Client dropout from psychotherapy is a huge problem. A recent meta-analysis found that about 1 in 5 patients leave treatment before they have reached an acceptable level of recovery, against the recommendation of their therapist. The consequences of premature client dropout are far-reaching, affecting everyone involved.
Clients receive incomplete treatment, and are left to face their mental illnesses alone. These clients may return to therapy repeatedly over many years, stretching out their recovery, and increasing the burden on the system. Or—even worse—they may never return.
Therapists often feel burnt out by client dropout, and being powerless to help. Burnout tends to fester and diminish the quality of treatment, which creates a dangerous cycle of increasing dropout rates and clinician apathy.
Community mental health agencies struggle with the financial burden of no-shows and empty appointment slots. Even agencies with long waiting lists can be forced to shut their doors because of thin margins between salaries and revenue. Agencies may respond by becoming unforgiving and quick to discharge, just to stay afloat.
Who's Dropping Out?
Thanks to a mountain of research on the subject, we have an idea of which client traits, and which treatment factors, contribute to the risk of premature dropout. Note that the research we looked at pertains to adult clients.Treatment factors that increase the risk of dropout:
- Inexperienced clinicians
- Treatments with undefined time limits
- University counseling centers
- Eating disorders
- Personality disorders
- Younger clients
- Treatment theory
- Clinician age, gender, and race
- Treatment format (group or individual)
- Client gender, race, marital status, and employment
Reducing Client Dropout
A lot of factors—like a client's transportation, finances, and external obligations—are beyond a clinician's control. No matter how good the therapist, some clients will inevitably drop out of treatment.
That being said, there are some simple techniques that can be used to minimize the frequency of client dropout. Without further ado, let's take a look at what we can control.
Educate new clients about therapy.
Many clients enter therapy with an inaccurate idea of what to expect during treatment. They might plan on going to a session or two with the hope that their therapist will tell them how to solve all of their problems. Or maybe they think they'll be kicking back on a couch a few times a week, rehashing memories from their childhood.
When a client's expectations for therapy are drastically different than reality, dropout is likely. A client's uncertainty about their role in treatment, a lack of timeframe for treatment, and confusion about what to expect during sessions can be anxiety-producing.
To address these issues, psychotherapists should start treatment with basic education about what to expect. Try to answer these questions for your new client:
"How long will therapy last?"
"What are the roles of the therapist and client during treatment?"
"What sort of effort will the client need to make during treatment?"
"What can the client expect to happen during a typical session?"
To make your job a little easier, here's a handout you can use to begin teaching clients about what to expect during treatment:
Frequently check in with your clients.
Make an effort to check in with your clients about their progression in therapy, and their feelings about treatment, at the end of every session. Many clients are not comfortable giving feedback to their therapist, especially when it's negative.
Sharing an open dialogue about the ups-and-downs of treatment will allow you to head off any issues before they turn into no-shows, while contributing to the development of a strong therapeutic alliance, and giving you valuable insights into your own style as a therapist.
Most dropout occurs after the first and second sessions, so we suggest starting check-ins right away. Once you've made check-ins a regular part of your treatment, you'll wonder what you were waiting for.
Focus on relationship building.
It's a common mistake to get caught up in finding the perfect therapeutic technique, while forgetting about the person in front of you. Research has shown again and again that the client-therapist relationship is the single most important factor in treatment outcome.
Building a strong therapeutic relationship is a huge topic, beyond the scope of this article. Here are just a few key points to keep in mind as you approach new clients.
- Focus on exploration and understanding—not action.
- Encourage the expression of emotions over facts.
- Don't be afraid to use humor and have fun. Be relaxed, yet professional.
- Show empathy through your body language and words.
If building therapeutic relationships is a topic you would like to learn about in more depth, I strongly recommend the following book:
Make sure clients are aware of their progress.
The changes that occur during psychotherapy can be very gradual, and difficult to detect for that reason. Because you'll only be seeing your clients every week or two, it may be easier for you to pick up on changes that were too gradual for your client to detect.
Your client might feel like they are drudging through session after session, with nothing to show for it. You, on the other hand, have noticed that they have become more talkative and cheerful session after session. They're even reporting positive changes outside of session, without realizing it. Say something about it!
A lot of improvements might be difficult to detect, even for a therapist. This is where the regular use of assessments can be invaluable. Ask your clients to complete a short questionnaire about their symptoms every few sessions, and discuss their responses. Oftentimes, both you and the client will be surprised by the level of improvement.
Start talking about discharge right away.
Therapy with no clear goal can be bewildering and frustrating for clients. Why are they attending? What are they getting out of all this time and money? By discussing discharge during the first session, you can establish clear goals, and paint a picture of what will be different once treatment is complete. Give your client something to work toward.
Discussing the successful completion of treatment addresses several areas that contribute to client dropout. By discussing discharge, you will be teaching your client about what to expect during treatment, giving them hope by illustrating a goal, and setting a general time-frame for treatment.
Client dropout can be difficult to deal with as a clinician. It might shake your confidence, and cause you to question your own abilities. That's OK. That's normal, and healthy. Use client dropouts as an opportunity to learn about, and grow from, your weaknesses. If you continue to be plagued with this issue, seek supervision and consultation with colleagues.
Oftentimes, dropouts are outside of your control. But when you start to blame clients exclusively, without honest self-reflection, that's when you should worry.
1. Barrett, M. S., Chua, W. J., Crits-Christoph, P., Gibbons, M. B., & Thompson, D. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training, 45(2), 247.
2. Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438.
3. Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547.