In 2011 Centennial, the organization I managed, began tracking client retention numbers for our therapists. We then compared them to the practice as a whole. As we shared those numbers, it became clear that many factors contributed to whether a client continued in therapy and for how long. I collected some notes on those conversations. I am summarizing them here. This is not any sort of scientific discussion and is highly biased. These ideas are based on my own experiences as a therapist and supervisor of therapists. I hope it stimulates some productive thought and self-examination.
Based on our analysis and years of doing therapy myself, here are some suggestions of ways to think about and do therapy.
Structure the therapy schedule
On the face of it, those with the highest client retention were those who were more focused on structuring a consistent regular schedule with clients. The clients knew their appointment slot was theirs. It was consistent until there was a conversation about changing the structure. Some therapists clearly spent a lot of time and effort thinking about and working on getting the structural elements of the therapy. They set up therapy in such a way that it created a safe framework for the coming work. It showed in their client retention numbers.
Build expectancy from the first
From the first session, therapists with the best numbers show clients that the problems they have brought in are not as intractable. Clients often come to therapy assuming change is not possible. Building hope, believing that change is possible, is critical. Hope will bring clients back and may in itself lead to more satisfying therapeutic outcomes.
Set up a plan
During the early sessions, discussing the plan for how you will proceed helps generate trust and “buy-in.” Here are a few approaches I have used:
- “I’d like to spend a couple sessions getting to understand the dynamics of what is going on here and then we can go on. Does that sound okay with you?”
- “How about I meet with each of you once, and then we can come back together and I’ll offer some observations and maybe even some suggestions. Sound okay?”
- “I’m thinking we should meet every week to get some momentum going, then we can come back and have a conversation about frequency. Were you thinking we would meet each week for a while?”
- Over the phone before the first session: “How about I meet with you parents first, and then in the second session I’ll meet your child. How does that sound?”
Approaching the early sessions this way provides confidence that we can change the pattern if what we are doing is not working. Clients like a mutual decision-making process rather than having us assume that they will follow wherever we want to take them.
Follow up on commitments
It is quite clear that our clients test us early on. They wonder if we really do care about them. They are testing us in these ways:
- Do we start and end on time?
- Do we call them when they do not show or late cancel?
- Will we write the letter they ask from us?
- Do we connect with the primary care physician, referrer, or other person as we said we would?
These all communicate to our clients, whether we intend that message or not. Our responses shape the client’s assumptions about us. Our goal is to pass these tests or, failing that, to discuss our failures in a non-defensive and direct way. We are setting an example for how we would want them to discuss their failures with us. Doing so helps build the safety and security needed to go to the next level.
Pay attention to early attachment
Client retention seems to go up as therapists focus their early attention to how the relationship is going. This early attention to attachment seems essential for clients to feel the safety needed to absorb what eventually will be their biggest challenge—taking responsibility for where they find themselves. And those therapists with the best retention seem very slow to push for that “squaring up to responsibility” process. Early on they are looking for signs that the client-therapist relationship is secure enough to endanger it with confrontations.
All clients are seeking to be assured that the therapist:
- Respects him/her
- Is safe for sharing what may have never been shared with anyone before
- Can handle whatever is brought to the therapy
- Is comfortable going where the client wants to go with the therapy
Rarely do clients directly ask a therapist any of these questions. And yet they certainly watch us in order to decide if we are worthy of their continuation in therapy. Usually the decision happens without a conversation with us about how we did on any of these dimensions.
Handle confrontations gently
Retention goes up for those therapists who are careful about early confrontation. One of my early psychodynamic supervisors taught me that any time the therapist expresses knowledge of something the client does not know or makes a suggestion about what the client might do, it will be experienced as a confrontation by the client. That is indeed a very low threshold for defining a confrontation. And yet the longer I have practiced the more I understand the importance of what he was saying. Additionally implied in his definition of confrontation is the notion that clients come to us in a very fragile place. They may be agitated, defensive, or angry yet they fear we may push them to face up to more than they are ready for.
Slow down and listen
Unfortunately, we sometimes do move too fast. (Also see “Why don’t my client change like they are ‘supposed to'”). And since most clients have ambivalence about our power, it makes sense to be slow to push and careful when we do. By carefully probing and constantly watching for clients’ reactions, we can gauge the pacing that is comfortable for our clients. In my supervisor’s view, the easier part of therapy was figuring out what needed to happen. The challenge was to bring our clients along as we gently showed them what we had figured out.
Only when the relationship with the client is ready (which can take weeks to months in usual cases and, when trust is a primary issue, even years) can the client withstand even the most gentle confrontation. And even out suggesting that there might be better options than the way the client is already handling things can be too much for some. I am suggesting that those therapists with the best retention numbers are slow to confront, even in these careful ways.
These comments and ideas will not apply in all cases. And they do not help us with all types of issues. And unfortunately following the above suggestions will not help us retain every client. Yet my hope is that looking at our therapy through this retention lens may add to our insight and understanding about our therapy and how we might improve our process. It is indeed a very complex task that we undertake.
Written in December 2011 for the training Centennial Counseling Center clinicians