Ronald J. Nielsen, Psy.D., is a 2020 graduate of the PsyD Program in Clinical Psychology at Antioch University, Santa Barbara.

Dissertation Committee

Brett Kia-Keating, EdD, Chairperson

Elizabeth Bates Freed, PsyD, Committee Member

Steve Kadin, PhD, Committee Member


Attrition, Dropout, Retention, Termination, Return, Intake, Continuity, Discontinuity, Quantitative, Community Counseling Center, Binary Logistic Regression

Document Type


Publication Date



There is a large body of research examining the effects of client, therapist, and treatment modality variables on client outcome in mental health treatment. However, there are only a handful of retrospective studies of the intake process and its effect on client dropout or retention. The genesis of this research study was to examine and evaluate the intake methods of a community based, not for profit counseling center. The clinic found that clients would fail to return for therapy following an intake interview with a different counselor. Feedback from stakeholders indicated that the formal intake process was inefficient and direct assignment to a treating therapist would support a stronger alliance with the client, thereby increasing retention. To provide evidence-based support for a change to direct assignment, a study was developed that randomly assigned clients to either of the clinic’s intake methods. The direct (DIR) method established continuity by assigning clients from the waitlist to a treating therapist. In the indirect (IND) model, clients were given a formal intake appointment and, if completed, were assigned from the waitlist to a treating therapist. Binary logistic regression was used to test the hypothesis that client return rates differ between the two intake models. The results are mixed. After controlling for client gender and age, clients in the DIR group were more than 8 times more likely to return for therapy following the intake with their treating therapist than those indirectly assigned to a treating therapist. This result supports the belief that continuity can play a role in client retention. However, the DIR group clients were also two-thirds less likely, although non-significantly, to complete an intake interview with their treating therapist. Moreover, from the initial request for service, the DIR and IND groups were equally likely to achieve the goal of returning following the intake interview. This result may be explained by the break in continuity created by the waitlist. The DIR and IND groups experienced a break in continuity while waiting for assignment to a treating therapist averaging 17.7 and 18.7 days respectively. The waitlist effect in the intake process should be addressed to realize the benefits of continuity of care. Additional suggestions were developed that addressed clinical practice based on the study results. Limitations of the study were highlighted and suggestions for future research discussed. This dissertation is available in open access at AURA, and OhioLINK ETD Center,


ORCID: 0000-0002-0903-6005