Clients ‘no-show’ for sessions at an uncomfortable rate, and while it’s incredibly common for new therapists to feel insecure about their abilities, these no-shows are often a special source of self-doubt. A related culprit for generating worry is ‘single sessions’—when clients meet with you once then cease contact or book a second session but no-show. Rest assured this happens to all of us. Rates vary between therapists, but some studies put single sessions at 20% of a caseload, up to 57% depending on context (Lambert 2001). Older research from the 1960s suggested approximately 50% of clients drop out by the 3rd session.

Why does this happen? Besides therapists actually making mistakes (which most of this will be about), you can give yourself a break on the client-based reasons:

• Clients recognize therapy is opening up a more complicated or painful situation than they expected

• They stop attending once their (initial) crisis has ended

• Quite a few clients misinterpret (or just don’t know) what psychotherapy actually is, so they leave seeking the correct service or leave disappointed

• The client doesn’t want to say goodbye

• They sort of ‘pause’ counselling but then get busy and/or avoid reinitiating it

• They don’t want to continue paying for it, or can’t afford it but don’t tell you

• Context matters: unpaid/free counselling can have higher no-show rates, and some presenting issues may have higher dropout rates (e.g., perhaps addictions?)

However, we need to take responsibility for our role in this equation, which we may be worse at doing than we think. The following uncomfortable quote is from Scott Miller’s chapter in The Cycle of Excellence (2017):

Instead of improving with experience, the effectiveness of the average practitioner plateaus early on and slowly deteriorates (Miller & Hubble, 2011). To illustrate, in the largest study of its kind, Goldberg, Rousmaniere, and colleagues (2016) documented an erosion in performance in a sample of 170 therapists working with more than 6,500 clients, tracked over a 5‐year period. This decline was unrelated to initial client severity, number of sessions, early termination, caseload size, or various therapist factors (e.g., age, years of experience, theoretical orientation). What does reliably improve is therapists’ confidence in their abilities (Miller et al., 2007). Studies show that the least effective believe they are as good as the most effective and that average clinicians overestimate their outcomes on the order of 65% (Chow, 2014; Hiatt & Hargrave, 1995; Walfish, McAlister, O’Donnell, & Lambert, 2012)

So, stay humble and measure your clinical outcomes. Improving rates of dropout and single sessions is very possible. With your healthy professional self-doubt in hand, consider the following approaches.

Improving Rates of Premature Termination:

• Role induction: ensure your clients are clear on what therapy is and who’s responsible for what. This improves attendance, decreases misconceptions, and gives realistic expectations

• Motivational interviewing: research suggests motivation for treatment is linked to premature termination, which I discuss here in relation to the transtheoretical model, with one study (Carroll, 2001) demonstrating up to a 50% reduction in dropout rates. Meeting your clients where they’re at is critical. This point and the previous one came from Joshua Swift’s 2012 paper and 2015 book on the subject

• Related to stage-matched interventions, we have to be able to track our clients’ affect effectively and know what to do in first sessions. Daryl Chow wrote a helpful book on this subject “The First Kiss: Undoing the Intake Model and Igniting First Sessions in Psychotherapy”

• Know which characteristics and behaviours of yours help therapy and which are irrelevant to outcomes

• Have a strong alliance—Barrett (2008) found the alliance was central to almost every domain that impacted client dropout. Improving your alliances, overall, can be done by addressing the items on this list. People need to feel safe and understood by us in session.

• Agreement on goals for therapy, which is related to alliance. You both need to be clear on what the client wants from therapy, make sure it’s achievable and useful, and be working toward that

• Return client contact (e.g., calls) within about 24 hours; Saporito (2003) found a failure to do so was reported by clients as having a significant impact on their decision to stop attending

• Too long of a wait for a first session can cause clients to no show, especially if it’s longer than a week (Barrett, 2007). If we can’t see the client that promptly, it can help to connect for a brief phone call to introduce ourselves and discuss presenting concerns, expectations etc 

• Ask about what worked and didn’t work in previous therapy. This not only gets you actionable information but also demonstrates to clients that you care, will ask good questions, and will listen

• Listen to the podcast Very Bad Therapy, where the hosts interview clients and discuss bad therapy experiences as well as how they resolved, or what clients hoped could have happened to repair the relationship (shocking results: they say that most issues in session arise from therapist defensiveness, a failure of tracking/responsiveness when applying what is normally a reasonable intervention or statement, or a failure of the therapist to take responsibility and apologize for mistakes)

It takes courage to do an honest self-assessment, and even more so to show our work to our peers and supervisor. But we do this to improve. What each of us needs to improve is unique, and the nature of our locality and place of work will also inform best practices. The more we can set ourselves, but not our identities, aside and deeply listen to our clients, the more likely they are to feel witnessed, and increasingly safe to open up.

Get feedback often and be open to discussing it and reflecting. Few things are more off-putting in a therapist than arrogance or condescension. Solicit feedback from your clients regularly, your peers, and certainly your supervisor or a more senior therapist. Ideally supervisors will directly observe the session via recorded video (audio is okay but less useful), and seek informed consent before recording clients. One-way mirrors are great and allow for impactful team-based therapy interventions (e.g., reflection teams), though this is a somewhat rare setup to have physically. 

Merely describing what happened in a session to your supervisor/colleague is far less useful than video because we’re all limited by our own perception, egos, things we fail to notice and/or understand, our preconceptions, and gaps in knowledge. Don’t forget about our bad days, being exhausted, going through divorce, etc. So! Show video. Some clients dislike the idea, but you might be surprised by how often clients say yes. My experience has been that at least 30 or 40% of clients I ask to record a session are happy todo so when I explain the purpose and the cyber security measures and so on.

Feedback is tremendously valuable for reducing no shows and early client dropout, so improving the ability to solicit useful feedback gives a therapist a real path to ongoing growth as a clinician

We all have areas for improvement, and I encourage you to address yours gently and with persistence. We have to research and, most importantly, deliberately practice whichever skill we’re targeting at the time. Experiment with the idea of approaching your current skills and this task with total curiosity. Not self-judgement, or confidence, or anything like that. Curiosity. Being disappointed by failure is understandable, but it shouldn’t turn into bitterness or spite directed at yourself.

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