Differences in Treatment Utilization Between Fee Paying and Non-Fee Paying Clients in a Counseling Training Clinic

Freud’s writings and cognitive dissonance theories assume that paying a fee for mental health services is necessary for client motivation to progress through treatment; however, empirical study has failed to support this assertion. Regular client utilization (as measured by total number of sessions, number of cancellations, and persistence through a planned termination session) is correlated with improved client treatment outcome and is essential for providing counselors-in-training with the opportunity to practice and demonstrate counseling skills. Prior literature illustrates that counseling training clinics may experience premature termination at a greater rate than other outpatient settings due to two primary issues: (a) counselor competence; and (b) uninformed fee policies. Very little counseling-specific research exists to guide counselor educators in setting fee policies that promote regular client treatment utilization. Further study was needed to provide counselor educators with information to make evidenced-based practice decisions regarding fee payment in counseling training clinics. This study examined whether fee paying and non-fee paying clients differed in measures of treatment utilization when controlling for counselor competence. Records of 269 fee paying and non-fee paying clients of the training clinic were examined for the number of sessions attended, the number of cancellations, and persistence through a termination session. The final scores of counselors-in-training who served the selected clients were entered into the model to control for counselor competence. A MANCOVA was run to determine whether differences exist between fee paying and non-fee paying clients in the number of cancellations and the overall number of sessions when controlling for counselor competence. Violations of the independence of errors assumption prevented a determination regarding the null hypothesis. A logistic regression was run to determine if the amount of payment predicts attendance at a termination session when controlling for counselor competence. Fee payment was found to have a significant relationship with attendance at a termination session however, the underpowered nature of the Logistic Regression and the effect size indicate that the findings should be interpreted with extreme caution. The implications of this study include the importance of consistent record keeping and accounting for the complex nature of the relationship of fee payment in treatment utilization in future study. Development and standardized use of instruments with known psychometric properties for the evaluation of counselors in training is also discussed as a needed development in the field of Counselor Education and Supervision for the facilitation of research into the relationship of fee payment and treatment utilization in training clinics