Factors Influencing Psychotherapy Continuation and Premature Termination Based on Clients’ Lived Experiences: A Phenomenological Study

Introduction

Psychotherapy is one of the principal evidence-based approaches used to reduce psychological distress, improve adaptive functioning, and promote enduring changes in cognition, emotion, behavior, and interpersonal functioning. Although substantial attention has traditionally been directed toward the efficacy and effectiveness of specific therapeutic models, the actual benefits of psychotherapy depend not only on whether an intervention is theoretically sound or empirically supported, but also on whether clients remain engaged in treatment long enough to experience meaningful therapeutic change. From this perspective, psychotherapy continuation is not merely an administrative issue related to attendance; rather, it is a central component of treatment effectiveness because therapeutic outcomes emerge through a cumulative process of participation, reflection, emotional engagement, behavioral experimentation, and consolidation of change. Outcome research has consequently emphasized the importance of evaluating clinically meaningful change rather than relying exclusively on statistical improvement, highlighting the need to determine whether therapeutic gains translate into substantial changes in clients’ functioning and well-being (Lambert & Ogles, 2009). The extent to which such gains can develop is closely linked to the quality and continuity of participation in the therapeutic process.

Contemporary psychotherapy research increasingly recognizes clients as active agents in therapeutic change rather than passive recipients of professional interventions. The client contributes expectations, motivation, preferences, coping resources, relational patterns, readiness for change, interpretations of therapeutic events, and behavioral engagement, all of which can influence the course and outcome of psychotherapy. Bohart and Wade emphasized the active role of clients in assimilating, interpreting, and utilizing therapeutic experiences, suggesting that therapeutic change cannot be adequately understood without examining how clients participate in and make meaning of the treatment process (Bohart & Wade, 2013). Accordingly, continuation in psychotherapy may be shaped by the extent to which clients perceive themselves as capable of participating in change, recognize progress, maintain hope, and experience the therapeutic process as personally meaningful. Client personality characteristics may also interact with therapist characteristics and the therapeutic context, influencing the degree of compatibility, engagement, and persistence within treatment (Shabib Asl & Alinaghilou, 2020). Thus, understanding psychotherapy retention requires attention to the client’s subjective experience as well as to formal treatment characteristics.

Among the most consistently emphasized relational factors in psychotherapy is the therapeutic alliance. The alliance generally refers to the collaborative and affective bond between therapist and client, including agreement on treatment goals, agreement on therapeutic tasks, and the quality of the emotional bond. More recent conceptualizations have demonstrated that the alliance contains both relatively stable, trait-like components and dynamic, state-like fluctuations that may vary across sessions and phases of therapy (Zilcha-Mano & Fisher, 2022). This distinction is particularly important for understanding treatment continuation because a client may enter therapy with a relatively positive disposition toward forming therapeutic relationships yet still experience session-specific ruptures, misunderstandings, or disappointments that gradually undermine engagement. Conversely, a client who initially experiences uncertainty or hesitation may develop a stronger alliance as trust, collaboration, and mutual understanding increase over time. Phenomenological evidence has similarly shown that clients often describe feeling understood, emotionally safe, respected, and accepted as central dimensions of a meaningful therapeutic relationship (Ghamari Zamhareer et al., 2023). These experiences may strengthen the client’s willingness to disclose difficult material, tolerate emotional discomfort, and continue participating in therapy even when progress is gradual.

The importance of the therapeutic alliance becomes particularly apparent when successful and prematurely terminated psychotherapies are compared. Research comparing clients who successfully completed psychotherapy with those who discontinued treatment prematurely has suggested that differences in perceived alliance quality may play a meaningful role in distinguishing these trajectories (Safarzadeh & Dehghani, 2023). A strong alliance may facilitate sustained participation by increasing trust in the therapeutic process, enhancing collaborative goal setting, and helping clients interpret difficulties as manageable components of treatment rather than evidence of therapeutic failure. By contrast, unresolved alliance ruptures may contribute to disappointment, emotional withdrawal, and eventual termination. These relational difficulties may become especially consequential when therapists fail to identify client dissatisfaction, address misunderstandings, or respond flexibly to changing needs. Research comparing more and less successful psychotherapy cases has likewise demonstrated that treatment outcomes are influenced not merely by technical intervention but by the unfolding interaction between therapist responsiveness, client engagement, relational processes, and the capacity to adapt the therapeutic work to individual needs (Werbart et al., 2019). Therefore, psychotherapy continuation should be conceptualized as a relationally embedded process rather than simply a function of client motivation or symptom severity.

Premature termination, often described as psychotherapy dropout, represents one of the major challenges confronting mental health services. Although definitions vary across studies, premature termination generally refers to ending psychotherapy before the therapeutic goals have been sufficiently addressed or before termination has been mutually planned by therapist and client. A recent systematic review of psychotherapy termination has highlighted the conceptual complexity of this phenomenon and the variability in how termination is defined, measured, and interpreted across treatment contexts (Rabinowitz et al., 2025). This lack of conceptual uniformity is important because not every early ending reflects treatment failure, and not every prolonged treatment indicates therapeutic success. Some clients may discontinue because their goals have been met, whereas others may leave because of dissatisfaction, financial burden, relational rupture, reduced hope, logistical constraints, perceived lack of progress, or competing life demands. Consequently, premature termination is best understood as a heterogeneous phenomenon requiring attention to the meanings clients attribute to their decisions rather than being treated solely as an attendance statistic.

Qualitative investigations provide particularly valuable insight into the subjective mechanisms underlying psychotherapy dropout. Clients may discontinue therapy after a gradual accumulation of negative experiences rather than as a result of a single event. Recent qualitative evidence has shown that premature termination can emerge from complex interactions among client expectations, perceptions of the therapist, dissatisfaction with the treatment process, insufficient progress, practical barriers, and uncertainty about what should happen next in therapy (Lipner et al., 2026). Similarly, qualitative investigation of clients’ reasons for dropping out has emphasized that discontinuation may reflect perceived mismatch, unmet expectations, relational dissatisfaction, or contextual difficulties that are not always visible to therapists during treatment (Homan et al., 2025). These findings suggest that premature termination frequently develops as a process rather than an abrupt decision. Clients may first experience disappointment or uncertainty, subsequently reduce emotional investment, attend less consistently, and eventually withdraw from treatment. Investigating this process from the client’s perspective is therefore necessary for identifying early warning signs and developing preventive strategies.

The increasing diversity of psychotherapy delivery formats has further complicated the question of treatment continuation. Psychotherapy is now delivered through in-person, online, and blended formats, and clients may experience these modalities differently in terms of accessibility, emotional connection, privacy, flexibility, and perceived therapeutic presence. A phenomenological comparison of clients’ lived experiences across in-person, online, and blended psychotherapy has demonstrated that treatment modality can shape the subjective quality of therapeutic engagement and the meaning clients attribute to the therapeutic encounter (Choupani et al., 2025). The rapid expansion of remote psychotherapy during the COVID-19 pandemic also revealed how clinical practice can change in response to environmental demands and how therapists may need to adapt communication, boundaries, therapeutic structure, and relational practices when treatment is delivered through technological platforms (Boldrini et al., 2020). More broadly, rising demand for mental health services has accelerated the use of technology, peer-based models, and flexible forms of service delivery intended to improve access and respond to limitations in traditional care systems (Stringer, 2024). These developments indicate that continuation in psychotherapy cannot be separated from questions of accessibility, service organization, and the practical fit between treatment delivery and clients’ everyday lives.

Contextual and cultural factors also play an important role in determining whether clients engage with and remain in psychotherapy. Clients enter treatment with culturally shaped understandings of psychological distress, help seeking, family involvement, emotional disclosure, authority, stigma, and acceptable forms of intervention. Psychotherapeutic approaches that do not sufficiently acknowledge cultural expectations may be experienced as distant, incompatible, or difficult to integrate into the client’s life. A recent systematic review of culturally adapted psychotherapy emphasized the need to consider cultural values, language, explanatory models, relational norms, and contextual realities when modifying psychological interventions (Ziaei & Zarrani, 2026). Cultural adaptation is therefore relevant not only to treatment effectiveness but potentially also to treatment retention, because clients may be more likely to remain engaged when they perceive the therapeutic approach as congruent with their social and cultural context. Ethical responsiveness is similarly essential, particularly when therapeutic practice involves boundaries, confidentiality, informed consent, value differences, power asymmetries, and sensitive interpersonal dilemmas. Strategies for addressing ethical challenges in counseling and psychotherapy highlight the importance of professional judgment, transparent communication, client autonomy, and sensitivity to contextual circumstances (Hosseini Beyouki et al., 2024). Failures in these areas may erode trust and contribute to disengagement.

Therapeutic continuation may also be influenced by the broader conceptual framework through which change is understood and organized. Traditional psychotherapy research frequently focused on diagnostic categories and treatment packages, whereas newer process-based approaches increasingly emphasize the identification and modification of functional processes that cut across diagnostic boundaries. Process-based therapy proposes a flexible, individualized model in which interventions are selected according to mechanisms relevant to a particular client rather than applied rigidly according to diagnostic labels (Ghaderi & Mehrabi, 2023). Such an approach may have implications for treatment continuation because therapy that is experienced as responsive, individualized, and clearly linked to client-specific processes may enhance engagement and perceived relevance. At the same time, clients’ capacity to reflect on their own internal experiences, interpersonal patterns, and therapeutic processes may influence their participation in treatment. Reflective processes in psychotherapy have been conceptualized and measured in multiple ways, indicating that self-observation, meaning-making, metacognitive awareness, and reflective engagement are important but complex dimensions of therapeutic work (Sidis et al., 2023). These capacities may contribute to persistence in therapy by helping clients recognize gradual changes that are not immediately visible at the symptom level.

The practical consequences of treatment continuation become especially evident when psychotherapy is used with clients experiencing significant relational, emotional, or self-evaluative difficulties. Psychological interventions can facilitate improvements in constructs such as self-esteem and relational functioning when clients engage sufficiently with the therapeutic process. For example, strength-based counseling has demonstrated beneficial effects on self-esteem among women experiencing marital conflict, illustrating how targeted psychological intervention can support adaptive change when treatment participation is sustained (Darbani & Parsakia, 2022). However, such therapeutic benefits depend on more than the formal presence of an intervention; they require continued participation, collaborative engagement, and sufficient opportunity for therapeutic mechanisms to operate. In this sense, treatment dropout may limit access to potential benefits even when the selected intervention is theoretically appropriate.

Therapist characteristics and professional development may likewise affect clients’ willingness to continue treatment. Psychotherapists are required to combine theoretical knowledge, interpersonal sensitivity, emotional regulation, self-reflection, ethical judgment, and the ability to tolerate uncertainty and complexity. The professional development of psychologists involves both competencies and challenges that can influence how they understand clients, manage difficult therapeutic situations, and maintain effective professional relationships (Rokach & Boulazreg, 2024). Therapist limitations in responsiveness, communication, flexibility, or self-awareness may affect the treatment relationship, particularly when clients perceive their experiences as minimized, misunderstood, or interpreted through an overly rigid framework. These observations reinforce the need to examine psychotherapy continuation as an interaction between client-related and therapist-related factors rather than attributing dropout exclusively to client resistance, motivation, or pathology.

Taken together, the literature suggests that psychotherapy continuation and premature termination are multidetermined phenomena produced by interactions among client agency, therapeutic alliance, perceived progress, treatment expectations, therapist responsiveness, contextual barriers, cultural considerations, ethical quality, service accessibility, and the broader organization of therapeutic care. Nevertheless, much of the existing literature has examined these elements separately, focusing on individual predictors, treatment outcomes, alliance measures, or dropout rates. Quantitative approaches are valuable for identifying associations and estimating the magnitude of relationships, but they may provide limited access to the subjective meanings through which clients interpret their experiences of staying in or leaving psychotherapy. A phenomenological approach can address this limitation by examining how clients themselves understand the processes that strengthened their engagement, weakened their commitment, created relational ruptures, or shaped decisions to terminate treatment. Such an approach is particularly appropriate when continuation and termination are understood not as isolated events but as evolving experiences embedded in clients’ personal, relational, cultural, organizational, and social contexts.

A further gap concerns the integration of risk factors for premature termination with factors that actively support treatment retention. Research often treats continuation and dropout as opposite endpoints, yet the mechanisms sustaining therapy may not simply be the reverse of those producing dropout. For example, the absence of severe relational rupture does not necessarily create a strong alliance, and the absence of financial barriers does not necessarily generate motivation or hope. Similarly, remaining in treatment may depend on active processes such as recognizing progress, developing self-awareness, participating in goal setting, experiencing empathic responsiveness, receiving feedback, and perceiving therapy as meaningful. Examining both continuation and premature termination within the same experiential framework can therefore provide a more comprehensive account of psychotherapy retention. Such an integrated perspective may also generate clinically useful strategies for detecting emerging disengagement, repairing therapeutic ruptures, adjusting goals, increasing flexibility, and responding to structural barriers before clients withdraw completely.

Accordingly, the aim of the present study was to formulate the factors influencing psychotherapy continuation and premature termination based on clients’ lived experiences.

Methods and Materials

Study Design and Participants

The present study was applied in terms of purpose and qualitative in terms of approach and was conducted using a descriptive–interpretive phenomenological method. A phenomenological approach is employed when the aim of research is to understand and explain the meaning of individuals’ lived experiences of a phenomenon and when the researcher seeks to uncover the fundamental structure of that experience through participants’ narratives. In this study, the phenomenon under investigation was clients’ experiences of the factors influencing the continuation and premature termination of psychotherapy. Accordingly, the phenomenological approach made it possible to analyze clients’ perceptions, emotions, and meaning-making processes regarding the continuation or discontinuation of treatment within the context of their real-life experiences. This method was considered appropriate for the principal objective of the study and for developing a framework of factors influencing psychotherapy continuation and premature termination. The study population consisted of all clients who had a history of receiving individual psychotherapy services in psychological clinics and counseling centers. The inclusion criteria were participation in at least five individual psychotherapy sessions, completion of at least part of the therapeutic process, the ability to articulate personal experiences, and informed willingness to participate in the interview. Individuals whose experience was limited to group psychotherapy or short-term counseling were excluded from the study. Criterion-based purposive sampling was employed, and participant recruitment continued until data saturation was achieved; that is, sampling was discontinued when themes became repetitive and no new concepts emerged. Ultimately, 18 clients participated in the study, including seven individuals with successful psychotherapy experiences, six with unsuccessful treatment experiences or premature treatment termination, and five with mixed or alternating experiences of success and failure in psychotherapy. This experiential diversity facilitated comparison and the extraction of themes related to treatment continuation and discontinuation.

Instruments

Data were collected through in-depth semi-structured interviews. The interview guide was developed based on the study objectives, theoretical foundations, and a review of the literature and included open-ended questions concerning treatment experiences, factors influencing continued session attendance, reasons for reduced motivation or treatment discontinuation, the therapist’s role, the quality of the therapeutic relationship, family and social circumstances, and clients’ recommendations for improving the treatment process. Interviews were conducted individually in a quiet environment while adhering to research ethics principles, and the duration of each interview ranged from 45 to 90 minutes depending on the participant’s level of engagement. All interviews were audio-recorded with participants’ consent, transcribed verbatim, and prepared for analysis. Data collection continued until thematic saturation was reached. In the final stages, participants’ narratives were also reviewed and supplemented to ensure that the various dimensions of clients’ experiences had been comprehensively covered.

Data analysis

Data were analyzed using inductive thematic analysis within a phenomenological framework. First, the interview transcripts were read several times to enable the researcher to develop an in-depth understanding of participants’ experiences. Meaningful statements were then extracted and initial codes were generated. Subsequently, similar codes were categorized into basic themes and organizing themes, and finally, the fundamental structure of clients’ experiences regarding the factors influencing psychotherapy continuation and premature termination was extracted. Data organization and management were conducted using MAXQDA 2020, and the thematic network and conceptual model of the study were developed based on the processes of coding and thematic clustering. In this article, the analyses specifically focused on themes related to factors facilitating treatment continuation, inhibiting factors, and reasons for premature psychotherapy termination.

To ensure the credibility and trustworthiness of the findings, the four criteria proposed by Guba and Lincoln (1985)—credibility, transferability, confirmability, and dependability—were applied. To enhance credibility, transcripts of the interviews and the preliminary interpretation of the themes were provided to several participants, and their corrective feedback was incorporated into the final analysis through member checking. In addition, the research process was audited by the supervisors and advisor, and a portion of the interviews was independently coded by a second researcher. Inter-coder agreement was calculated using Holsti’s coefficient, which exceeded .85, indicating satisfactory coding reliability. Moreover, rich description of the research process, documentation of all analytical stages, and retention of coding records enabled the process of theme development to be traced and verified. All ethical considerations, including informed consent, confidentiality of information, participant anonymity, and the right to withdraw from the study at any stage, were also observed.

Findings and Results

A total of 18 clients with experience of individual psychotherapy participated in this study. Participants were selected through purposive sampling until data saturation was achieved. The sample included individuals with successful treatment experiences, premature treatment termination, and mixed experiences of both success and failure, thereby allowing comparison across different therapeutic experiences.

The participants demonstrated adequate diversity in terms of gender, age, and treatment experience. The inclusion of clients who had prematurely terminated treatment alongside those with successful psychotherapy experiences made it possible to identify both shared and distinguishing factors associated with treatment continuation and discontinuation. Analysis of data obtained from 18 semi-structured interviews resulted in the extraction of five overarching themes, 15 organizing themes, and 36 basic themes. The overarching themes organized clients’ experiences concerning the factors influencing psychotherapy continuation or premature termination across individual, relational, contextual, and strategic levels.

Analysis of clients’ lived experiences indicated that psychotherapy continuation and premature termination have a multilevel and process-oriented structure and can be organized into five overarching themes.

1. Dynamics of Client Agency in Maintaining Psychotherapy Continuation

The first overarching theme extracted from clients’ experiences was “dynamics of client agency in maintaining psychotherapy continuation.” Clients described treatment continuation as resulting less from therapist-imposed requirements or recommendations and more from accepting their own active role in the therapeutic process. They stated that when they recognized that responsibility for change also rested with them, they became more motivated to attend sessions consistently, complete therapeutic assignments, and pursue treatment goals. In participants’ narratives, hope for change and the observation of gradual improvements in everyday life played an important role in sustaining motivation to continue treatment. Furthermore, increased self-awareness regarding emotions and acceptance of personal vulnerabilities facilitated active confrontation with problems and reduced the likelihood of treatment discontinuation.

Participant 3 described the role of personal responsibility in treatment continuation as follows: “Before therapy, I thought the therapist was supposed to fix everything; but gradually I realized that if I did not cooperate, nothing would change. From that point on, I decided to take the sessions seriously.” Participant 9 described the experience of hope for change as follows: “At first, I may not have noticed any major change, but when I realized that my reactions were different from before, I felt that the therapy was working, and that made me continue.” Participant 15 also described the self-awareness developed through therapy: “During the sessions, I learned to recognize my feelings. Before, I would just feel upset, but now I could understand why I was upset, and that made me not give up on therapy.” Clients’ narratives indicate that client agency is a dynamic process formed through responsibility, hope, and self-awareness. When clients perceive themselves as agents of change, their relationship with therapy shifts from dependence toward active collaboration, and this change in perspective facilitates treatment continuation.

2. Quality of the Therapeutic Alliance as a Mechanism of Treatment Retention

The second overarching theme was the quality of the therapeutic alliance, which was identified in the narratives of almost all clients as one of the most important factors contributing to psychotherapy continuation. Clients reported that psychological safety, trust, empathy, and respect from the therapist enabled them to express personal experiences without fear. Agreement regarding therapeutic goals and participation in decision-making also increased their sense of ownership over treatment. From the participants’ perspective, genuine therapist presence referred to active listening, authentic attention to the client’s emotions, and responsiveness tailored to the client’s needs. Participant 5 described the sense of safety within the therapeutic relationship as follows: “It was the first time I could talk without being afraid. I felt that I was not being judged, and that made me look forward to the session every week.” Participant 12 described the therapist’s empathy as follows: “The therapist was not just listening; I felt that they truly understood what I had experienced. That sense of trust made me continue therapy.” Participant 7 also described the importance of treatment-goal clarity: “When the therapist explained what we were going to work on at each stage, I was no longer confused, and the therapy started to make sense to me.” Clients’ experiences indicated that the therapeutic alliance is not a static construct but is continuously formed through the interaction of trust, empathy, clarity, and collaboration. The greater the client’s sense of participation in the therapeutic relationship, the greater the likelihood of treatment continuation.

3. Erosion of the Therapeutic Relationship and Development of Premature Treatment Termination

The third overarching theme concerned clients’ experiences of premature treatment termination. Analysis of the narratives indicated that discontinuing treatment was typically not an abrupt decision but rather developed through a gradual process characterized by reduced trust, perceptions of treatment ineffectiveness, and rupture of the therapeutic relationship. Clients reported that when they felt that the therapist did not understand them or provided stereotypical responses, their motivation to attend sessions declined. Ambiguity regarding treatment goals and the absence of feedback concerning therapeutic progress further intensified feelings of hopelessness. Participant 10 described rupture of the therapeutic alliance as follows: “During the last few sessions, I felt that what I was saying was not important to the therapist. From that point on, I distanced myself and eventually stopped going.” Participant 14 described the perceived ineffectiveness of therapy as follows: “The same things were repeated in every session. I felt that the therapy was not progressing and that I was only spending time and money.” Participant 6 described therapist–client incongruence as follows: “I felt that the therapist wanted to impose their own lifestyle on me rather than understand me. That was why I stopped therapy.” These narratives indicate that premature treatment termination results from an accumulated experience of relational ruptures and declining trust. When clients perceive that the therapeutic relationship is no longer responsive to their needs, motivation to continue treatment decreases, and discontinuation may be selected as a course of action.

4. Contextual Constraints Affecting Treatment Continuation or Discontinuation

The fourth overarching theme indicated that clients’ experiences were not limited to the therapeutic relationship and that economic, family, and social circumstances also influenced decisions regarding treatment continuation or discontinuation. Participants reported that session costs, transportation difficulties, time constraints, and lack of family support sometimes prevented them from continuing sessions even when they were satisfied with treatment. Some clients also referred to the social stigma associated with consulting a psychologist and opposition from significant others. Participant 16 described the financial burden of treatment as follows: “I liked the therapy, but the cost of the sessions was too high for me, so I had to stop.” Participant 2 described the role of family as follows: “My family believed that seeing a psychologist was useless, and that made it difficult for me to continue.” Participant 11 described time-related constraints: “Although I was interested in continuing therapy, my work schedule did not allow me to attend the sessions regularly.” This finding indicates that psychotherapy continuation does not occur in a vacuum but is influenced by economic circumstances, social support, and life pressures. Therefore, sustained treatment requires simultaneous attention to both individual and contextual factors.

5. Strategies for Reconstructing and Strengthening Psychotherapy Continuation

The final overarching theme concerned strategies proposed by clients to prevent premature treatment termination. Participants believed that therapists should continuously evaluate the quality of the therapeutic relationship, discuss treatment goals, and provide clients with opportunities to express dissatisfaction. Flexibility in scheduling sessions and attention to clients’ financial circumstances were also among the major recommendations made by participants. Participant 8 described the importance of reviewing treatment goals as follows: “When the therapist asked me every few sessions what changes I had noticed, I became more motivated to continue therapy.” Participant 13 described repair of the therapeutic relationship as follows: “If the therapist had asked me sooner about my dissatisfaction with the sessions, I probably would not have stopped therapy.”

Participant 17 described therapeutic flexibility as follows: “The fact that the therapist adjusted the session times to fit my work schedule made it possible for me to continue therapy.” Clients’ narratives indicate that preventing premature treatment termination requires an active, relationship-oriented approach. Readjusting therapeutic goals, repairing relational ruptures, and increasing flexibility in the delivery of therapeutic services were identified by clients as the three principal strategies for maintaining treatment retention.

Discussion

The present study aimed to formulate the factors influencing psychotherapy continuation and premature termination based on clients’ lived experiences. The findings showed that psychotherapy retention and premature termination are not isolated or single-cause events; rather, they emerge from the interaction of client-related, relational, contextual, and service-related factors. Five overarching themes were identified: dynamics of client agency in maintaining psychotherapy continuation, quality of the therapeutic alliance as a mechanism of treatment retention, erosion of the therapeutic relationship and development of premature treatment termination, contextual constraints affecting treatment continuation or discontinuation, and strategies for reconstructing and strengthening psychotherapy continuation. Taken together, these themes indicate that continuation in psychotherapy is a dynamic and negotiated process in which the client’s motivation, hope, responsibility, and self-awareness interact continuously with the therapist’s responsiveness, the quality of the therapeutic alliance, practical life circumstances, and the adaptability of treatment delivery.

The first major finding concerned the role of client agency in sustaining psychotherapy. Participants described continuation as being closely related to taking personal responsibility for change, maintaining hope, recognizing gradual improvement, engaging in therapeutic tasks, and developing greater self-awareness. This finding is consistent with the view that clients are active contributors to therapeutic change rather than passive recipients of professional intervention. Bohart and Wade emphasized that clients actively interpret, select, integrate, and use therapeutic experiences in ways that shape treatment outcomes (Bohart & Wade, 2013). From this perspective, treatment continuation may be strengthened when clients perceive themselves as participants in change rather than as individuals waiting for the therapist to produce change on their behalf. The current findings extend this view by showing that agency also appears to function as a retention mechanism: as clients increasingly perceive change as partly dependent on their own participation, their commitment to sessions and therapeutic tasks may increase.

The participants’ emphasis on hope and perceived progress also deserves attention. Several clients stated that even small observable changes in emotional reactions, self-understanding, or everyday functioning encouraged them to continue therapy. This is compatible with the broader psychotherapy outcome literature, which has emphasized the importance of clinically meaningful change and the client’s perception that treatment is producing tangible benefits (Lambert & Ogles, 2009). When clients do not perceive progress, treatment may be experienced as repetitive or ineffective, whereas noticing incremental change may reinforce expectancy and engagement. Process-based approaches likewise emphasize the importance of identifying meaningful changes in psychological processes rather than relying solely on diagnostic symptom reduction (Ghaderi & Mehrabi, 2023). In the present study, perceived progress appeared to function both cognitively and motivationally: it helped clients interpret treatment as worthwhile and provided a reason to tolerate the effort, emotional discomfort, and time investment required for continued participation.

The role of self-awareness identified in the present study also aligns with research on reflective processes in psychotherapy. Participants described becoming more able to recognize emotions, understand why they reacted in particular ways, and reflect on previous experiences. Such reflective capacities may support treatment continuation because they enable clients to perceive psychotherapy as personally meaningful and to recognize changes that might otherwise remain unnoticed. Reflective processing has been identified as an important psychotherapy-related construct involving awareness, meaning-making, and the capacity to examine internal and interpersonal experiences (Sidis et al., 2023). Therefore, the present findings suggest that the development of reflective capacity may not only facilitate therapeutic change but may also contribute to retention by increasing the client’s sense that psychotherapy offers a useful framework for understanding the self.

The second major finding was the central role of the therapeutic alliance. Participants repeatedly described psychological safety, trust, empathy, nonjudgmental acceptance, agreement on goals, and therapist responsiveness as key reasons for remaining in therapy. This finding is strongly supported by previous research indicating that the therapeutic alliance is a core process variable in psychotherapy. Zilcha-Mano and Fisher distinguished between trait-like and state-like aspects of the alliance, showing that some elements of alliance reflect relatively stable interpersonal tendencies while others fluctuate across sessions and can change during treatment (Zilcha-Mano & Fisher, 2022). This distinction is particularly relevant to the current findings because participants described the alliance not as a static characteristic but as something continuously constructed through therapist behavior, responsiveness, collaboration, and communication.

The present findings are also consistent with phenomenological evidence indicating that clients experience the therapeutic relationship through feelings of being understood, respected, emotionally safe, and genuinely heard (Ghamari Zamhareer et al., 2023). In the current study, such experiences appeared to create the relational conditions necessary for continued disclosure and engagement. Participants who experienced the therapist as empathic and genuine were more willing to remain in treatment even when therapy involved difficult emotional material. This finding suggests that treatment retention is partly relational because sustained engagement depends on whether clients believe that vulnerability can be expressed safely within the therapeutic relationship.

The importance of agreement on goals and collaboration also supports existing evidence comparing successful and premature treatment termination. Safarzadeh and Dehghani reported differences in therapeutic alliance between clients who successfully completed psychotherapy and those who terminated treatment prematurely (Safarzadeh & Dehghani, 2023). The present study provides a qualitative explanation for how such differences may be experienced by clients. Participants described goal clarity and collaborative decision-making as mechanisms that made treatment coherent and increased their sense of involvement. When the treatment pathway was explained and therapeutic goals were mutually understood, clients were less likely to experience confusion or disengagement. These findings are also compatible with comparative case analyses showing that successful psychotherapy is often associated with therapist responsiveness, appropriate adaptation to the client, and effective management of the therapeutic process (Werbart et al., 2019).

The third overarching theme concerned the gradual erosion of the therapeutic relationship and the emergence of premature termination. Participants rarely described dropout as a completely sudden decision. Instead, premature termination usually developed through accumulated dissatisfaction, reduced trust, perceived ineffectiveness, emotional disconnection, or perceived therapist–client mismatch. This finding is consistent with qualitative research showing that psychotherapy dropout is frequently preceded by dissatisfaction that accumulates over time. Homan et al. found that clients’ reasons for dropping out may include unmet expectations, therapist-related dissatisfaction, perceived lack of fit, practical barriers, and a sense that treatment is no longer useful (Homan et al., 2025). Similarly, Lipner et al. described premature termination as a complex process involving reasons for leaving, the manner in which therapy ended, and clients’ subsequent interpretations of the experience (Lipner et al., 2026). The present findings reinforce the idea that dropout should be understood as a process rather than as a discrete event.

Perceived treatment ineffectiveness was particularly important in participants’ descriptions of disengagement. When sessions were experienced as repetitive, unclear, or lacking feedback, clients began to question whether continued participation was justified. This observation is compatible with evidence indicating that psychotherapy outcomes depend partly on whether treatment processes are experienced as coherent, responsive, and connected to meaningful change (Lambert & Ogles, 2009). It is also consistent with process-based perspectives that emphasize ongoing assessment and adjustment of therapeutic interventions according to the client’s evolving needs (Ghaderi & Mehrabi, 2023). Thus, perceived ineffectiveness may not necessarily indicate that no therapeutic process is occurring, but rather that clients are unable to recognize progress or understand the rationale for treatment. This distinction highlights the importance of transparent communication and feedback.

Therapist–client incongruence was another important contributor to premature termination. Participants referred to value differences, mechanical communication, lack of understanding, and perceived imposition of the therapist’s worldview. This finding is compatible with the broader view that therapist and client characteristics interact in shaping psychotherapy experiences (Shabib Asl & Alinaghilou, 2020). When therapists fail to adapt communication or intervention to the client’s worldview, treatment may be experienced as invalidating or culturally incompatible. The findings also align with recent work emphasizing the importance of culturally adapted psychotherapy, including sensitivity to values, language, social expectations, and culturally shaped meanings of distress and help seeking (Ziaei & Zarrani, 2026). Therefore, therapist–client mismatch may involve more than interpersonal preference; it may reflect deeper differences in values, cultural assumptions, and expectations about the therapeutic process.

The fourth major theme concerned contextual constraints, including treatment costs, insurance limitations, work schedules, geographic accessibility, family attitudes, social stigma, and competing life responsibilities. These findings demonstrate that premature termination cannot be attributed solely to psychological motivation or the quality of the therapeutic relationship. Even clients who valued therapy sometimes reported being unable to continue because practical barriers outweighed their capacity to remain engaged. This result is consistent with broader concerns regarding access to mental health care and the growing pressure on service systems to provide more flexible and accessible treatment options (Stringer, 2024). The increasing use of technology and alternative delivery formats can partly be understood as a response to these barriers.

The present findings also resonate with research on online, blended, and in-person psychotherapy. Choupani et al. showed that clients’ lived experiences differ across treatment modalities and that factors such as convenience, accessibility, connection, and perceived therapeutic presence shape how psychotherapy is experienced (Choupani et al., 2025). Similarly, changes in psychotherapy delivery during the COVID-19 pandemic demonstrated that therapists and clients can adapt treatment structures when external conditions make conventional face-to-face psychotherapy difficult (Boldrini et al., 2020). In the current study, participants’ requests for flexible scheduling and greater attention to practical circumstances suggest that service flexibility may be an important protective factor against dropout.

Family support and social stigma were also important contextual influences. Some participants reported that family encouragement facilitated continued engagement, whereas opposition to psychotherapy or negative cultural beliefs about psychological treatment made continuation more difficult. These findings are consistent with the idea that psychotherapy takes place within a broader sociocultural environment rather than in isolation. Cultural beliefs may affect attitudes toward psychological help, emotional disclosure, family involvement, and the perceived legitimacy of psychotherapy (Ziaei & Zarrani, 2026). In contexts where seeking psychological help remains stigmatized, clients may face additional pressure that increases the likelihood of discontinuation even when they personally view treatment as beneficial.

The fifth theme involved strategies for strengthening psychotherapy continuation. Participants recommended periodic review of goals, active discussion of dissatisfaction, repair of relational ruptures, ongoing feedback, flexibility in service delivery, and attention to financial and practical constraints. These strategies are particularly important because they shift the focus from explaining dropout after it occurs to preventing disengagement before termination. The emphasis on continuous evaluation of the therapeutic relationship is consistent with the understanding that alliance quality can fluctuate and may therefore require ongoing monitoring (Zilcha-Mano & Fisher, 2022). It is also compatible with the ethical expectation that therapists remain responsive to clients’ experiences, protect autonomy, communicate transparently, and address problems that may compromise the therapeutic relationship (Hosseini Beyouki et al., 2024).

The participants’ emphasis on adapting the therapeutic process also aligns with findings from comparative psychotherapy research. Successful cases often involve therapist flexibility, responsiveness, and adjustment to the client’s needs rather than rigid adherence to a predetermined process (Werbart et al., 2019). Likewise, process-based therapy emphasizes tailoring interventions to the functional processes most relevant to a particular client (Ghaderi & Mehrabi, 2023). Flexibility may therefore contribute to retention because it communicates that therapy is responsive rather than standardized. This may be particularly important for clients facing fluctuating life circumstances, financial limitations, cultural concerns, or variable readiness for change.

Another implication of the findings is that continuation in psychotherapy may be strengthened when therapists explicitly recognize the client’s resources and capacities. Strength-based approaches emphasize existing competencies and adaptive resources rather than focusing exclusively on deficits, and previous intervention research has shown that such approaches can facilitate positive psychological outcomes (Darbani & Parsakia, 2022). In the context of the present findings, helping clients recognize progress, personal agency, and available resources may increase hope and strengthen commitment to treatment. Such an approach may be especially useful when clients become discouraged or perceive change as too slow.

The present findings also have implications for therapist development. Effective psychotherapy requires not only technical knowledge but also self-reflection, interpersonal sensitivity, flexibility, and the capacity to manage uncertainty and relational difficulty. The professional development of psychologists involves both competencies and significant challenges that may affect therapeutic practice (Rokach & Boulazreg, 2024). Therapists who are unable to recognize alliance ruptures, respond to dissatisfaction, or adapt treatment appropriately may unintentionally contribute to disengagement. Accordingly, professional training should include explicit attention to rupture identification, feedback processes, cultural responsiveness, and management of premature termination.

Overall, the present study supports a multidimensional understanding of psychotherapy continuation and premature termination. The findings suggest that treatment retention emerges when client agency, perceived progress, therapeutic alliance, contextual support, and service flexibility work in a mutually reinforcing manner. Conversely, premature termination is more likely when relational rupture, perceived ineffectiveness, reduced hope, mismatch, and practical barriers accumulate over time. This interpretation is broadly consistent with systematic and qualitative literature showing that psychotherapy termination is conceptually complex and shaped by multiple interacting factors (Lipner et al., 2026; Rabinowitz et al., 2025). The findings therefore argue against explaining dropout through a single-factor model and instead support a process-oriented framework in which engagement and disengagement develop dynamically across the course of therapy.

Conclusion

The findings further suggest that psychotherapy continuation and premature termination should not be conceptualized as exact opposites. The absence of a clear barrier does not automatically create engagement, just as the presence of a difficulty does not inevitably lead to dropout. Continued participation appears to require active reinforcing processes, including hope, perceived progress, collaboration, relational safety, and practical feasibility. At the same time, premature termination appears to emerge when several adverse processes accumulate and remain unaddressed. This distinction is important because interventions aimed at reducing dropout should not focus exclusively on removing barriers; they should also actively strengthen the mechanisms that sustain participation.

Limitations & Suggestions

This study has several limitations that should be considered when interpreting the findings. First, the study used a qualitative phenomenological design and a relatively small purposively selected sample; therefore, the findings are intended to provide an in-depth understanding of clients’ lived experiences rather than statistical generalizability to all psychotherapy populations. Second, the data were based on retrospective self-report, and participants’ accounts may have been influenced by memory processes, current emotional states, or subsequent reinterpretation of their therapeutic experiences. Third, the sample included participants with different forms and durations of individual psychotherapy, and the specific therapeutic orientation, therapist characteristics, presenting problems, and severity of psychological difficulties were not analyzed separately. Fourth, the study focused exclusively on clients’ perspectives and did not simultaneously examine therapists’ interpretations of the same termination or continuation processes. Finally, because psychotherapy experiences are shaped by cultural, economic, and service-system characteristics, the transferability of the findings to different cultural or clinical contexts should be approached cautiously.

Future studies could examine the proposed framework using mixed-methods and longitudinal designs to determine how the identified factors develop across different stages of psychotherapy. Repeated assessments during treatment may clarify when reductions in hope, alliance deterioration, perceived lack of progress, or practical barriers begin to predict disengagement. Future research could also compare different therapeutic orientations, diagnostic groups, age groups, and modes of treatment delivery to determine whether the relative importance of the identified factors differs across contexts. Dyadic studies involving both clients and therapists would be particularly valuable for comparing their perceptions of alliance rupture, treatment progress, dissatisfaction, and readiness for termination. Quantitative studies could further develop and validate measures based on the themes identified in the present research and test predictive models of treatment continuation and dropout. Cross-cultural studies are also recommended to examine how family attitudes, social stigma, economic constraints, and cultural expectations influence psychotherapy retention in different settings.

Clinical services should treat psychotherapy retention as an ongoing therapeutic concern rather than addressing dropout only after clients stop attending. Therapists should routinely review treatment goals, assess clients’ perceptions of progress, invite feedback about the therapeutic relationship, and explicitly provide opportunities for clients to discuss dissatisfaction or uncertainty. Particular attention should be paid to early signs of disengagement, including reduced participation, repeated cancellations, emotional withdrawal, diminished hope, or expressions of perceived ineffectiveness. Therapists should also be trained to identify and repair alliance ruptures and to adapt their communication and interventions to clients’ cultural values, expectations, and individual needs. Clinics and counseling centers can reduce preventable dropout by offering greater scheduling flexibility, alternative modes of service delivery, transparent information about treatment processes, and feasible options for clients facing financial or accessibility barriers. Where appropriate and with the client’s consent, supportive family or social resources may also be incorporated into the treatment plan. Most importantly, clients should be positioned as active collaborators in psychotherapy so that responsibility, autonomy, feedback, and shared decision-making become integral components of treatment continuation.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

All authors equally contributed in this article.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.