Therapists often have trouble understanding why clients leave therapy prematurely.

But it isn’t too hard to understand, if you can follow the breadcrumbs…

Here are some telltale signs a client is about to drop out—and that you may need to pivot:

1. Pointed comments about the cost of therapy

Before they leave suddenly, some clients will comment that therapy is expensive, or make a point of mentioning how difficult their financial circumstances are. Don’t ignore these comments—even though they make you feel uncomfortable.

Ask them whether they would like to continue attending therapy, and provide some options. These may include a reduced fee or spacing out appointments.

You’ll need to make a judgement call about whether this person typically just has difficulty investing in themselves, or whether their words reflect genuine financial strain.

If you believe it is the former, then confront them directly about the struggle they seem to be having in doing something that benefits them. If they don’t perceive a benefit, then this becomes your next conversation, and better to have it sooner rather than later.

2. An increase in the frequency of late cancellations or DNAs

When people are ambivalent about something, they usually do nothing. Inaction is the default—and this can result in them failing to attend therapy sessions (either deliberately, or subconsciously, due to pushing the sessions out of their mind).

Make a point of highlighting the pattern, and ask them how they feel about therapy. For some clients, you may need to tweak the frequency of sessions. I believe that there is a frequency sweet spot for each client. Some are really content to attend every three weeks, but would rather discontinue altogether than attend more frequently than this. Talk to them, and find the schedule that suits best.

3. The conversation feels one-sided in session

When clients seem to be holding back in therapy, it can be hard to know how to approach it. But if they continue to say almost nothing, or let you do all the talking—it’s difficult to imagine how they could be benefiting from therapy (and therefore, why they would want to continue).

You need to try to work out what is going on. There are several possibilities:

  1. The client has no will to do therapy (maybe therapy was suggested by a GP or family member, who never really established whether the client wanted it for themselves)
  2. Anxiety is too high (when anxiety becomes too elevated, people can have trouble thinking, connecting words, and maintaining conversation). Try to help them observe their anxiety in the body, shift the focus to another topic temporarily, or introduce humour.
  3. They have tendencies towards passivity or helplessness. You’ll need to point out that they are taking a passive and/or helpless stance in their own health journey, and remind them that they freely chose to attend.
  4. They are avoiding emotional closeness. Highlight how they keep things superficial, and that this prevents you from getting close enough to be useful to them.

Many of the above come from my training background in Intensive Short-Term Dynamic Psychotherapy (ISTDP) — so you may need to make adjustments that suit your modality.

Fundamentally, the key to preventing premature dropout is honesty. The more direct you are, the better the outcome, generally speaking. It may be that now isn’t an ideal time for therapy, or that they really don’t have the will to attend. This isn’t a problem. But let’s be open about it, and keep things clean.