Research shows that about 20% of clients drop out of therapy prematurely.
People end therapy for many reasons, some of which are not a therapist’s fault. And while no therapist can perfectly meet every client’s need, it’s important to pay attention if your retention rates concern you.
Understanding Why Clients Stop Going to Therapy
Clients sometimes stop going to therapy for obvious reasons, and they will explicitly tell you their reasons for ending care. But, in many cases, clients simply stop showing up and may resort to ghosting instead of addressing why they’re discontinuing treatment. With that in mind, here are some of the most common reasons clients drop out prematurely:
Incompatibility: Therapy is a relationship, and a mismatch in personalities can certainly affect a client’s willingness to engage in treatment. Ultimately, a client has the right to determine what works best for them, and if they don’t resonate with a certain approach, they may look elsewhere or stop therapy.
Financial reasons: Money is one of the more straightforward barriers affecting a client’s decision to continue therapy. However, when finances feel tight, people often scan through their budgets to determine which products and services they can cut. Therapy may not make the chopping block.
Relocation: A client moving makes for a natural termination. However, in the changing landscape of telehealth, some clients may choose to continue meeting with their therapist virtually. But if you met in person in the past, they may seek to work with another in-person provider.
Therapeutic rupture: It’s estimated that 20-50% of individuals and couples experience a significant therapeutic rupture during their treatment. Ruptures can happen for many reasons, but it speaks to when a client feels misunderstood, judged, or negatively perceived by their therapist. Some therapists are aware of these ruptures, but others are not, as it may require the client to come forward and acknowledge their feelings.
Sense of stagnation: Some clients drop out of therapy because they don’t feel like things are getting better. They may feel like going to sessions is a waste of time, money, or both. Even if they “like” you, this may not translate to them wanting to continue services.
Regression: Relapses or moments of regression can also coincide with dropping out of treatment. When these moments happen, clients may worry about disappointing their therapists. Or, they might feel that therapy was not helpful enough to prevent them from having such a setback.
Certain presenting issues: Some clients may be more apprehensive or resistant to therapy approaches. For example, it’s well-documented that clients with active substance use disorders, eating disorders, or personality disorders have higher drop-out rates(2). A therapist should never assume premature termination, but they should be aware of these potential risks.
Unrealistic expectations: Some clients come to therapy seeking rapid transformation. Other times, they want their therapist to give them advice or essentially make the changes for them. Once the reality of therapy sets in, they may feel disheartened and quit prematurely.
What Is Considered Good Retention For Therapists?
It’s important to note that measuring retention isn’t always a quantifiable process. Many mental health professionals argue about how to define or even concretize what retention means within this profession.
With that, a therapist’s workplace setting, population, and theoretical orientation must all be considered when assessing retention rates. For example, someone who specializes in solution-focused therapy for work-related stress will likely have shorter treatment episodes than someone who specializes in psychodynamic therapy for chronic, developmental trauma. In addition, a therapist who operates a cash-pay private practice will likely have drastically different retention rates from a therapist who exclusively works with mandated clients.
Some therapists simplify their client retention rate as the mean difference between the number of sessions recommended to a client versus the actual number of sessions they attend. For example, if you estimate that a client will benefit from six months of treatment, do they stay in your care for the duration of those six months?
That said, the nuance matters, and it needs to be addressed. Life circumstances change, and as the treatment unfolds, you may believe your client needs more (or fewer) sessions than either of you originally anticipated. This can complicate retention rates, especially if the client wants to adhere to their original plan or feels they no longer benefit from such services.
In all of this, it is important to ask yourself the following questions:
- Do most of my clients come back after their first appointment?
- Do clients plan out terminations with me in advance?
- Do I feel like I generally have a good rapport with most of my clients?
- Do my clients come to therapy consistently?
Answering no to any of these questions may mean you have problems with retention. The most important part of considering retention is reflecting on main patterns rather than one-offs. If you have patterns of clients quitting prematurely, mistrusting you, or being flaky with their treatment, it may be a sign you need to improve how you practice.
How to Improve Your Therapy Practice Retention Rates
Therapists should always strive to strengthen their craft, no matter how much experience or confidence they have in their work. Improving retention is just one angle of shaping expertise. Here are some considerations to keep in mind.
Always Make a Good First Impression
Retention starts before a client ever walks into your office. When someone reaches out, aim to respond to their inquiry promptly and professionally. Invite them to schedule a consultation call with you, and if they don’t reach out, consider kindly following up to see if they are interested in moving forward.
Before you have your first session, ensure that you have read all the paperwork ahead of time. Take a moment to look at your office and consider how the client might feel when they sit down with you. Clear out any clutter, and make sure the temperature is comfortable.
Don’t Overlook the Process of Building Rapport
Many therapists act like rapport is simply an item to cross off on their professional checklist. But research consistently shows that the therapeutic relationship is one of the most important predictors of treatment success. Your presence matters, and clients want to feel safe and connected to their providers.
Rapport is an ongoing process, and it is never fully actualized. The more you can focus on slowing down and truly listening and connecting with your clients, the greater the sense of safety you emulate.
State Your Boundaries Clearly
Clients like to know what they can reliably expect from their treatment. This is why establishing clear limits is so important. Boundaries shouldn’t just be outlined in your informed consent- they should be restated and reinforced whenever potential issues arise.
Keep in mind that upholding certain boundaries may affect your retention. For example, someone might drop out if you charge them for canceling their session at the last moment. But in the long run, most therapists find that maintaining boundaries maintains a sense of consistency among their clients.
Be Mindful of Self-Disclosure
While self-disclosure certainly can have its place within the therapy session, it’s important to avoid making therapy about yourself. If a client senses that you want their support or validation, that can put them in an uncomfortable position. Similarly, sharing too much may cause clients to question your competence.
Remember that you should consider why you’re disclosing personal information before you actually do so. If you feel uncertain, it’s a good idea to seek consultation or supervision.
Truly Identify Your Niche
No therapist can help everyone, but providers with excellent retention rates strive to work with clients that truly align with their expertise. They specialize in a certain population or modality and they center their practice around that group of people (even if it’s fairly narrow).
Not only is it unethical to treat clients out of your scope of competence, but most clients can sense when their providers lack the skill set to truly help them. Remember that it’s okay to refer out and that doing so will likely improve your retention rates.
If you’re struggling to identify your niche, think about the clients that most excite you. What are their main issues or needs? What kind of support are they looking for? Even if your mind changes later, this may be your starting point for developing your specialty.
Pay Attention to All Feedback
If you do receive any constructive feedback from colleagues or clients, reflect on it. It’s especially important to note any trends. While feedback can be uncomfortable, integrating it is one of the best ways therapists can grow.
Moreover, consider asking clients for feedback directly before or after sessions. You can either send structured forms or informally ask, “What are your takeaways from today?” or “What was most helpful for you last week?”
Prepare Well For Your Sessions
While therapy can entail relying on your intuition and trusting the here and now, successful therapists prepare for sessions accordingly. It shouldn’t feel like you’re just winging your career- that’s disingenuous to your clients.
You should always have goals that you’re working toward. You should also think about rereading notes before meeting with clients to remember what was referenced in previous sessions. Finally, if you feel stuck on a certain issue, seek external support from a supervisor or colleague. In other words, make it a priority to come ready to work.
Strive to Repair Ruptures Effectively
Ruptures can erode trust and safety quickly. If you note that a client may be upset with you, it’s important to address the situation. Remember that apologizing can be one of the most genuine reactions you offer. While it’s permissible to make a mistake, it’s far more important that you know how to hold yourself accountable.
While ruptures can be uncomfortable, it can be healing for clients to receive corrective emotional experiences from their therapists. Sometimes, the main part of resolving a rupture is responding differently than the client expected (or differently than people did in the past).
Revisit Treatment Goals
Clients want to know that they’re on track and making progress. Every therapist needs to make treatment plans and update them regularly. It’s also helpful to collaborate with your clients to review how they feel about their treatment. Are they satisfied with their progress? What goals do they want to revise?
While not all clients drop out when things feel stagnant, many do. Therapy is a service that requires significant time and money. If someone doesn’t feel like they’re truly getting something out of the work, they’ll be less inclined to participate.
Final Thoughts
While retention rates can be difficult to measure, you should generally feel like clients enjoy coming to you and that your caseload is fairly consistent. If that isn’t the case, it may be time to revisit the basics: rapport, warmth, safety, and good boundaries. These make for the heart of good therapy, and they’re also the heart of client retention.
