We’ve all been there. We think therapy is going along swimmingly, and then all of a sudden, our client stops showing up. Sometimes we get a cancellation email or text that says they will call us to reschedule when we really know it's code for, “I ain’t coming back.”
It is all too easy to blame clients for dropping out of therapy. We say very clinical things like, “They weren’t ready to do the work,” or “We reached a climax in treatment and it was too much for them”. There may be some truth to those statements, but as therapists, are we doing a good enough job of educating clients about the termination process? Because it is a process.
It is a privilege to walk with a client from the beginning to the end of their counseling journey, but it is often a privilege we do not get. We lose clients when one of us goes on vacation. We lose clients when life gets extraordinarily full for them. We lose clients, and sometimes, we don’t even know why.
“Where Did I Go Wrong?”
If you are anything like me, you tend to eschew any tendency to fault a client for not following through with treatment. Instead, I wonder where I missed the mark or went wrong. What could I have done differently? Did that brilliant intervention I made fall flat? Was it not as well-timed and relevant as I thought? You can see how easy it is to go down the rabbit hole of self-condemnation.
We may never know why our clients do not return for our sessions, but a fully insightful and self-aware therapist must look at how we contribute to a client's dropping out of treatment and what we can do about it. Below are some suggestions.
Address the End of Therapy During the Informed Consent Process
Yes—talk about the end of therapy at the beginning. By addressing termination at the start, clients can better understand that counseling does have a beginning, middle, and end. The informed consent process lets the client know what they can expect from working with us.
In the midst of talking about confidentiality, payment contracts, and consents, we would be wise to address how the client and therapist know when treatment should end. Ask clients to imagine what life will look like when therapy is over. What would be different? What skills would they possess that they do not currently have? This lets them know you are looking at therapy with the end in mind and shooting for a mutually agreed upon goal.
As therapists, we keep the big picture in mind and hold a long-range view. Meanwhile, clients often only see immediate concerns. Of course, goals can change as therapy progresses, and they often do. When issues sprout up that the client didn’t even know were there, we revamp and incorporate new goals into our treatment planning. Once we share that terminating is a process and not an abrupt ending, we can continually check in about how the process of therapy is going.
Encourage Open and Honest Feedback About the Therapeutic Experience
This can be done during at least two points in therapy. The first is during the informed consent process, when we can educate clients about the collaborative nature of our relationship and any expectations of them as clients.
Let them know that at times, they may be asked to do homework, and any feedback about how beneficial it was will will be helpful. Tell them you may miss the mark. When they let us know the assigned homework wasn’t very useful or effective, that gives us information to steer sessions in another direction. I make sure to provide assurance that my feelings won’t be hurt.
Secondly, directly ask them for feedback throughout the process to model the two-way exchange mentioned during the first appointment. Inquire about how opening up in a session was for them, especially after a particularly vulnerable disclosure on their part. How did that affect rapport and trust? Ask about the pace. Is it too fast or too slow? Are they seeing the kind of progress they hoped? What is working in therapy, and what is not? These kinds of questions invite feedback in a safe atmosphere.
What to Do When a Client Stops Coming to Therapy
So what do we do when clients suddenly stop showing up? Here are a few ideas:
- Address your own feelings. Are you irritated? Worried about the lack of income or a dwindling caseload? Recognize these are your own feelings and do not let them enter into the dialogue with the client.
- Don’t take it too personally. Often, leaving therapy has more to do with what is going on with our client than about us or anything we said or didn’t say. Technology makes it much easier to cancel appointments, and it’s easier to send a text or email than to confront us about why they aren’t coming back.
- Reach out empathically when clients no-show or cancel. The purpose is to let clients know you available to them, not to chastise them. You are leaving the door open for returning back to treatment. A phone call is more personal, but if you hear nothing back, follow up with an email a week or so later. After that, take a hint and know you have given a safe invitation to return to treatment on their terms.
This approach is no guarantee a client won’t drop out of treatment suddenly and without an explanation, but encouraging open communication along the way may help reduce attrition.
Some clients might feel sheepish about returning to a therapist once they no-show an appointment or have an outstanding balance. These are common issues therapists must address. While I might be annoyed that I have a hole in my schedule, my bigger concern is if my client is okay.
Most of all, I’d like my clients to know I care about them. Otherwise, I wonder what happened. Was therapy helpful for them? Sometimes we have to make peace with the fact we may never know.