Q: After joining a group practice, several clients who were referred to me dropped out of therapy. I’m trained in many therapeutic approaches. What am I missing?
A: I’m sorry that you’re losing clients, but believe me, you’re not alone. Studies vary, but we now know that between 20 and 57 percent of therapy clients don’t return after an initial session. Of those who do come back, another 37 to 45 percent will stay for only two more sessions.
Why? There’s a slew of potential reasons: people change jobs, run out of money, reconcile with their romantic partners, and so on. But the number-one reason clients cite for not returning to therapy is dissatisfaction with the therapist.
This can be a hard pill to swallow, particularly when several of our clients drop out of treatment at the same time. We may even be tempted to dismiss the evidence that there’s something about our bedside manner that could use a little tweaking and polishing. But the good news is, we can make some small adjustments to increase our clients’ satisfaction with us. We now have a better grasp of how to build the kind of therapeutic relationships that reduce dropout and increase positive treatment outcomes. And we’re better able to discern where and how we mess these relationships up.
Connection, not Correction
To reduce client dropout, our first focus must be on building a warm, collaborative, and genuinely supportive relationship. Establishing rapport is essential, no matter how solid your training is, or how statistically impressive or inventive your preferred technique may be.
Recently, a supervisee, Eva, was learning about the use of paradoxical intention in her advanced counseling class and tried to use this technique with a new client during their first session.
Overwhelmed after returning to school on the heels of a divorce, the client couldn’t get herself to do any schoolwork, and she was failing to complete the simplest of chores at home. Eva’s intervention was to have her “join the symptom,” so she prescribed that the client do no work at all for the entire week, and report back at the next session about how this went.
Unfortunately, the client never shared her report because there was no next session; she was never heard from again. Eva’s paradoxical intervention might’ve proven effective in the long run, but she and her client hadn’t developed enough rapport before she implemented it for us to find out.
Since we know that no other single factor affects therapy outcomes more than the quality of the client–therapist relationship, therapists would be wise to begin building that relationship even before the first session. How? One way is to send a welcome letter to the client, providing background information about their practice and emphasizing the collaborative nature of therapy. Here’s an example:
Thank you for reaching out and scheduling a session with me. Seeking support is a big part of addressing challenges, and I appreciate your courage in taking this important step.
Our first appointment is set for this Friday at 3:00 p.m., and I’m looking forward to working with you. Therapy is a joint venture, so always feel free to ask questions and let me know how you think things are going. During our first session, I’ll be gathering some background information and exploring possible goals that you might have for our sessions.
If your new client has opted to meet with you in person, relationship building starts with the first hello and handshake (or elbow-bump). If you’ll be meeting in person regularly, try not to leave this quick physical connection out. Many studies have documented the power of touch in therapeutic relationships. Even with medical appointments, patients most often cite shaking hands with their doctor as the most positive factor in their visit.
Words of welcome are also important in that first meeting, and in every subsequent session. This may seem obvious, but when I’ve asked therapy interns about the first words they typically utter to their clients, the most common answer is: “So how did your week go?” Not exactly warm and welcoming.
I always try to put my new clients at ease by saying, “Welcome, good to see you,” and then offering tea or coffee. Research shows that drinking a warm beverage enhances relaxation when people are stressed. Warm clients can lead to warm emotions.
Keeping an Eye on the Relationship
Once we’ve made it through a first session, what else can we do to increase the likelihood of retaining our clients? Well, psychologists Adam Horvath and Leslie Greenberg have developed a short client questionnaire that lets us know whether clients are likely to drop out of therapy. The Working Alliance Inventory (WAI) not only predicts dropout with a high degree of accuracy, but also points to possible areas of disconnection that can prevent it if addressed. It does this by focusing questions on three key issues.
Does the client feel liked, understood, and respected? Feeling negatively judged by therapists, even if it’s subtle, is a big contributing factor to client dropout. So we therapists need to be very careful when providing feedback. If, for example, clients don’t complete an out-of-session activity, resist the urge to remind them about how much likelier they are to make progress in therapy if they complete the exercises you assign. It may be true, but your client is likely to experience that feedback as critical and rejecting. A better approach would be to communicate your openness to problem-solving with something like, “I wonder what got in the way of your completing the activity.”
Do the client and therapist agree on the goals of therapy? Not being on the same page about the goals of therapy can be ruinous to the therapy relationship. I once had a new client who came in with a black eye on the same day that she wanted to discuss whether her husband was an alcoholic. Instead of starting where she wanted, I immediately focused on the husband’s treatment of her, which I worried included physical abuse. I was right to be concerned, but my client wasn’t yet ready to talk about that. Sadly, she didn’t continue therapy. I’d rushed the process and ignored her stated concern, missing an important opportunity to help her.
Do clients see the tasks they’re given as valid and relevant? Sometimes a therapist recommends a course of action to achieve an agreed-upon goal, but the client doesn’t see the connection between the action and the goal. Take journaling, for example, long used as a powerful means of helping clients clarify their feelings. Many therapists assume the rationale for putting pen to paper and describing our emotions is obvious, but unless we connect the dots between the assignment and the client’s therapeutic goals, follow-through is unlikely.
Because most clients who drop out of therapy do so by the fourth week, it’s crucial to administer the WAI in the second or third session, and it’s equally important to ask clients to be completely honest with their answers. Clients don’t want to offend their therapists, so try to assuage that worry. I’ll say something like, “My goal is for you to get the most out of our sessions. Answering these questions will tell me whether we’re on the right track or if we need to make some adjustments, so please don’t worry about offending me.”
Empathy Isn’t Easy
Getting negative feedback from clients may be uncomfortable, but I want to reiterate that the most common reason clients fail to return is dissatisfaction with their therapist. When former clients are asked to be specific about what they disliked about their therapists, the most common response is that the therapist maintained a professional distance and seemed like they’d heard everything the client was saying before.
To prevent this, most graduate programs incorporate a section on the importance of empathy. Often, they quote Jim Wallis, a writer and political activist, who said, “It is the experience of touching the pain of others that is the key to change.” But despite our training, it can be a challenge to “touch the pain of others,” especially when we haven’t had similarly painful experiences.
Terry, a supervisee, told me recently that her client was upset with her because when he talked about having lost his dog, she hadn’t reacted with fully engaged support. Terry admitted that it was hard for her to connect with her client’s loss because she’d never had a pet. I suggested that she ask herself, What would my emotional response be to losing someone or something important to me?
Tuning into our own pain allows us to “touch the pain” of our clients. This means communicating how significant the loss of a pet can be through our facial expression and tone of voice. Although Terry had said, “It’s natural to feel sad when a pet dies,” her body language hadn’t echoed it, and her client had felt that mismatch.
In the end, when we make every effort to “touch the pain” of our clients, and they feel our concern and our empathy, then we’re giving our clients what they most need from us. Thankfully, this is also the path to retaining clients and to the richly fulfilling practice so many of us seek.
Bernard Schwartz, PhD, is a licensed clinical psychologist and the author of several books on child–parent relations and clinical effectiveness. He currently supervises interns at several organizations in Orange County, California.
PHOTO © PEXELS/Timur Weber