Professional Psychology: Research and Practice1993, Vol.24, No. 2.190-195

Copyright 1993 by the American Psychological Association. Inc0735-7028/93/S3.00

A Meta-Analysis of Psychotherapy Dropout

Michael Wierzbicki and Gene Pekarik

A meta-analysis was conducted of 125 studies on psychotherapy dropout. Mean dropout rate was46.86%. Dropout rate was unrelated to most of the variables that were examined but differedsignificantly as a function of definition of dropout. Lower dropout rates occurred when dropoutwas defined by termination because of failure to attend a scheduled session than by either therapistjudgment or number of sessions attended. Significant effect sizes were observed for 3 client demo-graphic variables: racial status, education, and income. Dropout rates increased for African-Amer-ican (and other minority), less-educated, and lower income groups. Recommendations for futurepsychotherapy dropout research are presented.

Premature termination of psychotherapy, or psychotherapydropout, is generally recognized as a significant obstacle to thedelivery of effective mental health services. For example, re-views of the psychotherapy dropout literature (Baekeland &Lundwall, 1975; Eiduson, 1968; Garfield, 1986) and aggregatedU.S. community mental health center data (National Instituteof Mental Health [NIMH], 1981) indicate that between 30%and 60% of psychotherapy outpatients terminate prematurely.

Psychotherapy dropouts pose clinical, fiscal, and moraleproblems for mental health professionals (Pekarik, 1985a), per-haps the most significant of which are reduced treatment effi-cacy and decreased cost-effectiveness (Garfield, 1986; Pekarik,1985a). Relatively few studies have investigated treatment out-come for dropouts, typically reporting a pattern of poor out-come (Pekarik, 1986) and low client satisfaction (Lebow, 1982),especially when dropout occurs within the first few sessions.Impaired outcome for early dropouts erodes the overall impactand hence the cost-effectiveness of treatment. Thus, concernsabout both the efficacy and cost-effectiveness of treatment havecontributed to recent research attention to dropouts (Garfield,1986).

Two major reviews of psychotherapy dropout research havebeen published in the past 2 decades. Baekeland and Lundwall(1975) comprehensively reviewed 362 articles from the litera-

MICHAEL WIERZBICKI received his PhD in 1980 from Indiana Univer-sity. He is currently Assistant Professor of Psychology at MarquetteUniversity, and his research interests are in cognitive-behavioral mod-els of depression and in the empirical evaluation of clinical techniques.GENE PEKARIK received his PhD in 1977 from the State University ofNew York-Stony Brook. He is currently Professor of Psychology atWashburn University, and his research interests are in mental healthservice delivery issues.A PORTION OF THIS ARTICLE was presented at the 1992 meeting of theMidwestern Psychological Association, Chicago, IL.THE AUTHORS THANK Stephen Frommelt, Kathie Nichols, Kere Pond,Anne Salyer, and Denise Hooper for their assistance in locating andcoding studies included in this review.CORRESPONDENCE CONCERNING THIS ARTICLE, including requests forreprints or a list of the studies included in the meta-analysis, should besent to Gene Pekarik, Department of Psychology, Washburn Univer-sity, Topeka, Kansas 66621.

tures on medicine, alcohol/drug use, and mental health treat-ment and reported findings from 74 dropout studies of outpa-tient psychotherapy (62 on adult individual therapy, 5 on childtherapy, and 7 on group therapy). They concluded that drop-ping out of individual adult outpatient therapy was moststrongly associated with several client variables (i.e., low socio-economic status [SES], female gender, and low anxiety and/ordepression) and with low levels of therapist experience.

Garfield (1986) selectively reviewed 86 dropout articles, 23 ofwhich had been published after Baekeland and Lundwall's(1975) review. Garfield concluded that dropout rate was mostconsistently related to client social class variables, such as lowSES, low level of education, and minority racial status.

Several investigators (Brandt, 1965; Garfield, 1986; Pekarik,1985a, 1985b) have noted that the psychotherapy dropout litera-ture is replete with conflicting findings, replication failures,and generally small differences between dropouts and com-pleters. The most consistent finding in the literature, accordingto both Baekeland and Lundwall (1975) and Garfield (1986), isthat there is a modest inverse relationship between dropout andsocial class.

There is no up-to-date review of the outpatient dropout litera-ture. Most of the studies that Baekeland and Lundwall (1975)cited were published before 1965, the advent of the modernmental health era, in which treatment delivery is characterizedby federally subsidized community mental health centers, wide-spread third-party payment, and the availability of alternativesto psychodynamically oriented treatment. Garfield's (1986) se-lective review cited only 23 studies published after Baekelandand Lundwall's review, whereas over 150 reports on outpatientdropout have been published since 1975 (Hooper, 1988).

In addition to being dated, previous reviews are also limitedby their reliance on a simple "box score" approach to summar-izing findings. The box score approach simply tabulates andcompares the numbers of studies that reported different re-sults. This procedure is limited because it does not systemati-cally consider methodological features of the studies (e.g., sam-ple size). One methodological problem in many therapy drop-out studies is particularly troublesome. The majority ofdropout studies have defined dropouts and completers in termsof treatment duration or number of treatment sessions. Several

190

META-ANALYSIS OF PSYCHOTHERAPY DROPOUT 191

investigators (e.g., Brandt, 1965; Feister, Mahrer, Giambra, &Ormiston, 1974; Pekarik, 1985b), however, have argued thatboth treatment completion and dropout can occur after vir-tually any number of sessions, making duration-based defini-tions of dropout conceptually distinct from definitions basedon therapists' judgments of client termination status. Ideally,methodological factors, such as the study's sample size and defi-nition of dropout, should be considered when reviewing drop-out studies. The traditional box score literature review, how-ever, typically fails to consider such factors.

Meta-analysis refers to a set of statistical techniques that havebeen developed to help reviewers summarize and interpret alarge and diverse body of studies. Meta-analysis makes explicitthe criteria used to include and evaluate studies. Thus, meta-analysis has been described as more accurate and objective thantraditional qualitative approaches to reviewing research (Cook& Leviton, 1980; Smith, Glass, & Miller, 1980).

The purpose of this project was to conduct a meta-analysis ofthe variables associated with psychotherapy dropout rate. Ofparticular interest was whether the conclusions based on pre-vious box score reviews of this literature would be replicated.Thus, this review attempted to determine: (a) the average drop-out rate from psychotherapy; (b) the relationships betweendropout rate and methodological, subject, therapy, and thera-pist variables.

Method

Sample

A sample of 125 studies on psychotherapy dropout was identified byusing four methods: (a) a computer search of Psychological Abstractsthrough June 1990 was conducted using the key terms attrition, clientvariables, continuance, dropout, psychotherapy dropout, termination,and therapist variables; (b) a manual search of Psychological Abstractswas conducted for these same terms from January 1974 to June 1990;(c) reference sections of previous reviews of psychotherapy dropoutresearch were examined; and (d) reference sections of identified stud-ies were examined.

Studies were included in the review if they met the following criteria:(a) published in English, (b) reported a psychotherapy dropout rate, (c)included actual psychotherapy clients and not therapy analogues, and(d) were not limited exclusively to drug or alcohol clients.

Studies were excluded if they failed to meet these criteria. Criterion(a) led to the exclusion of reports published in languages other thanEnglish, dissertations, papers presented at meetings, and other unpub-lished reports. Rachman and Wilson (1980) argued that restricting ameta-analysis to published works should improve the average designquality of the studies (although this has been disputed by Glass,McGaw, & Smith, 1981). It was decided to restrict this review to pub-lished works so that all the studies would be readily available to readersof this journal. Criterion (b) above ensured that all the studies pro-vided a common metric: dropout rate from psychotherapy. Criteria (c)and (d) increased the homogeneity of the sample and allowed the gener-alization of the results to actual clinical populations.

Procedure

Originally, 42 variables were coded for each study. Because somevariables were not examined in many studies and because several pairsof variables were highly dependent on one another, and so providedredundant information, 10 variables were omitted. Only those 32 vari-

ables that were included in the analyses are described below. Thesevariables were assigned to one of four categories: study, demographic,psychological, and therapist.

Study variables were coded as follows: year of publication (year),definition of dropout (1 = termination by failure to attend a scheduledsession; 2 = therapist judgment; 3 = number of sessions attended), treat-ment mode (1 = individual therapy; 2 = group/family/couple therapy),setting (1 = university counseling center or department of psychologyclinic; 2 = private clinic/private practice; 3 = public clinic/communitymental health center; 4 = other), clients (1 = adult; 2 = mixed; 3 =children), and sample size (number of dropouts and completers com-bined).

Traditional reviews of the dropout literature have not typically ad-dressed study variables. Mela-analytic procedures, however, easily ac-commodate these variables. For example, meta-analyses of therapyoutcome (e.g., Shapiro & Shapiro, 1982; Weisz, Weiss, Alicke, & Klotz,1987) have routinely examined study variables. Of particular interestwas the relationship between dropout rate and the definition of drop-out, because previous reviews had not examined this factor. Adult,child, and mixed samples were distinguished because research (Pe-karik, 1991; Pekarik & Stephenson, 1988) has found that adult andchild clients differ in continuance rates and in the variables associatedwith continuance.

Demographic, psychological, and therapist variables were exam-ined because these variables are frequently studied by dropout re-searchers and have been used by reviewers of the dropout literature tocategorize the variables.

Demographic variables were coded as follows: sex (percentagemale), race (percentage White), age (mean years), education (meanyears), SES (mean Hollingshead & Redlich, 1958, rating), and maritalstatus (percentage married). In studies with child clients, parents' edu-cation, SES, and marital status were recorded.

Psychological variables included emotional disorders; behavioraldisorders; psychotic disorders; substance abuse disorders; and health/developmental disorders (for emotional disorders through health/de-velopmental disorders, the percentage of clients with the designatedtype of disorder was recorded); prior treatment (percentage havingreceived prior treatment); waiting period (mean number of weeks);diagnosis (percentage psychotic); sessions (mean number); and referral(percentage self-referred).

Therapist variables were coded as follows: sex of therapist (percent-age male); race of therapist (percentage White); experience (mean num-ber of years' experience); PhD, MD, MSW, MA, and Other Degree (forPhD through Other Degree, the percentage of therapists with the desig-nated degree was recorded).

Two analyses were conducted. First, the relationship between drop-out rate and the study, demographic, psychological, and therapist vari-ables was examined. Although studies defined dropout in differentways, dropout rate was reported in all studies as a percentage of clientstreated. This analysis had the advantage of incorporating informationfrom all 125 studies; however, it had the disadvantage of omitting in-formation concerning the strength of the relationship between drop-out rate and individual variables that had been reported in the studies.

For this reason, a meta-analysis was also conducted. Meta-analysisrequires that a common metric be obtained that can then be examinedacross studies. Effect size (d) was calculated to determine the relation-ship between dropout rate and individual demographic, psychological,and therapist variables. For studies that reported test statistics con-cerning these relationships, these statistics (z, t, F, x2, r) were trans-formed to d, using standard meta-analytic procedures (Glass et al.,1981; Rosenthal, 1984; Wolf, 1986). For studies that reported sufficientraw data (e.g., dropout rates and numbers of subjects in two groups) ordescriptive statistics (e.g., means, standard deviations, and numbers ofdropouts and completers), test statistics were calculated and then

192 MICHAEL WIERZBICKI AND GENE PEKARIK

transformed to d. In several cases, multiple groups of subjects werecombined into two groups to permit the calculation of effect sizes.

Studies differed in the number of evaluations made of the relation-ship between dropout rate and some demographic, psychological, ortherapist variable. For example, several studies reported data sepa-rately for the education levels of mothers and fathers of child clients.Other studies reported data from two or more subsets of a single clientpopulation. Because multiple effect sizes from a single study are notindependent and so do not contribute independent information (Land-man & Dawes, 1982), multiple effect sizes from a single study concern-ing the relationship of dropout rate to a variable were averaged. Thisreduced the possibility that a poorly designed study that made manycomparisons would have a greater influence on the meta- analysis thanwould a stronger study that made fewer comparisons.

Results

Analysis of Dropout Rate

Across all 125 studies, the mean dropout rate was 46.£(SD = 22.25). The 95% confidence interval for the estimate ofmean dropout rate was 42.9% to 50.82%.

Dropout rate was then examined as a function of categoricalStudy variables. Analyses of variance demonstrated that drop-out rate was not significantly related to treatment mode, F(l,123) = 0.19, ns\ setting, F(3, 115)= 1.04, ns; or clients, F(2,121) = 0.00, ns. Dropout rate differed significantly, however, asa function of definition of dropout, F(2,118)= 3.22, p < .05.This difference was because studies that defined dropout interms of termination by failure to attend a scheduled sessionreported substantially lower dropout rates than did studies thatdefined dropouts in terms of either therapist judgment or num-ber of sessions attended before discontinuing therapy Meandropout rates are presented for the levels of these factors inTable 1.

The relationship of dropout rate to the continuously codedvariables was then examined. None of these variables was signif-icantly correlated with dropout rate.

Table 1Mean Dropout Rate Across Definition of Dropout,Treatment Mode, Setting, and Clients

Factor M SD

DefinitionTermination by failure to attend

a scheduled session 23 35.87 16.47Therapist judgment 29 48.43 23.59Number of sessions 69 48.23

Treatment modeIndividual therapy 82 47.49Group/family/couple therapy 43 45.66

SettingUniversity 12 41.52Private clinic 37 43.69Public clinic 47 49.99Other 23 51.19

ClientsAdults 78 47.15 24.11Mixed 30 46.77 18.86Children 16 46.81 19.76

Meta-Analysis of Effect Size

The meta-analysis was then conducted. Effect sizes for therelationship between dropout rate and individual demo-graphic, psychological, and therapist variables were calculatedand examined. Only those variables for which there were atleast 10 effect sizes were retained for the following analyses.This limited the meta-analysis to six demographic variables(sex, race, age, education, SES, marital status). Mean effect sizesfor these variables were calculated and then tested to determinewhether they were different from zero. Mean effect sizes, stan-dard deviations, and numbers of studies that yielded effect sizesare presented in Table 2.

Increased risk for dropping out of therapy was significantly(p < .01) associated with the following: African-American (andother minority) race, low level of education, and low SES. Drop-out rates also increased, although not significantly so, for fe-male, young, and married clients.

Effect sizes for these six demographic variables were thenexamined as a function of the study variables. Because only onestudy yielded effect sizes for all six demographic variables andbecause a small number of studies did not provide sufficientinformation to permit the coding of all study variables, multi-variate analyses were not feasible due to the large number ofmissing data points. Instead, multiple bivariate tests were con-ducted, examining the relationship between individual studyvariables and the effect sizes of individual demographic vari-ables. These results should be regarded with caution because ofthe large number of tests that were conducted.

A series of analyses of variance was conducted to examinethe effect sizes of the six demographic variables across the lev-els of the categorical study variables. None of these analysesyielded significant results for the study variables of definition,treatment mode, or setting. Three of the analyses for clients,however, were significant: age, F(2, 20) = 3.93, p < .05; maritalstatus, F(2,12) = 5.56, p < .05; and sex, F(2,27) = 5.00, p < .05.

Effect size for age was greater in adult (M = .34) than inmixed (M = -.31) or in child (M = —.04) samples. That is, foradults, younger clients dropped out of therapy more often thandid older clients; however, for mixed child and adult samples,older clients (adults) dropped out of therapy more often thandid children.

Effect size for marital status was positive for adults (M - .06)

Table 2Mean Effect Sizes for Six Demographic Variables

Variable M SD£i.jy

22.7021.54

24.4325.049 t Q1Z. 1 .7 1

17.40

SexRaceAgeEducationSESMarital status

Note. SES = socioe

-.09.23*.10.28*.37*

-.11

conomic status. Effi

.35

.34

.50

.44

.27

.56

:ct sizes were cal

362130223019

culated sothat positive values indicated higher dropout rates for male, African-American (and other minority), young, less-educated, low-SES, andnonmarried clients.

META-ANALYSIS OF PSYCHOTHERAPY DROPOUT 193

but negative for mixed (M = -.09) and child (M = -.68) sam-ples. That is, for adults, nonmarried clients dropped out oftherapy more often than did married clients; the reverse wastrue for mixed child and adult samples, with married clients(and child clients whose parents were married) dropping out oftherapy more often than did other clients. (The value for thechild sample was based on only a single study and so should notbe regarded as a stable estimate.)

Effect size for sex was less extreme for adult (M = -. 14) andmixed samples (M = .04) than for child (M = -.52) samples. Inboth child and adult samples, female clients dropped out oftherapy more than did male clients. This difference was larger,however, in child than in adult samples.

Discussion

The average outpatient psychotherapy dropout rate across125 studies was 46.86%. This is virtually the midpoint of therange (30% to 60%) of previous estimates of psychotherapy drop-out rate (Baekeland & Lundwall, 1975; Garfield, 1986; NIMH,1981; Pekarik & Stephenson, 1988) and supports traditionalclaims that dropout is a significant problem for psychothera-pists (Garfield, 1986; Pekarik, 1985a).

The studies that generated this figure represented a widerange of settings, diagnoses, and treatments. Thus, this esti-mate is a robust one that should generalize to many clinicalcontexts. The wide range of studies, however, may have limitedthe ability of the meta-analysis to detect clear relationships be-tween dropout rate and other variables.

Although dropout rate was not significantly correlated withany of the continuously recorded variables that were examined,it was related to the way in which investigators defined dropout.Studies that defined dropout in terms of termination becauseof failure to attend a scheduled session reported lower dropoutrates than did studies that defined dropout in terms of eithertherapist judgment or the number of sessions attended.

Defining dropout by failure to attend a scheduled session isinherently conservative. Pekarik (1985b) noted that this methodclassifies clients as completers simply if they decline to scheduleanother visit after having attended one session. This applieseven to clients who are highly symptomatic and judged by thera-pists as in need of continued treatment (i.e., clients who areclassified as dropouts by therapist judgment). This method alsoclassifies clients as completers regardless of the number of ses-sions attended, as long as they declined to make an appoint-ment after attending one. Thus, highly symptomatic clientswho need but decline further treatment after only one or twosessions (i.e., clients who are classified as dropouts by duration-based definitions) are labeled completers. In summary, manyclients who would be classified as dropouts by the therapistjudgment or treatment duration methods are classified as com-pleters by the "termination-by-failure" method.

Although the termination-by-failure method has the virtueof potentially high reliability, it appears to be a very conserva-tive estimate of dropout rate. Because unilateral inappropriatetermination (and the converse—mutual, appropriate termina-tion) can occur after virtually any number of sessions (Pekarik,1983, 1985b; Sledge, Moras, Hartley, & Levine, 1990; Tutin,

1987), duration-based definitions also have inherent limitationsand should be used with caution.

Therapist judgment may ultimately prove to be the bestmethod of defining dropout. Therapist judgments of dropoutare face valid—the very concept of dropout stems from thera-pists' judgments that some clients terminate inappropriatelyfrom therapy. Because therapists judge some early termina-tions from therapy to be appropriate (Pekarik, 1983) and be-cause clients who are terminated because of failure to attend ascheduled session may be judged as appropriate terminaters,therapist judgments of dropout are also more flexible than theother definitions. Finally, therapist judgments of dropout aremore "fundamental" than other definitions: Selecting a num-ber of sessions attended to define completers and deciding thata client who fails to attend a scheduled session should be consid-ered terminated from therapy are both forms of therapist judg-ment.

The greatest potential problem with therapist judgments ofdropout is reliability—therapists may use different criteria forjudging the appropriateness of termination. Future researchshould address the reliability of therapist judgments of dropoutby developing explicit criteria to be used by multiple judges.

Pekarik (1985b) discussed the relative advantages of thesedefinitions of dropout and showed that definition of dropout isrelated to the variables found to be correlated with dropout.The present result provides further support for Pekarik's(1985b, 1991) recommendations that researchers consider care-fully and operationalize appropriately their concept of therapydropout.

The meta-analysis determined that psychotherapy dropoutwas significantly related to minority racial status, low educa-tion, and low SES. These factors have often been reported to berelated to risk for therapy dropout, both in individual studies(e.g., Berrigan & Garfield, 1981) and in previous reviews ofdropout research (Baekeland & Lundwall, 1975; Garfield,1986). Although these variables were significantly related todropout in this meta-analysis, their mean effect size was only ofmoderate magnitude, ranging from .23 to .37.

This study did not examine why these social class indicatorsare related to dropout. Previously, Garfield (1986) noted thatthe mutuality of expectation between client and therapist mayunderlie the relationship between SES and therapy dropout.Lower-class clients may differ from therapists in several impor-tant respects, including education, value systems, and expecta-tions concerning the nature and duration of therapy. If low-SESclients expect brief, symptom-oriented treatment (e.g., Brill &Storrow, 1960; Overall & Aronson, 1962), their higher dropoutrate could be partly explained by the finding that clients' expec-tation of treatment duration is highly related to continuance(Pekarik & Wierzbicki, 1986). This interpretation is supportedby studies that have found that univariate relationships be-tween low SES and dropout disappear when multivariate analy-ses later use both social class and client duration expectationvariables; in the latter case, expectation, but not social class, hasbeen found to be related to continuance (Pekarik, 1991; Pe-karik & Stephenson, 1988; Pekarik & Wierzbicki, 1986).

Although this study supported previous reviewers' conclu-sions concerning the relationship to dropout rate of social classvariables, one limitation of the methodology of this report

194 MICHAEL WIERZBICKI AND GENE PEKARIK

should be noted. When examining individual studies, it wasfound that many did not provide sufficient data to permit thecalculation of effect sizes. Nonsignificant effects are morelikely than significant effects to be reported with insufficientinformation to permit the calculation of effect size and aretherefore more likely to be excluded from the meta-analysis. Asmany as one fourth of the number of effect sizes per demo-graphic variable were excluded from the meta-analysis in thisway. Thus, the mean effect sizes calculated for race, education,and SES should be regarded as upper estimates of the truevalues of these effects.

Examination of the effect sizes for client demographic char-acteristics found that the relationships of these variables todropout rate were independent of most of the study or demo-graphic variables examined. One exception, however, occurredfor the client variable. Differences among child, adult, andmixed samples were observed in the relationships of three de-mographic variables to dropout rate: age, marital status, andsex. These findings are consistent with reports (Pekarik, 1991;Pekarik & Stephenson, 1988) that different variables are relatedto adult and child dropout and suggest that adult and childsamples should be analyzed separately in future research on thissubject.

Client and therapist demographic characteristics were thevariables most often investigated by researchers on dropout.Such demographic variables were generally not related to drop-out, except for client social class variables, which were onlymodestly related to it. The ease of securing demographic infor-mation undoubtedly accounts for their widespread investiga-tion. Given our results, however, it would seem that dropoutresearchers would better spend their time investigating othervariables.

Studies that have investigated more complex variables, suchas clients' intentions and expectations and client-therapist in-teractions, have found them to be far more powerfully related todropout than simple client and therapist variables. Pekarik andhis colleagues have found that clients' expected treatment dura-tion was a better predictor of actual treatment duration (num-ber of sessions) than was any of the other variables they exam-ined, including indexes of problem severity and several clientand therapist demographic variables (Pekarik, 1991; Pekarik &Stephenson, 1988; Pekarik & Wierzbicki, 1986).

Epperson, Bushway, and Warman (1983) found that dropoutrate increased threefold when therapists failed to identify accu-rately the client's conceptualization of the problem, a resultreplicated by Pekarik (1988). This threefold increase in dropoutrate is far more powerful than any relationship reported to datebetween demographic variables and dropout. Perhaps it is timeto abandon the search for simple demographic predictors ofdropout. Future research on psychotherapy dropout shouldfocus on more complex psychological variables, such as clients'expectations and the interactions between client and therapistvariables.

In summary, several conclusions can be drawn from this re-view. First, the dropout rate in outpatient settings is nearly 50%.Second, of the variables commonly examined, client socialclass variables are the ones most strongly associated with drop-out. Third, use of a client's failure to attend a scheduled sessionas the criterion for defining dropout produces a lower dropout

rate than do other definitions; future dropout researchersshould consider carefully which definition of dropout they use.Fourth, adult and child samples should be analyzed separatelyin dropout research. Fifth, the types of simple variables typi-cally investigated in dropout research are not strongly asso-ciated with dropout; hence, future research should use morecomplex psychological variables.

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Received February 3,1992Revision received September 8,1992

Accepted September 24,1992 •

Low Publication Prices for APA Members and AffiliatesKeeping You Up-to-Date: All APA members (Fellows; Members; Associates, and StudentAffiliates) receive—as part of their annual dues—subscriptions to the American Psychologist andAPA Monitor.

High School Teacher and International Affiliates receive subscriptions to the APA Monitor,and they can subscribe to the American Psychologist at a significantly reduced rate.

In addition, all members and affiliates are eligible for savings of up to 60% (plus a journalcredit) on all other APA journals, as well as significant discounts on subscriptions from coop-erating societies and publishers (e.g., the American Association for Counseling and Develop-ment, Academic Press, and Human Sciences Press).

Essential Resources: APA members and affiliates receive special rates for purchases of APAbooks, including the Publication Manual of the APA, the Master Lectures, and Journals in Psychol-ogy: A Resource Listing for Authors.

Other Benefits of Membership: Membership in APA also provides eligibility for low-costinsurance plans covering life, income protection, office overhead, accident protection, healthcare, hospital indemnity, professional liability, research/academic professional liability, stu-dent/school liability, and student health.

For more information, write to American Psychological Association,Membership Services, 750 First Street, ME, Washington, DC 20002-4242, USA