The research team, led by Julianah Fakolade alongside Peter Kinderman, Shaima Hassan, and Anam Elahi, searched six electronic databases from 1983 through February 2026, initially identifying 12,608 records. After deduplication, screening of 8,926 titles and abstracts, and assessment of 62 full-text articles, thirteen studies met the inclusion criteria, ten from database searching and three through backward citation searching. The team used the SPIDER framework to structure the search and the Critical Appraisal Skills Programme qualitative checklist to appraise methodological rigour, which informed rather than dictated the weighting of evidence during a four-stage narrative synthesis. The included studies spanned more than four decades, from a 1985 dissertation on dropout among Black psychotherapy patients to work published in the mid-2020s, underscoring how persistent the problem has been.

The participants, comprising 138 males and 102 females with gender unreported in two studies, came from diverse backgrounds including African American, African-Caribbean, Latinx, Hispanic, Somali, Asian, and other ethnically minoritised communities. Nine studies were set in the United States and four in the United Kingdom. Most relied on interviews and purposive sampling, employing analytic techniques ranging from thematic analysis and interpretative phenomenological analysis to grounded theory-informed approaches. From this body of evidence, six interconnected themes crystallised: perspectives and expectations of therapy, cultural and societal influences, practical and accessibility barriers, the therapeutic relationship, systemic and service-level barriers, and autonomy and control in treatment engagement.

The first theme revealed that discontinuation often begins with doubt. Participants questioned whether therapy would help at all, frequently perceiving faith, conversations with family and friends, or even substance use as more effective coping strategies. Others found that treatment failed to meet their needs, or that their difficulties eased earlier than the planned course anticipated, prompting them to leave. Some participants described feeling pressured, even hounded, by services to engage, an experience of pursuit that felt coercive rather than supportive. The review situates these findings within the psychotherapy literature on outcome expectations, which consistently shows that belief in therapeutic efficacy fuels hope, engagement, and improvement, a process researchers call remoralisation. When expectations were low or misaligned with the reality of sessions, motivation drained away and dropout followed.

Cultural and societal influences emerged as perhaps the most distinctive thread for ethnically minoritised clients. Eight studies identified stigma, emanating from communities, families, and friendships, as a powerful engine of shame that discouraged continued attendance. Participants described being labelled mad or crazy, and absorbing cultural narratives that framed mental health difficulties as personal weakness or something to be confined within the family. For those holding intersecting marginalised identities, such as being both ethnically minoritised and LGBTQ+, stigma compounded, intensifying isolation and accelerating the decision to quit. Language posed a further obstacle: many participants felt they lacked the English vocabulary to articulate their distress, while others found therapists unwilling to acknowledge faith or cultural context, perceiving a lack of holistic support. This resonates with established evidence that mental health stigma robustly suppresses help-seeking and that perceived cultural competence strengthens alliance formation and retention.

Practical barriers, though not unique to minoritised populations, weighed heavily and often interacted with socioeconomic disadvantage. Transportation difficulties produced discomfort that eventually curtailed attendance; unstable housing, relocation, financial constraints, work, and childcare responsibilities competed with therapy for scarce time and energy. These logistical pressures echo decades of research identifying practical constraints as key predictors of premature termination. Crucially, the review argues that such discontinuation frequently reflects constrained access rather than diminished therapeutic interest, a reframing with direct implications for how services interpret and respond to missed appointments and early exits.

The therapeutic relationship proved decisive in eight of the thirteen studies. When therapists were perceived as inexperienced, insensitive, or biased, and when clients felt their feelings were insufficiently considered, disengagement became markedly more likely. Participants reported disliking a therapist’s style, experiencing boundary crossings, or suffering relational ruptures that went unacknowledged. Where ruptures were recognised and repaired, engagement often continued; where they were left to fester, therapy ended. This pattern aligns with rupture-repair models of psychotherapy and with meta-analytic evidence identifying the therapeutic alliance as one of the strongest predictors of retention and outcome. Some participants simply could not form a working bond, breeding doubt about whether the intervention could work at all.

Systemic and service-level barriers added another layer. Participants described under-resourced services, rushed sessions, fragmented care pathways, confusing transfers between therapists, and departures of therapists that severed hard-won relationships. Many felt poorly informed about what therapy involved and what expertise their therapist held. Others resented being labelled dropouts when, in their view, they were simply selecting the services that best met their needs. Those prescribed medication described a focus on long-term pharmacological management that left them unheard and disempowered. The final theme, autonomy, ties these threads together: participants who were pressured into treatment, denied choice of therapist, or excluded from decisions sometimes used discontinuation itself as a means of reclaiming control, a dynamic consistent with self-determination theory, which positions autonomy as a core psychological need underpinning sustained engagement.

The authors translate these findings into a multi-level agenda. Clinically, culturally adapted interventions that align therapeutic approaches with clients’ cultural, religious, and social contexts may improve engagement, particularly given that much of the evidence base for psychological therapies was developed in predominantly White populations. At the service level, distinguishing systemic dropout patterns from therapist-level variation could inform training, supervision, and evaluation, while flexible delivery models, including remote and hybrid formats with variable scheduling, could dismantle logistical barriers without compromising effectiveness. Relationally, shared decision-making, explicit goal setting, early alignment of expectations, and collaborative review of progress offer concrete tools for building alliances that survive ruptures and sustain hope.

The review is candid about its limitations. Heterogeneous methodologies, inconsistent definitions of dropout, reliance on US and UK samples, restriction to English-language studies, and the inclusion of six dissertations all constrain generalisability, as does the grouping of diverse ethnic groups that may obscure within-group differences. Yet the convergence between dissertation and peer-reviewed findings strengthens confidence in the synthesis. The core message is unambiguous: when ethnically minoritised adults leave therapy early, they are rarely disengaged or unmotivated. They are responding, often rationally, to structural barriers, culturally incongruent care, broken therapeutic relationships, and curtailed autonomy. Closing the retention gap therefore demands more than better appointment reminders; it requires culturally responsive, flexible, and genuinely collaborative models of care that confront inequality while honouring the client’s voice.

Subject of Research: Psychotherapy discontinuation experiences among ethnically minoritised adults: a systematic review and qualitative synthesis

Article Title: Understanding Psychotherapy Discontinuation Among Ethnically Minoritised Adults: A Systematic Review and Qualitative Synthesis

Article References: Fakolade, J., Kinderman, P., Hassan, S., & Elahi, A. (2026). Understanding Psychotherapy Discontinuation Among Ethnically Minoritised Adults: A Systematic Review and Qualitative Synthesis. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01720-8

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01720-8

Keywords: psychotherapy discontinuation, therapy dropout, ethnic minority mental health, therapeutic relationship, cultural competence, stigma, mental health services, qualitative synthesis, therapeutic alliance, shared decision-making, health inequalities, autonomy