How providing mental health services in schools transformed my practice
Running a therapy private practice is incredibly rewarding. Many therapists enjoy the freedom that comes with running their own business, such as determining their own policies and procedures, deciding which client populations to specialize in, flexibility in scheduling, and the opportunity to make a good living while doing meaningful work.
However, one of the most common concerns that can get in the way of running a successful practice is not being able to maintain a caseload, mainly due to client dropout.
Client retention strategies and treatment engagement methods can help address this issue.
This article details specific, evidence-based tools to keep clients engaged and prevent unnecessary dropout.
Treatment engagement methods
There are many client retention strategies to increase clients’ engagement in treatment and reduce the risk of dropout.
These include:
Preparing clients for therapy ahead of time
Marketing your practice authentically so clients understand who you are and what you offer before they see you
Being mindful of the common factors in therapy: the real therapeutic relationship and therapeutic alliance, providing culturally appropriate rationales for treatment, instilling hope and high expectations, and utilizing credible approaches
Regularly monitoring and assessing symptoms and goals
Consistently eliciting feedback from clients, and modeling and inviting transparency and an openness to client feedback
Being mindful when therapeutic ruptures happen, and proactively taking steps to resolve these
Ensuring the client intake process is smooth (e.g. using a solid EHR like SimplePractice that makes onboarding easy)
Starting and ending sessions on time
How to prevent early termination
There is a large body of research showing that therapists are generally less effective than they believe they are at predicting clients who will drop out of treatment early.
Therefore, one of the most important changes therapists can make in preventing early termination is consistently seeking feedback from clients.
There are two broad ways to do this:
Using formal assessments
Measurement-based care (MBC) is the act of choosing psychometrically validated measures and administering them to clients on a regular or semi-regular basis (e.g. every session, every other session, once per month).
Measures like the GAD-7 and PHQ-9 (SimplePractice offers automatic scoring and graphing on a chart) measure specific symptom improvement (e.g., anxiety and depression).
If therapists choose to monitor progress over time, it’s easy to notice any unexpected changes that would otherwise go unnoticed and lead to client dropout.
Other measures specifically designed to measure a client’s experience in therapy and the quality of the therapeutic relationship, such as the Session rating scale (SRS), and others like Outcome questionnaire-45 (OQ-45), can even predict client dropout ahead of time.
These questionnaires are great because they allow therapists to take a more objective view of the client's experience, and not get blinded by our own biases or expectations.
Informally, during sessions
Another helpful way to prevent early termination is to pay attention to signs of client dissatisfaction or resistance during sessions.
Client dissatisfaction can show up in many ways and often begins with some sort of noticeable change.
For example, clients beginning to show up late or cancel early, less engagement during therapy sessions, nonverbal shifts (e.g., clients beginning to avoid eye contact), or sessions that feel directionless.
What engagement tools work?
One of the most powerful engagement tools is using the here-and-now to process any concerns that a client might drop out. As Yalom says, “it's all Grist for the Mill!”
Here’s an example of how this might sound:
Therapist: I wanted to bring something up with you that I’ve noticed recently. Is that okay?
Client: What do you mean?
Therapist: Over the last several sessions, I’ve noticed that there’s felt some distance between us. Have you noticed that, too?
Client: Yeah, well, now that you mention it, I guess so.
Therapist: Yes, that’s right! I think we’re both feeling it. I wonder if there’s something I’ve said or something that you experienced in session a few weeks ago that maybe didn’t feel so good?
Client: It’s nothing you said, but whenever we start talking about my mother, I feel so numb and shut down. I feel like I’m doing this whole therapy thing wrong.
Therapist: Thank you so much for sharing that with me. It makes so much sense, and it's incredibly important for me to know.
In this interaction, it would have been easy for the therapist to miss this client's dissociation if it had never been brought up.
There is a good chance the client would have continued to be frustrated and potentially dropped out of treatment, leaving both the client and the therapist confused.
Of course, there are other options to maintain engagement as well if you notice clients are at risk of dropping out. These include seeking further supervision from a trusted colleague, using motivational interviewing (MI) to help evoke change and increase motivation for therapy, and getting clear on the client's goals.
When to address dropout riskAll therapists have had the experience where they feel like they are doing great, meaningful work with a client, only for that client to not show up to their next session, and ignore follow-up calls from the therapist.
All therapists need to be mindful that, generally, the research shows we’re not very good at predicting dropout.
Therefore, assuming any client might be at risk of dropping out is helpful.
As soon as we gather data that this might actually be happening (e.g., using an assessment tool or your own intuition), it’s essential to address this as soon as possible, preferably in that very session.
How to maintain alliance
When thinking about client retention strategies and treatment engagement methods, it's important to distinguish between therapeutic rapport and alliance.
They are both critical in unique ways to help prevent dropout.
Rapport is the general quality of the therapeutic relationship, ideally trusting, warm, and safe for the client.
Alliance refers to the idea that both the therapist and client have shared goals and intentions for therapy.
The most effective ways to maintain alliance include being clear about the client’s goals for treatment, seeking permission/informed consent before engaging in specific techniques or interventions, and simply bringing the intention to be on the same page as the client into every session.
Some questions therapists can ask themselves to help with this include:
“Is this what I want for the client, or what the client wants for themself?”
“Did I ask permission from the client to take this approach or intervene in this way?”
“How is this intervention related to my client's treatment goals?”
I find the “Perfect Session” question (an interaction of the “Miracle Question” from solutions-focused therapy) a quick and easy way to do an alliance check, where I can make sure my interventions are aligning with my clients' needs and goals:
“Imagine this session goes perfectly today. You walk out of here with everything you need. How would we know? What would be different?”
What about follow-up?
If it looks like a client is in the process of dropping out of therapy, it's important to remember that they have their own agency and to respect their decision.
From an ethical perspective, if a client drops out, it’s a good idea to always send a follow-up communication offering them referrals and a brief note informing them you are closing out their care.
Sometimes, dropping out of therapy can be another form of avoidance, and there are times when a therapist can help clients work through this by offering a phone call or a follow-up session.
How to get feedback
As we discussed above, getting feedback about the client's experience in therapy (e.g., effectiveness of interventions, quality, rapport, or alliance) is essential to avoid unnecessary dropout.
While objective assessment measures to elicit feedback, like the SRS, can be beneficial, this is not feasible for all therapists to include as one of their client retention strategies.
Another great option is to elicit feedback more naturally and informally.
As one of my client retention strategies, I’ll always elicit feedback in the first few sessions and as much as needed throughout my work with clients. For example:
Therapist: “You did great work today, client. Before we wrap up, I just wanted to say that I deeply value feedback from my clients. I know it can be hard to give constructive feedback to therapists, and I don’t want you to feel any pressure, but I want to make sure I’m doing the best I can, and this sort of feedback can be helpful. So, what about this session did you find helpful and want to ensure we continue taking forward with us? What about this session did you find unhelpful, or do you want to ensure we do less of it in the future?”
Clients typically respond very well to being asked these questions and have likely never had a therapist elicit feedback from them before.
Treatment engagement methods are one of the best ways to show that we take this work seriously and care about our clients’ well-being.
Sources
Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of consulting and clinical psychology.
Roos, J., & Werbart, A. (2013). Therapist and relationship factors influencing dropout from individual psychotherapy: A literature review. Psychotherapy Research..
Zimmermann, D., Rubel, J., Page, A. C., & Lutz, W. (2017). Therapist effects on and predictors of non‐consensual dropout in psychotherapy. Clinical psychology & psychotherapy.
Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World psychiatry.
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy.
Hannan C, Lambert MJ, Harmon C, Nielsen SL, Smart DM, Shimokawa K, Sutton SW. (2005). A lab test and algorithms for identifying patients at risk for treatment failure. Journal of Clinical Psychology: In Session.
De Jong, K., Conijn, J. M., Gallagher, R. A., Reshetnikova, A. S., Heij, M., & Lutz, M. C. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical psychology review.
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