)
therapist initiated the end of therapy (n � 14, 4.2%), (d) the end of
therapy was mutually decided (n � 103, 30.7%), and (e) ran out of
allotted sessions (n � 50, 15.2%). These categories are similar
with other studies in which client-rated termination is assessed
(e.g., Callahan et al., 2009). Furthermore, this measure of termi-
nation status has successfully differentiated clients’ alliance scores
and treatment outcomes, with clients who ended therapy via uni-
lateral termination reporting worse alliances and outcomes as
compared with clients who ended in other ways (Owen, in press;
Owen et al., 2009). Consistent with these findings and the previous
literature regarding unilateral termination, clients were dichoto-
mized into unilateral termination (30.4%, n � 101, coded 1) and
other methods of termination (69.6%, n � 231, coded 0).

Schwartz Outcome Scale-10 (SOS-10; Blais et al., 1999).
The SOS-10 is a measure of psychological well-being (over the
past week), which has 10 items that are rated on a 7-point scale
ranging from 1 (Never) to 7 (All the time or nearly all the time).
Example items include “I am generally satisfied with my psycho-
logical health” and “I feel hopeful about my future.” The SOS-10
has exhibited test–retest correlations and Cronbach’s alphas above
.85 (e.g., Blais et al., 1999; Hilsenroth, Ackerman, & Blagys,
2001; Young, Waehler, Laux, McDaniel, & Hilsenroth, 2003).
Convergent and discriminant validity has been supported in pre-
vious studies with correlations in the predicted direction with a
variety of clinical and psychological well-being scales (e.g., Out-

come Questionnaire-45, Beck’s Hopelessness Scale, the Positive
and Negative Affect Schedule, and Personality Assessment Inven-
tory), and reliably discriminated between clinical and nonclinical
samples (see Owen & Imel, 2010, for a review). The Cronbach’s
alpha for this sample was .95.

Working Alliance Inventory-Short Form Revised (WAI-SR;
Hatcher & Gillaspy, 2006). The WAI-SR is a client-rated
measure of working alliance that consists of 12 items that assess
goals and tasks for therapy as well as the relational bond between
the client–therapist. An example item is: “We agreed on what is
important for me to work on.” (Note, the items were adjusted to
reflect the past tense, because therapy had been completed for the
present sample). Items were rated on a scale ranging from 1
(Never) to 7 (Always). The WAI-SR and the other variations of the
instrument are commonly used in psychotherapy research, and the
reliability and validity has been demonstrated in numerous studies
comparing it with other working alliance and therapy outcome
scales (Hatcher & Gillaspy, 2006; Horvath, Del Re, Flückiger, &
Symonds, 2011). For purposes of this study, the total scale score
was used, yielding a Cronbach’s alpha of .97.

Procedure

Participants were recruited from a large West Coast university
counseling center. Clients were asked on their intake card(s)
whether they would be willing to receive a survey about their
therapy experience. All clients who agreed were sent an e-mail at
the end of the academic quarter regardless of whether they were
still in therapy or have ended therapy and were able to access the
anonymous survey instruments online. For purposes of this study,
clients were excluded if they were currently in therapy, endorsed
multiple individual therapists (or no therapist), or they did not
report their race/ethnicity. Clients initially completed an informed
consent and then the outcome and process measures. For clients
who were no longer in therapy, they were given measures wherein
the items were adjusted to reflect the past tense. The participants
from this study were drawn from previous published studies
(Owen, Leach, Wampold, & Rodolfa, 2011; Owen, Quirk, et al.,
2011; Owen, Tao, & Rodolfa, 2010; Owen, Wong, & Rodolfa,
2010), although the purpose of this study differs from those stud-
ies. In the previous studies, the response rates ranged from 30% to
40% (37.4% for this study).

Data Analysis

Because clients were nested within therapist (i.e., therapists
treated multiple clients), multilevel modeling (MLM) was used to
account for the nonindependence of observations within therapists
(Raudenbush & Bryk, 2002). MLM adjusts for the fact that clients
of the same therapist have more similar outcomes than therapists
of different therapists; that is, some therapists generally have better
outcome than other therapists (Wampold & Serlin, 2000). There
was a particular interested in the variability among therapists and
the standard errors for that variability. However, maximum like-
lihood estimates and their standard errors are biased with small to
moderate number of therapists (Maas & Hox, 2005), making
interval estimates of the parameters problematic (Draper, 2008).
Additionally, maximum likelihood works best with balanced data
(Raudenbush & Bryk, 2002). Due to the moderately small number

316 OWEN, IMEL, ADELSON, AND RODOLFA

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of therapists and the unbalanced number of clients treated by each
therapist, a Bayesian MLM was used. Because Bayesian models
are not based on normality assumptions or asymptotic results (see
Hamaker & Klugkist, 2011), this is recommended when the out-
come variable is dichotomous (Draper, 2008), as in this study.

Two MLM models were conducted. In both models, the out-
come variable was a dichotomous indicator of whether the client
unilaterally terminated therapy or not. In the first model, client
unilateral termination status was predicted by clients’ racial/ethnic
status (1 � White, 0 � REM) at Level 1, therapists’ racial/ethnic
status (1 � White, 0 � REM) at Level 2, and the cross-level
interaction between client and therapist racial/ethnic status. This
model is used to determine whether therapists vary in their clients’
termination status. Also, if REM clients were more likely to report
that they ended therapy unilaterally as compared with White
clients, then this would provide support for general mental health
disparities. In the second model, clients’ racial/ethnic status was
allowed to vary across therapists and included other predictors
(alliance, psychological well-being, number of sessions, and pro-
portion of REM to White clients for therapists’ caseload). If the
random slope for clients’ racial/ethnic status is significant, it would
provide support for the therapist-specific racial/ethnic disparity
hypothesis.

Results

Preliminary Analyses

Descriptive statistics for the variables are provided in Table 1.
Prior to conducting the main analyses, we first tested whether
clients who unilaterally terminated had lower alliance and psycho-
logical well-being scores as compared with clients who ended
therapy in other ways. To do so, we conducted two MLMs,
wherein WAI and SOS-10 scores were the dependent variables,
respectively, and termination status was the only predictor variable
at Level 1 (unilateral termination � 1, other termination � 0). The
results showed that clients who unilaterally terminated had lower
alliance scores (B � �0.55; 95% credible interval [CI] � �0.83,
�0.24; p � .001; d � �0.46) and lower psychological well-being

(B � �0.40; 95% credible interval � �0.67, �0.13; p � .01; d �
�0.36), compared with clients who ended therapy in alternative
ways. Effect sizes were based on Cohen’sd, wherein a small-sized
effect � 0.20, medium-sized effect � 0.50, and a large-sized
effect � 0.80 (note that effect sizes were based on the coefficient
divided by the standard deviation for the WAI and SOS-10, re-
spectively). These results correspond to previous studies that have
demonstrated that clients who reported ending therapy unilaterally
also reported lower alliances and were more psychologically dis-
tressed as compared with clients who terminated therapy in other
ways (e.g., Owen et al., 2009; Sharf et al., 2010).

Primary Analyses

We tested our first hypothesis—that therapists would differ in their
clients’ termination status— by examining the proportion of variance
in unilateral termination status accounted for by therapists. The results
demonstrated that the mode of the posterior distribution for the
variance in the intercept in Model 1 was statistically significant
(�therapists

2 was 0.26, 95% CI [0.05, 0.78]; see Table 2, random effects
in Model 1). This finding suggests that clients’ termination status
varied across therapists insofar that therapists accounted for 7.3% of
variance in their clients’ termination status (supporting Hypothesis 1).
The intraclass correlation for unilateral termination status was calcu-
lated by: �therapists

2 /(�therapists
2 � �3) (Goldstein, Browne, & Rasbash,

2002). Additionally, as seen in the first model, REM clients were
significantly more likely to unilaterally terminate as compared with
White clients (�10 � �0.37, 95% CI [�0.70, �0.08]), which sup-
ports our second hypothesis. Therapists’ racial/ethnic status and the
interaction between clients’ and therapists’ racial/ethnic status were
not statistically significant.

Next, we tested whether the association between clients’ race/
ethnicity and unilateral termination status varied across therapists
(Hypothesis 3). We replicated Model 1, but we also controlled for
number of sessions (Level 1, grand-mean centered), psychological
well-being (Level 1, grand-mean centered), working alliance
(Level 1, grand-mean centered), and proportion of REM to White
clients for each therapist (Level 2, grand-mean centered). The
association between clients’ race/ethnicity and unilateral termina-
tion was allowed to vary across therapists, which will provide a
test of our hypothesis. As seen in Model 2, the mode of the
posterior distribution for the variance in clients’ racial/ethnic status
was statistically significant, (�RE

2 � 0.07, 95% CI [0.02, 0.66]),
supporting our third hypothesis. In other words, some therapists
were more likely to have their REM clients report unilateral
termination as compared with their White clients (and vice versa).
Additionally, number of sessions was significantly related to uni-
lateral termination, with clients who attended fewer sessions were
more likely to unilaterally terminate. Also, clients who reported
stronger alliances were less likely to unilaterally terminate.

For illustration, we randomly selected 10 therapists who treated
at least four REM and four White clients each to illustrate the
differences across therapists in their REM and White clients’
unilateral termination (see Figure 1). Therapist 2 had a similar
proportion of White and REM clients unilaterally terminated (ap-
proximately 25%), whereas Therapist 7 had approximately 75%
and 80% of his or her REM and White clients unilaterally termi-
nated, respectively. For Therapist 5, 75% of his or her REM clients
unilaterally terminated and approximately 25% of his of her White

Table 1
Descriptive Information for Clients’ Unilateral Termination,
Psychological Well-Being, Working Alliance, and Number
of Sessions

Variable

Unilateral term Other term

N (%) N (%)

Client: REM 57 (36.8%) 98 (63.2%)
Client: White 44 (24.9%) 133 (75.1%)

M (SD) M (SD)

SOS-10 4.94 (1.27) 5.36 (1.13)
WAI 5.05 (1.38) 5.63 (1.22)
Number of sessions 5.26 (4.71) 7.40 (5.69)

Note. Ns � 101 (Unilateral term.), and 231 (Other term.). term. �
termination; REM � racial/ethnic minority; SOS-10 � Schwartz Outcome
Scale-10 (possible range � 1–7); WAI � Working Alliance Inventory
(possible range � 1–7).

317TERMINATION STATUS AND RACIAL/ETHNIC DISPARITIES

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clients unilaterally terminated. In contrast, Therapist 10 had 20%
of his or her REM clients unilaterally terminated and none of his
or her White clients unilaterally terminated.

Discussion

Consistent with the therapist effect literature examining therapy
outcomes (e.g., Baldwin & Imel, 2011; Wampold & Brown, 2005),
we found that therapists accounted for approximately 7% of the
variance in clients’ unilateral termination status. To our knowl-
edge, the present study is the first in which therapist variability in
clients’ unilaterally termination status or client dropout of any kind
has been examined. This finding provides support for the notion
that therapists difference in their general competence or ability,
insofar that some therapists were more likely to have clients
unilaterally terminate as compared with other therapists. Addition-
ally, we found that REM clients were more likely to unilaterally
terminate as compared with White clients, suggesting a mental
health disparity, which is consistent with prior research (Wierz-
bicki & Pekarik, 1993).

In addition, racial/ethnic disparities varied across therapists.
That is, some therapists were more likely to have their REM clients
report that they unilaterally terminated as compared with their
White clients (and vice versa). Yet for some therapists, the rate of
unilateral termination was consistent across their REM and White
clients. These differences were evident even after accounting for
other factors, such as clients’ psychological well-being, number …