We have a hidden crisis in therapy: Clients leave therapy before they can see the results of treatment. They leave too soon, in large numbers, without warning, abruptly. This is both a clinical issue and a business one, because it undermines the efficacy of your services and weakens your business. To learn what you can do to reduce client “ghosting” and improve client satisfaction, read more below.
The Problem of Client Ghosting
Do you have clients who dropout or disappear before finishing treatment and don’t respond to your attempts to connect?
Having a client leave therapy prematurely can be upsetting and unsettling. You wonder: What happened? What might you have done differently? What was wrong with the client?
Like most therapists, you do your best to provide empathy, caring, and solid treatment methods. When a client ends treatment abruptly, without explanation or notice, it can feel like a bad breakup: You were dumped, with no real understanding as to why.
The rate of clients leaving treatment before getting the results they need and want is a bigger and broader problem for our profession then you may know. It’s a serious concern for all of us to consider.
Improving Client Retention
Since improving client retention is both a clinical and a business issue, we need solutions that address both aspects. Here is some data about the scope of the dilemma we face as a profession:
Studies show that from twenty to fifty percent of all therapy and counseling clients leave therapy long before they see results of treatment.
Over fifty percent of clients never come back after the first session; a slightly smaller percentage leave within the first five sessions. We need to change something about our treatment process to stop this pattern. In any industry, this would be cause for alarm.
The Reason Clients Leave Too Soon
What are the reasons for this significant rate of dropout in the therapy profession?
Let’s set the context: Few clients are happy to find themselves in a situation that determines a need for therapy. Clients usually seek therapy at a low point in their mental health and/or their lives. They seek us at their most vulnerable moments. And they often are embarrassed or ashamed about their need for us. In our culture, therapy is often viewed as a sign of personal weakness or failure. The act of coming to therapy can provoke anxiety by itself, given that the nature of therapy can be uncovering difficult feelings and thoughts.
Given this, its essential that we not compound the problem. Having made the significant effort to find a therapist and then come to a session, a client needs to leave feeling that it was absolutely worth the time, money, and effort. Clients need to know that they are making clear and noticeable gains. Even better is if the client feels compelled and motivated to return. Too often, the opposite is true.
Disappointment and Dissatisfaction
Surveys suggest that the number one cited reason clients stop treatment is a lack of satisfaction with the therapy process. Their dissatisfaction is a combination of ambivalence or negativity about their therapist and a lack of tangible results gleaned from one or several sessions.
We know that for most therapy to work, repeat visits are necessary. We have to be more proactive in helping engage clients to stay longer, to see treatment results. We must make an effort to help clients see clear and concrete measures of success.
What can you do to take responsibility to help a client stay in treatment? How can you increase a client’s understanding and sense of value and satisfaction about your services? Can you reduce client disappointment in the therapy process?
I suggest that a strategic model of client retention be part of every therapist’s treatment plan.
A Strategic Model of Retention
I have been interested in resolving the problems of poor client satisfaction and low retention for a long time and written and given workshops on this topic.
I have a chapter on this topic in Building Your Ideal Private Practice: 2nd Edition, titled “Retaining Today’s Clients” that explains why those coming for therapy now are often even more difficult to engage than those clients who sought therapy in earlier times.
My new book, Therapy with a Coaching Edge: Partnership, Action and Possibility in Every Session (W.W. Norton, 2018) takes it one step further. I offer a new model of psychotherapy that embeds a strategic model of retention and client satisfaction into the structure of each session. Its easy to apply and can help clients understand the value of a therapy session more clearly, in the moment. Here is how it starts:
First, stay alert for obvious and hidden signals of client confusion and disappointment, beginning with the first session.
Have you heard clients say the following during a session? If so, failure to return may be imminent:
- “I can talk to a friend and get the same kind of help you are giving me”
- “I am too busy for this”
- “You therapists charge too much.”
- “I don’t see what good this is doing.”
- “How long is this going to take?”
Stay alert to these and other objections. Think of these comments as feedback. Invite direct, consistent client feedback as a way to open a conversation about client satisfaction. I ask clients to share their therapy experience with me, in real time, during a first session and then in subsequent sessions. I listen non-defensively. Keeping this line of communication open during each and every session reduces unexpected dropout.
For many vulnerable clients, therapy is hard to fathom: They wonder “Is it working? Am I getting better? Does this really help?” If therapy results are couched in psychological jargon and kept vague, clients feel torn about returning. They can’t figure out the process and they don’t know if what you are doing with them even helps.
You won’t know how your clients feel about services and whether they are pro or con about returning unless you ask. You will need to ask often, to stay on track.
How to Ask for Feedback
I like to set up therapy sessions with some structure, so that each session has a beginning, middle and end. On the front end of any session, I ask a client what the session needs to focus on and how we will measure, as the session proceeds, to know if we are making progress together during the session. During the middle phase, as we work through the issues on our agenda, I take time to pause and see if we are progressing in the direction that the client understands. On the back end, I encourage feedback with a few questions that I ask to consolidate gains of the session.
This takes time away from the therapy, many might say, but I suggest that this kind of transparency is essential to the therapeutic process.
The ending process is especially important in the process. I leave the last ten minutes of a therapy session for a time to help my clients articulate the progress and value made in the session. (For more specific examples of this session process, see Chapter 5, “Results in Every Session” in Therapy with a Coaching Edge.)
I take an active role in making this structure work, especially in ending well. I think of this role as a form of therapeutic responsibility and leadership. I watch the time with a purpose in mind: I want to see if our objectives have been met and help my client identify what has been useful and helpful. I want to observe, with the client, what progress has been achieved in this session. I want to anticipate what we can expect for the next time. This is an example of how I combine a coaching approach with therapy, to be very strategic about the goal, progress, and completion of each and every session.
I don’t assume that because I thought a session went well and see its value, that my client agrees or can articulate the same results. I want to hear this in the client’s own words. I don’t presume that a client, even one who seems pleased with our session, will return–unless I can help provide a compelling reason.
If a client can’t identify any value in the session, I am glad to educate them with what I will be putting in my notes.
When I take time to end this way, summarizing gains, it’s not unusual that a client will indicate the she has already forgotten some of what has just been talked about or worked through. This makes sense, because a client is absorbing new ideas, and integrating on both a conscious and unconscious level. Some questions I might use to help this consolidate gains include:
- What will you take away from our session?
- Did you get results or make gains you wanted?
- Do you feel a need or see a reason to return?
- May I share what I think was valuable from our session?
Finding the right words to sum up may be difficult for a client, so I am willing to collaborate with a client in this task.
Helping Clients to Stay in Treatment
At the start of this article, I said that better retention was both a clinical and business issue. Clinically, helping clients stay longer involves building a better connection with your client and giving them a sense of how and when and why the therapy is moving forward. With this feedback conversation in place, clients have the language to articulate to themselves and others what they are doing in therapy and how it is helpful. It shows clients how and why therapy works and helps them to value a long considered vague and mysterious service.
From a business perspective, helping clients to see a return on their investment, to increase their satisfaction, is always an important factor in terms of increasing referrals and enhancing the chance of returning customers. It strengthens your profit picture.
The time and cost of replacing clients who terminate early means more marketing, advertising, networking, outreach, and continual intakes to get new clients settled in for treatment, clients to replace those who leave too soon. Staff who are ready to see clients may sit with empty hours unfilled. Office space sits empty, adding to a lack of productivity. You need engaged clients, those who appreciate and make good use of your services. You want clients who feel glad that they have taken the time for therapy and are willing to make the effort to complete their treatment, not a revolving door of unsatisfied clients who come and go at will and feel that “therapy just didn’t work for me.”
So my challenge to you is that you consider how you might help to reduce this professional problem and help clients feel more satisfied and invested in their treatment. I look forward to hearing your experience and what works for you in this regard.
Dr. Bernard Schwartz and John Flowers: How to Fail as a Therapist: 50+ Ways to Lose or Damage Your Patients, 2010.
Joshua Swift and Roger Greenberg: Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes, 2014.
Ryan Howe: “4 Reasons Not to Ghost Your Therapist” Psychology Today.