By Bernard Schwartz, PhD, author of How to Fail as a Therapist
Depending on which study you read, between 20 and 57% of therapy clients do not return after their initial session. Another 37 to 45% only attend therapy a total of two times. Although many factors contribute to premature client termination, the number one cited reason by clients is dissatisfaction with the therapist. The problem of the “disappearing client” is what Arnold Lazarus has called “the slippery underbelly to the successful practice of psychotherapy that is almost never discussed in graduate programs or medical schools.”
As clinical supervisors of interns at a university community clinic, we are painfully aware of the high rate of client dropout, and thus the idea for our book How to Fail as a Therapist was born. What we found in doing the research for the book is that high dropout rates are not just common amongst intern therapists, but are equally prevalent among experienced therapists.
When clients drop out early, everyone loses. We clinicians lose a chance to help someone in need and our wallets and reputation suffer as well. The consequences for clients are even more dire. Those clients who drop out early display poor treatment outcomes, over-utilize mental health services, and demoralize clinicians.
The good news: there are a number of well-researched strategies which have been proven to reduce dropout rates and increase positive treatment outcomes. For example, in one study a simple phone call to confirm a client’s first appointment resulted in a two-thirds reduction in dropouts.
When clients drop out early, everyone loses.
Unfortunately, it is often labor intensive to seek out and review much of the relevant research because it is scattered throughout the literature—a journal article here, a chapter in a book there. And most clinicians simply feel as though they don’t have the time to read the latest research on how to keep their clients.
Thus, a major challenge in writing the book How to Fail as a Therapist was to assemble, organize, and condense the vast body of research addressing therapeutic effectiveness. Of the 50 therapeutic errors described in the book, here we present three of the most common ones made by clinicians—both beginner and experienced therapists.
1. The "Infallibility Error"
One of the most distinguishing characteristics of therapists who have low dropout rates is that they actively seek feedback—both positive and negative—regarding the effectiveness of their clinical work. Some therapists believe that after years and years of study, comprehensive exams, postgraduate supervision, and licensing exams, they have all the answers to clinical matters. So when their clients voice concerns about their progress, or worse yet, when they drop out or deteriorate under the therapists’ care, there is a tendency to avoid accepting responsibility for committing a possible therapeutic error. It is easier to point the finger elsewhere: “maybe the problems were too severe”; “the patient was not ready or willing to change”; there was too much transference operating.” The possibility for rationalization and denial is endless. These explanations, even when partially valid, may soothe the ego, but they protect clinicians from engaging in an honest and comprehensive exploration of what might have gone wrong in a case.
A group of interns were asked to describe a case in which a client of theirs terminated early in therapy. One intern described the case of a 10-year-old male client, who had been referred by his teacher because he seemed disconsolate over his parents’ divorce. When, in the first session, the intern probed about the effect of the parents’ separation, the client became emotional and wanted to change the subject. But the intern persisted. The client stood up, in tears, and refused thereafter to return to therapy. The supervisor responded to the case presentation by emphasizing the need for therapists to be very cautious during early sessions, particularly when eliciting difficult material from clients. Before the supervisor could get very far, the intern interrupted by stating: “I am already discussing this case with my other supervisor, so I probably shouldn’t get input from both of you.”
Clearly, this intern was desperate to avoid facing the possibility that he did not handle the case as delicately as he should have. None of us really relishes the idea that we may have blundered, but if we deny this possibility, we deny ourselves the chance to grow as clinicians.
A Solution for the Infallibility Error
One way to avoid the infallibility error is to seek feedback from clients who have dropped out prematurely. Arnold Lazarus describes in his book Multimodal Behavior Therapy how he has gained great insights by writing “early terminators” and suggesting that they come in for a “feedback session” for which he doesn’t charge. In one such case, a client reported that she felt the therapist had not been sympathetic when she was recounting the loss of a beloved pet. The therapist apologized for the insensitivity and the client decided to continue in therapy.
A little awkwardness is better than losing a client before they can be helped.
One crucial statistic to keep in mind is that most clients who drop out do so after the first or second session. Thus, we must elicit client feedback, positive and negative, early on to head off any misunderstandings or negative feelings about the therapist, the therapeutic process or the therapists. Clients can be asked directly at the end of the first session if they feel therapy is on track and if they feel liked, understood, and respected.
Asking for direct feedback may feel a little awkward; however, a little awkwardness is better than losing a client before they can be helped.
2. Underutilizing Clinical Assessment Instruments
Assessment tools, used early in therapy to measure the type and intensity of the initial problem and occasionally during treatment, can aid in treatment effectiveness, client morale and reduction of termination by resistant clients.
Despite this, clinicians are often skeptical about the value of utilizing assessment tools. For example, one clinical supervisor described a case where a postdoctoral intern was not following agency policy to administer a well-known and highly validated instrument. The trainee stated that she did not “believe in” the assessment because it was not particularly useful and took a lot of time to score, even though the specific instrument had proven its validity and utility in dozens of studies.
There are many factors that contribute to the effectiveness of utilizing assessment instruments:
The therapist gains information from a source that allows comparisons to other clients regarding the severity of the problem.
Repeating the test at periodic intervals can help demonstrate to the therapist and client whether treatment is effective.
If the results indicate improvement, positive expectations are reinforced. If there is no improvement, the client and therapist can adjust the treatment approach appropriately.
Clients tend to see assessment utilization by the therapists as an act of caring, and it enhances client regard for a clinician’s expertise.
All of this and more—and yet clinicians often ignore assessment tools like the plague. Two common reasons for the underutilization of these instruments involve the perception that they require a lot of time to take and score, and that they cost an arm and a leg.
While using assessment tools is a good starting point for improving therapeutic outcome, there are two other factors which can enhance their use. First, it is crucial to explain to clients that just like medical doctors, therapists use assessments to pinpoint possible problem areas. Lastly, results of assessments should not be kept secret from the client. It would seem quite odd if your medical doctor did not provide any feedback after a patient had a series of tests such as blood work or X-rays. Similarly, several studies have shown that an open discussion of the results of psychological tests enhances therapeutic outcome by increasing client engagement in the therapeutic process.
Bernie Schwartz, PhD, is a licensed clinical psychologist who was the founder and director of the Student Psychological Services at Santiago Canyon College in Orange, California, where he worked for over thirty years. He is the author of How to Fail as a Therapist. In addition to his teaching and clinical work, he has performed over a thousand child custody evaluations for Superior Court of Orange County.