Preventing Attrition

During the assessment session, it is important to anticipate potential obstacles to successful treatment, especially factors that can lead to early attrition. The counselor should explore any instances in which the client previously dropped out of treatment and urge the client to discuss any thoughts of quitting treatment. Open discussion can resolve problems and prevent the client from dropping out. Progress in treatment is not steady—there are ups and downs. Most clients experience hopelessness, anger, frustration, and other negative feelings at times. Clients should be encouraged to discuss their feelings, even if they fear that the discussion might be embarrassing or difficult.

The counselor can point out that prematurely terminating treatment may be one of a series of seemingly irrelevant decisions that eventually lead to a relapse. For this reason, any hint that a client is considering dropping out should be taken seriously and discussed fully.

Many clients quit treatment after their first relapse. Clients should be warned that, even with efforts to maintain abstinence, some might slip and begin using. They should be encouraged to continue attending after a using episode so that they can receive help in regaining abstinence, coping with their reaction to the slip, and avoiding future lapses.

A delicate balance exists between setting the stage for clients to feel they may return after a lapse and giving them permission to use. Counselors should ensure that clients understand this distinction clearly.

Recognizing Change Readiness

Following is a list of questions to assist counselors in determining clients’ readiness to accept, continue in, and comply with a change program (Zweben and O’Connell 1988):

• Has the client missed previous appointments or canceled sessions without rescheduling?

• If the client was coerced into treatment, have his or her reactions—anger, relief, confusion, acceptance—to this forced attendance been discussed?

• Is the client hesitant to schedule future sessions?

• Is treatment different from what the client has experienced before? If so, have the differences and the client’s reactions been discussed?

• Does the client seem guarded during sessions? Is he or she hesitant or resistant when a suggestion is offered?

• Does the client perceive treatment to be a degrading experience rather than a new lease on life?

If the answers to these questions suggest a lack of readiness for change, the counselor may explore the client’s uncertainties and ambivalence about abstinence and change. This could be an opportunity to use motivational enhancement therapy (MET) strategies to enhance client determination.

The counselor should proceed carefully with clients who make a commitment to change too quickly or too emphatically. Even when a person seems to enter treatment committed to change, his or her motivation should be assessed before beginning treatment. Likewise, the counselor should not assume that, once the client has decided to change, he or she will no longer experience ambivalence.


If the client is reluctant to commit to making a change in behavior, the counselor should not push too hard. If the client commits to a change he or she is not ready to make, he or she may drop out of treatment rather than renege on an agreement. Premature commitment evokes resistance and undermines the MET process.

The counselor should not assume that ambivalence has been resolved and commitment is firm. It is safer to assume that the client is still ambivalent and to continue using motivation-building and commitment-strengthening strategies.

The counselor should reflect and explore the client’s expressions of uncertainty and ambivalence. It can be helpful to “normalize” ambivalence and concerns, for example:

Counselor (C): What you’re feeling is quite common, especially in these early stages. Of course you’re feeling confused. You’re still attached to smoking, and you’re thinking about changing a pattern that has developed over many years. Give yourself time.

The counselor also should reinforce any self-motivational statements and indications of willingness to change and provide reassurances that people can change, often with only a few consultations. The client may reconsider resistance to change after accepting that the counselor understands his or her reasons for being hesitant to change. Alternatively, pushing the client may result in a treatment dropout.

Treatment Dissatisfaction

A client may say that the treatment is not going to help or may want a different treatment. The counselor should first reinforce the client’s honesty. The counselor should confirm that the client has the right to quit treatment at any time (unless mandated into treatment), seek help elsewhere, or decide to work on the problem in another way. The counselor should explore the client’s feelings further. Concerns that arise in the first session are probably reservations about an approach the client has not tried. No one can guarantee that a particular treatment will work, but the counselor can encourage the client to try it for the planned period. The counselor can add that, should the problem continue or worsen, other possible approaches can be discussed.

Compliance Enhancement Procedures

A variety of strategies can facilitate compliance and overall client retention in treatment. They include devoting time to educating clients about treatment participation, treatment expectations, and potential barriers to involvement in treatment, such as transportation or childcare needs and work or school conflicts.

Didactic Material

The counselor gives brief presentations of the material in clear and concise language. It is important not to overload clients with too much material or use a lot of jargon. At the end of each session, the counselor asks whether the client understands major points of the presentation rather than assumes that the client comprehends.