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Since part of our role as therapists is to encourage clients to stay in therapy long enough to complete their work, it’s hard to watch treatment be cut short, not only because we’re invested in our clients and want them to heal, but also because—let’s face it—we need to make a monthly income. For this reason, talking about client retention is both a clinical and a business issue. When working with ECs, retention needs to be discussed early on in the purchasing process. ECs want to understand how to get their money’s worth, and that means a therapist must explain the concept of sticking with treatment for a certain amount of time, even when it feels uncomfortable.

A stockbroker might talk with a new investor about the need to stay in the market long enough to see a profit, despite inevitable ups and downs. A gardener might talk about the need to be patient with seedlings planted in new soil. A personal trainer might explain the need to endure discomfort with a strength-training routine before seeing new muscles emerge. But how does a therapist start this conversation?

In Harriet’s case, I asked her to find an easy-to-understand metaphor or analogy to give her new clients a frame of reference for how therapy works in the consulting room. An avid hiker, Harriet liked the idea of relating therapy to climbing a mountain. Although you can’t see the view at every step, you need to trust the path and the guide until you can get to a clearing, look back to see progress, and imagine the end point. We role-played how to build on this metaphor with clients, and she added a picture of a mountain path to the artwork in her office, which gave her new clients a visual reference to understand the therapy process and their own path in any given session.

To prepare for the next session with the father of the defiant teen who didn’t want to come back, I asked Harriet, “Can you give him a clear and concrete reason to stay, one that would be more important than his reason to leave?”

Since Harriet wasn’t used to having to address clients’ tough objections so directly, we practiced what she might say and how to talk honestly and openly about each issue the father had raised. When the family came in the following week, Harriet started by saying that she knew that therapy was an effort and an expense and that they needed to measure progress. Dad jumped in saying “It’s cost me $320 to be here so far, plus four afternoons of leaving work early. And that’s not all. I have to listen to my wife at home criticizing me by saying, ‘Harriet says you’re supposed to do this,’ or ‘Harriet says don’t do that.’”

Some therapists might have been intimidated by his anger, but because Harriet and I had been discussing ECs and their purchasing-driven patterns, she simply said, “I know this is really costing a lot and it’s hard to stick with, so I want you to feel that you’re getting a return on this investment. Let me be straight with you about what’s in store for your family. I think you and your family will need to see me for two more months in order for things to calm down a bit more with your daughter and for all of you to learn the steps needed to resolve issues as parents with her at home. What would make it worth your while to stay?”

“I need to know that it’s working,” he said.

Again, Harriet immediately validated this need, and together they set up specific markers, based on small goals that seemed reachable over two months, to help him feel assured that the therapy was moving forward. At the end of the session, the father said that the most important part of it for him was that Harriet understood how important his time, money, and effort were. He appreciated her being straight with him. He liked the clear idea she gave him of what to do next. He took notes, with Harriet’s encouragement, so that he would remember what was said without prompting from his wife. “He took ownership of the therapy,” Harriet said. But what also changed was that Harriet took responsibility as a business owner and service provider to address issues of money, expectations, and potential results, with clarity and candor.

Making the Shift

As a therapist in my own private practice, and thus a businessperson like the therapists I coach, I’ve had to learn the strategies and skills I describe, too. I admit that I’m not always successful with ECs, in part, because—even with all my business experience—I still sometimes miss practicing therapy the old-fashioned way. I liked doing long-term therapy the way I was trained to do it, and at times, I yearn for those committed clients, many of them veterans of past therapy, who already “got it” in their first session with me. But to make a living as a therapist, I’ve had to teach myself to shift gears and embrace the ECs just as they are: people who conduct an Internet search for the kind of therapist they want and then call for an appointment. I’ve also had to learn that these clients are often facing much harder odds than the typical “patient” of the past, who—despite personal problems—most likely had a solid income, good insurance, and reliable prospects for the future.

Most of the online shoppers who find their way to me are younger than I am, challenged by an unstable society, slippery cultural mores, uncertain careers, insecure jobs, and a stagnant economy. Many are not yet in solid marriages, or even firm relationships, nor are they homeowners. They seem in flux, and those in their twenties exhibit what might look like a sense of overweening entitlement and opinions. They come into therapy with the traditional presenting problems of anxiety, depression, and unhappy relationships, but they haven’t yet, even as adults, developed a secure sense of self. They need clinical holding from the first hello.

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