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Drop It Like It's...Not: Managing Client Dropout in Clinical Supervision

Sarah M. Thompson, PhD

How can we help our supervisees cope when a client unexpectedly drops out of therapy?


My very first therapy client dropped out after only five sessions. What I remember most about that experience is that while the client offered a very reasonable explanation for why they no longer had the time, money, etc. for therapy, I was convinced that a better, more seasoned therapist could have helped the client remain engaged.


Whether that assumption is correct - who knows. But I remember the thought coming to me not so much as one more thought within a stream of daily cognitive content, but as an inescapable fact. And I carried this sense of certainty around my failings into supervision.


So what are we as supervisors to do when our supervisees' clients drop out? With advanced trainees, the process is a little easier. Typically, trainees at later stages have experience with dropout and have seen enough clients to recognize that many factors influence engagement in therapy. Thus, a drop out is not solely a reflection of therapist skill. But for beginning trainees, this situation can be acutely personal, often experienced as a confirmation of deeply held fears about their inadequacy as clinicians. The sense of high stakes can be challenging for supervisors.


As in many situations in supervision, beginning from a place of validation can be helpful. Aim for warm validation of the pain of this circumstance. We have all been there. I doubt there's a licensed mental health provider in existence who hasn't experienced an unexpected termination, including with clients we were convinced would benefit from therapy and for whom dropout is an unexpected and painful outcome. Create space to engage in gentle reflection around the trainee's emotional experiences, normalizing painful reactions to client dropout. What feelings show up? Is the trainee surprised? Sad? Angry? Anxious about what this means about their abilities as a therapist? Worried about the implications for meeting their required practicum hours or accomplishing other training tasks? Do they feel any sense of guilt for this outcome? Are they sitting with unresolved questions they wish they could ask the client? Help the trainee observe these experiences, normalize them as part of dropout, and validate the difficulty of a one-sided ending to a relationship.


After validating the trainee's emotional reactions, it is important to build a conceptualization of the dropout as a supervisor. Your reaction to and guidance around this situation should be shaped by thoughtful reflection on the facts. Consider the various factors that may have precipitated the client's choice to drop out.


Perhaps you have a sense that the client's choice to leave therapy was (at least partially) driven by an error or difficulty that your supervisee exhibited. Maybe the trainee had difficulty connecting with the client, presented as invalidating or aloof, or even made an offensive comment. With a beginning trainee, it is not unexpected for them to struggle with the basics of therapy. Of course they are struggling! There is no way to practice a new skill for the first time without making mistakes along the way. However, as the supervisor, you must consider whether there is a grain of truth to any self-blame that the trainee may demonstrate in supervision. If so, your supervisory approach is likely to differ from situations in which you genuinely do not believe that the supervisee's skills or specific behaviors contributed to the client's choice to end therapy.


If it seems likely that the trainee's behaviors did not contribute to the client's choice to drop out (e.g., the client consistently expressed difficulties making time for therapy, the client experienced a change in personal circumstances that made the financial or time commitment of therapy unsustainable, the client moved away, etc.), then you can consider sharing this perspective with the trainee. If the trainee's thoughts about the situation suggest inaccurate self-blame, you may consider highlighting the inaccuracy of the trainee's assessment as a means of building their self-reflection skills and helping them move toward an accurate conceptualization of themselves as a clinician. Cognitive defusion ("Let's work on noticing this judgment as a product of your mind without necessarily buying into the content") and cognitive restructuring ("What is the evidence that it is your fault? What is the evidence that suggests other factors were at play? What would an alternative, more accurate thought be in this situation?") skills can be helpful here.


However, if you believe that some part of the client's decision to leave therapy was influenced by the supervisee's behavior in sessions, then it is important to consider how to respond effectively. In this case, reassurances of the trainee's infallibility may not be especially helpful. I'm a big believer in being direct with trainees about both their successes and their struggles, primarily because most have a tendency to assume the worst about their performance, which means that blanket statements about trainees' competence or attempts to absolve them of all responsibility can feel inaccurate and invalidating. Often, their default is to assume that supervisors are 'just being nice.' That's why specific feedback is so important, and why building a track record of honest positive and corrective feedback can provide a helpful backdrop to the tricky discussions that take place after a client dropout. If trainees believe you will be honest with them, they are more likely to accept your assurances about things they did right in therapy, even with a dropout. In this circumstance, they are also more likely to expect your honest assessment of what role their behavior as a therapist may have played in the client's choice to end therapy.


If you consider your conceptualization and come to the conclusion that the trainee's behaviors likely contributed to the dropout, then it is important to help the trainee reflect on this circumstance in a gentle, developmentally appropriate manner. For beginning trainees, consider starting by framing the plethora of circumstances that may have contributed to a dropout. It is rare for the decision to end therapy to be entirely driven by one comment, one rough session, or one mangled intervention. Help trainees reflect on all of the factors that may have contributed to the client's decision. What about their environmental contexts may have made dropout easier (e.g., financial considerations, lack of support among loved ones for their decision to seek therapy, stigma within their communities around mental health concerns, limited time, accessibility of the therapy office, childcare burdens, work commitments, etc.)? What did they want out of therapy? How were they responding to the interventions implemented so far? What did you notice about their engagement in the tasks of therapy? What about their presenting concerns may have actually made dropout more likely? (For example, if a client is seeking therapy to manage anxiety after months or years of engaging in avoidant behaviors, it is not entirely surprising if they choose to leave therapy when they learn what it feels like to confront their fears.) How was it to try to foster a connected therapeutic relationship that invited the client's emotional openness? What, if anything, got in the way of that process? What about this treatment felt like a good fit for the client? Why aspects of treatment felt less relevant or helpful?


Here, we aim to help the trainee develop an accurate sense of the constellation of factors that likely facilitated dropout. Then, we can turn to facilitating a gentle explanation of any pieces of this constellation that are the responsibility of the trainee therapist. Often, self-blaming explanations are the first reflections trainees will offer when asked what could have contributed to or made dropout easier for the client. Thus, they are usually not difficult to elicit. If trainees offer self-blaming explanations as the primary factor for the client's dropout, aim to help expand their viewpoint.


Supervisor: So, let's think a little bit about how to understand this because unexpected dropouts are a complex thing. What are some of the various factors that might have contributed to your client deciding to end therapy at this point?

Trainee: Well, I probably could have done a better job. Maybe if she had a better therapist, she would still be in therapy. I just can't help but think that.

Supervisor: Well, I understand why your mind might naturally take you there, and I'd like us to step back just for a second. You said a better therapist might have been able to keep her in therapy. Before we talk about therapist factors, I wonder if we might consider other variables for a minute. What in the client's life or environment served as barriers to therapy? Can you think of some of those?


Here, the supervisor is both normalizing the complexity of conceptualizing dropouts and helping the trainee expand their thinking beyond pure self-blame. Ideally, this is also helping the trainee gain a bit of distance from the painful emotions associated with self-blame by inviting a more cognitive process of self-reflection. After a discussion around factors other the therapist's actions, the supervisor can return to the question of the trainee's influence.


Supervisor: Okay, so you mentioned a few minutes ago that you are having some thoughts that your actions as the therapist might have contributed to her decision to end treatment. Can you say a little more about that?

Trainee: I just think that if I was a better therapist already or if she was seeing someone more experienced, then she would probably have wanted to stay.

Supervisor: Mmm, okay, so your mind is giving you a lot of thoughts about your role. Help me understand what you're imagining a more experienced therapist might have done differently that would have changed this outcome. [Here, the supervisor is attempting to move the trainee from global self-judgments to considering more specific behaviors.]

Trainee: I just think that someone who knows what they are doing would have done a better job with her.

Supervisor: And if someone 'knew what they were doing,' what additional things would they have done that you didn't do? What specific behaviors?

Trainee: Probably they would have been able to come up with interventions that were more helpful for her. I remember the day in session when I did the creative hopelessness exercise, you said that it felt like it didn't really stick for her. I feel like someone more experienced could have made that exercise hit home, and that would have helped her realize that she needs to be in therapy.

Supervisor: Okay, so what you're saying is that if that exercise had helped the client connect more with the ways her control strategies aren't working, she would have been more motivated to stay in treatment. [Reflecting the trainee's perspective before offering the supervisor's own perspective.] And there may be some truth to that. It may be that someone who has more practice with ACT could have led the client through these exercises in a way that might have resonated with her a little bit more. I would agree that there were times when your experiential exercises with her ended up feeling more like you were telling her some 'answer' rather than leading her to her own realization. [The supervisor gently acknowledges some of the trainee's behaviors that may have negative impacted the therapy.] At the same time, as we just explored, there are a lot of reasons why someone might choose to leave therapy. And even people who have been doing ACT for decades are still going to have exercises that don't resonate for a particular client on a particular day. Doing everything perfectly can't be the only way to have successful therapy or none of us would ever keep a client. So while I do want to work on getting you more practice with leading experiential exercises, I'm hesitant to say that that's the main or only reason that she chose to drop out. [Here, the supervisor again tries to expand the trainee's view, placing any errors they made in context.]


Sometimes, trainees might show the opposite behavior: rather than focusing on things they did wrong, they may attempt to avoid acknowledging any mistakes, even if you observed some therapist behaviors that likely facilitated dropout. In that case, it's appropriate to gently facilitate self-reflection.


Supervisor: Great, so you've already named several factors that could have contributed to the dropout. I totally agree - I suspect there were probably a lot of factors here. One thing we haven't talked about yet is that sometimes our own actions as therapists can contribute to a client's choice to leave therapy. [Here, the supervisor softens this discussion by looping themselves/other professionals into the conversation, 'our actions' vs. 'your actions in this specific case.'] In thinking back on the therapy, is there anything you can think of about your relationship with her or what happened in therapy that may have made dropout more likely for her? I'll just name that the point of this isn't self-blame but self-reflection: it's always helpful to reflect on our therapy and try to learn from it.


Of course, you could certainly experience a situation in which it appears that a trainee's behavior or behaviors were a primary (or the only) contributor to dropout. If that is the case, I would again advise gently acknowledging this reality. Sugarcoating likely isn't helpful, especially if the trainee's behaviors are important to change, such as limited relational skills or identity-based macro- or microaggressions against the client.


When a supervisee's client decides to drop out of therapy, a combination of warm validation around the pain of this situation, reflection around the various factors that contributed to dropout, and gentle acknowledgement of the ways that the trainee may have inadvertently contributed to the client's decision alongside a commitment to support the trainee's ongoing clinical development can be helpful.

Once you've created space to gently acknowledge the therapist's role in the dropout, it is important to help the trainee contextualize this experience within their overall developmental trajectory. Are the behaviors that contributed to the client's dropout expected of someone at this developmental level? If so, be clear about that. If the behaviors suggest that the trainee is behind where you would want them to be developmentally, you can acknowledge that as well. Ultimately, the goal is to the help the trainee continue to move forward in their development as a clinician, with your help, through supervision. Aim to frame this experience as a chance for learning and growth. Highlight how you and the trainee will work toward improvement in a way that will hopefully reduce (though realistically never eliminate) unplanned terminations.


Supervisor: It sounds like we agree that the therapeutic relationship was likely a factor in the termination. The client didn't seem to feel particularly connected to you, and that may have made it easier for them to decide to terminate. As we've discussed before, I think that continuing to work on your ability to communicate warmth and caring for the client will be important. You tend to ask a lot of questions in session, with less room for reflection and validation. While there are moments where those questions can certainly be helpful, when it becomes mostly about questions, you can sometimes miss the client, and in this case, I suspect she wasn't feeling heard and understood consistently. Since building a strong relationship is such a central factor in therapy, I think it makes sense for us to continue to work on those relationship-building skills in supervision moving forward. Given that you are in the second semester of your first clinical practicum, this seems like a really helpful focus at this point in your training, especially before you move to taking on more clients next year. I'd like to keep working on reflection and especially validation skills in our supervision together as a way to help you feel more confident in your ability to build strong therapeutic alliances with your clients moving forward. What do you think?


Here, the supervisor aims to name the trainee's area of difficulty in a way that is direct without being harsh. They reiterate that these skills are helpful ones to be working on at this point in the trainee's development and suggest a path forward in supervision, which hopefully helps to instill a sense of hope in the trainee that they can make progress around a current growth edge. This sort of statement could certainly be softened further, made even more direct (which I would recommend only in the case that a supervisee did not seem able/willing to acknowledge an error on their part), and/or slowed down and made more conversational by integrating Socratic questioning of the trainee. The supervisor could also consider ways of more overtly expressing their belief in the supervisee's ability to make these changes and enhance their clinical skills. How you frame this piece of the conversation will largely depend on how you are conceptualizing both your trainee and the dropout.


We cannot prevent all client dropouts. In fact, the data show that the modal (meaning most common) number of therapy sessions clients receive is one. One! Dropouts are common. The goal as a supervisor is to help the trainee reflect on the experience of a client dropout to develop a comprehensive conceptualization of the situation, promote an accurate self-conceptualization as a therapist, and ultimately foster learning and growth. Validate the trainee's emotions around this experience. Help them contextualize and conceptualize their role accurately. Approach this situation as a chance for growth, learning, and further development as a clinician. And finally, consider how you might share some of your own experiences with unexpected and painful dropouts, particularly if you can highlight a situation in which your own lack of skills, missed opportunities, or mistakes seemed to have contributed to a dropout. Research demonstrates that trainees particularly appreciate supervisor disclosures around their own mistakes as clinicians. Use your own painful history of dropouts (I'm sure you, like me, have a few!) to normalize your trainee's experience and demonstrate how to use client dropout as a chance for self-reflection and learning, rather than solely self-blame.

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