An Open Letter to My Students II: Why Most Clients Only Come for a Few Sessions

Once, when I was still in school, I sat with a woman who informed me that she needed help but she had a hard time trusting. “I’ve got paranoid personality disorder so you’re going to have to push me,” she said, “cause at some point I’m going to think you’re out to get me.” Halfway through the session I left the therapy room and went back to the viewing room to consult with the team.

“This woman wants me to take responsibly for the therapy process,” I grumbled to my team. “Besides, paranoid personality disorder! What’s that? That’s not even a real thing!” “Wah waw wah wah,” my processor said, her words only half registering. I picked up my clipboard and went back into the room. I don’t remember what happened, but I do remember she came back only once more.

Retention of clients is a huge problem. I’ve seen several things which say that the average client is in therapy for 4 to 5 sessions. I’ve also known many brief therapists who assume that clients don’t come back because the client’s problem is fixed. I tend to not believe them, mostly because I’ve done in-home therapy. What I learned from my time in homes where I had to follow up with clients week after week, whether they wanted therapy or not, was that the intensity of problems cycle due to stress.

For example:

A kid might routinely talk back to mom, but, even though mom and dad bicker, dad doesn’t put up with kid talking back to mom. When kid is rude dad punishes kid and mom has some support. Then dad goes to work offshore. Mom is more stressed. Kid goes to school and talks back to teacher. Teacher, in an attempt to not suspend kid, refers the kid to therapy. Mom cooperates with therapy for two weeks because she’s in “crisis,” mostly because she’s now got the added stress of the school breathing down her neck. The third week of treatment the family has disappeared cause dad is back from working offshore and took the family on a trip to visit grandma. This is where in-home differs from in-office therapy. If it’s in-office therapy and you’re of the brief therapy persuasion you assume that things are “done” and you pat yourself on the back. If it’s in-home therapy no one cares about your “therapeutic orientation.” You continue to follow the case ’cause your boss tells you to and as you do you notice that in a few weeks dad leaves and the troubles flare up again. It’s like shingles. Or eczema. The problem is always there but flares out of control because of stress. When problems flare, people feel like they are in crisis. It’s important that you as a therapist take this seriously but not literally. Take it seriously because there is a person in front of you who’s in serious pain. Do not take it literally because it’s happened before and the person, who thinks the world is going to end, has already survived this multiple times. So if problems cycle around stress, and people come to therapy because of a felt crisis, why don’t people stick with therapy? Because of shame. Shame is an emotion in the sadness family which leaves you with the feeling that you are bad, so bad that you don’t deserve connection, even though that’s what you secretly want more than anything. Shame is about identity and says you, not what you do, you are “bad” and the best way to protect yourself is to hide. I’ve even had several clients, and have been the client, who’ve come into therapy with no “problems” just a sense that something was wrong. What I didn’t know, nor the therapist I went to, was that therapy was about managing emotions and that the emotion of feeling like something was wrong with me was the feeling of shame.

You HAVE to know this because this is the question which defines your relationship with your client and your relationship with your client is the intervention. When therapists don’t attend to this clients don’t come back. It took me a long time to figure this out. Clients talk about this as “feeling judged”. When a client comes into therapy they are bringing their deepest darkest secrets with them. Even if they don’t tell you what the secrets are, it doesn’t matter because the emotion of the secrets is in the room. It’s as if the emotional lens through which they are viewing everything you’re saying and doing is “If I tell you this will you reject me and confirm my worst fears about myself…

that I really am a bad mother, that I really am a dead-beat dad, that all the things they say about me at school are true, that all the white folk are right about me, that maybe I am nothing?”

When I went in with that client, I didn’t realize any of this. When my teacher was hinting at, but I was too deaf to hear, was that the underlying message my client was sending me was, “I’m feeling vulnerable. Please show me acceptance.” My flippant response, even though I didn’t say it to her, seeped into how I did therapy. Hence she didn’t return because I didn’t convey, “Hey you can share here. I don’t believe those things about you.”

Most therapists are completely unaware of this. Each client is asking “If I tell you my secret will you confirm my worst fear?” and they will drop out if we fail to convey “I believe in you.” So how do you do that? Well you have to be present so that you can read your clients’ emotions in the moment. Then when you see that shadow of shame you can just say, “Hey I could be wrong, but I get the sense that I need to say that I believe in you. I think that’s hard for you to take in. And probably for good reason. But I still feel like I need to let you know that even though you’ve made mistakes that’s not who you are.”

That’s it. That’s the secret. Of course if you do this your no-show rate won’t be 0%. People will still drop out before you think they are ready. But this will change the trajectory of therapy. It's question hidden behind every other question.