Client Retention: A guide for child and adolescent therapists

when it comes to providing telehealth services for children, client retention is key for long term success the majority of children who are seeking mental health services are likely going to need several sessions and require ongoing support and care as hopscotch telehealth providers, it's important to communicate to parents and caregivers that multiple sessions may be necessary to achieve the best possible outcomes for their child's health and well being by emphasizing the importance of regular check ins and follow up appointments, we can help parents feel confident in their decision to choose telehealth services and build a strong relationship with our clients ultimately, focusing on client retention can lead to better outcomes for both the children and their families, while also helping to establish hopscotch telehealth providers as a trusted and reliable source of care in the telehealth industry while it's important to attract new patients, it's equally important to focus on patient retention develop strategies to keep current clients engaged and satisfied with your services, which can lead to positive word of mouth referrals are your client’s leaving too soon? you've worked hard at your marketing you're excited to begin working with your new clients, but you're starting to notice that caregivers only schedule one or two sessions with you after those sessions, you begin experiencing "no shows", cancellations, and even "ghosting" by caregivers you're frustrated and even perplexed as to why this keeps happening you thought things were going well some of these client/caregiver avoidance behaviors may be linked to the virtual relationship itself uncomfortable and difficult conversation are hard, so it can be easier to just not have them, and solely online interactions makes it more tempting to stop communication without providing further explanation a child or adolescent client’s termination of therapy before meeting treatment goals is usually a result of the caregiver’s decision or influence the parent/caregiver is usually the one scheduling and paying for sessions with older children and teens the minor client may have more influence regarding therapy continuation child and adolescent clients and/or their caregivers discontinue therapy with their counselor for many reasons common reasons why therapists may find it difficult or impossible to retain clients financial reasons (i e caregivers may be unable to afford the cost of treatment, including copays or deductibles, or a potential job loss or change may have occurred affecting insurance and/or financial resources caregiver priorities and motivations for therapy may have changed caregivers may be busy seeking support for their own mental or physical health issues family stress could be mounting, and the caregiver may feel too overwhelmed to keep up with their child’s treatment due to a hectic family schedule there could be an illness in the family, or another family member’s needs might be taking priority they may have moved or have unstable living arrangements lack of rapport between therapist and client and/or caregiver client’s needs are outside the therapist’s scope of practice or niche client (and/or caregiver) is not ready to begin or continue the therapeutic work and make needed changes for progress client or caregiver’s lack of confidence in the therapist client or caregiver feels therapist doesn’t understand their child or family’s problem(s) or needs and cannot agree on course of action caregiver has unrealistic expectations client or caregiver believes they are not seeing any improvement or changes (or as quickly as they had hoped caregiver feels their child's behavior has gotten worse since beginning therapy these are just a handful of plausible explanations why retention might not be possible, and there are dozens more not all of these issues are solely influenced by the therapist’s actions, but the therapist does have many opportunities, and possibly even an ethical responsibility, to discuss, educate and offer the client/caregiver a different perspective on some of these issues things happen – when retention is not an option even with the strongest rapport building skills and client retention strategy, the reality is that sometimes things just happen so many factors are far beyond your control, and there are times when retaining a client may simply not be an option but keep in mind, an unretained client is certainly not a reflection of your abilities as a clinician it can understandably feel disappointing and even demoralizing when a client does not return, but a client who does not return is a situation every clinician faces – so don’t lose heart! by following the prompts in this guide, you will be set up for success, and in time, your client retention rate will improve, thus helping you to meet your private practice goals! retention is an ongoing process client retention is an ongoing effort on the part of therapists that requires intentional and proactive approaches throughout each phase of treatment it’s important for therapists to remember that from the initial contact to the intake, and throughout the continuation of working sessions, having and consistently employing a retention strategy is a must for all child and adolescent therapists it’s also crucial that the therapist keep in mind the stages of therapy with a child/adolescent, and help educate (and remind) parents of this process, as this will influence a client or caregiver’s willingness to continue services there are many ways to improve your client retention rate, and having a good rapport with your clients is the foundation of every strong retention strategy the connection between rapport and retention a successful retention strategy always begins with establishing and nurturing rapport, because without having a rapport with your clients, retention is nearly impossible the reverse is also true, and by cultivating a strong rapport, client retention is almost inevitable in many ways, client retention starts, continues, and even ends based on the quality of your rapport, and it could be easily argued that a strategy for building rapport with clients is a client retention strategy how to build rapport and retain clients there are many ways to build rapport and retain clients, and in this guide, we will take a comprehensive look at the three primary methods for building rapport and retaining clients it is important to clarify that the three primary retention methods listed above are not chronological rather, they occur simultaneously and continuously throughout every stage of the client treatment cycle let’s explore how… rapport & retention method #1 communicate all essential information communicating all essential information includes everything from expectations and functionality to processes and obligations related to the therapeutic relationship avoid assuming that the clients know what to expect instead, set and provide frequent reminders of expectations from the beginning below are essential topics clinicians can communicate to clients ☑️ communicate expectations when a clinician client relationship seems “off,” it is typically because expectations are not sufficiently clarified it is common for caregivers to have preconceived expectations for child therapy, such as what all is involved, how it works, and how it progresses to ensure the caregiver’s expectations are reasonable, realistic, and accurate, it is important to examine these expectations holistically before administering therapeutic care expectations should be set early on, and the intake session with caregivers is a good time to align expectations remember, they are looking to you for guidance by having this conversation upfront, you are in a better position to avoid clients “ghosting” you, no shows, and other scheduling mishaps the therapist should take the lead in initiating this discussion and be prepared to follow up with the caregivers to reiterate or update expectations as needed throughout the course of treatment time for reflection ideally, what expectations do you have for the therapeutic relationship? (for example, how will you communicate with the parent between sessions, how often do you meet with parents, how do you determine progress is being made, etc ) what are the “line in the sand” expectations (i e confidentiality) and what are the expectations around which you feel you can compromise? ☑️ communicate how therapy works with children avoid assuming the caregivers know what to expect in therapy they often don’t and even if their child has been in therapy previously, therapy with you may look different the myths and preconceived ideas surrounding therapy – particularly teletherapy, child therapy, and play therapy – are abundant, and the reality is that most caregivers do not know what teletherapy, child therapy or play based therapy is or how it works they are also likely to be unfamiliar with clinical jargon, such as attachment style and level of care, and acronyms such as ace’s, scared assessment, or cbt to name a few it is therefore necessary to give caregivers a general overview on what teletherapy with children is, what it is not, and how it works, and check for understanding during parent meetings doing so can help clear up any misunderstandings and minimize preconceived ideas related to therapy which helps to set the relationship up for success another example of a common misunderstanding related to child and adolescent therapy is that many caregivers provide child therapists with a “list of problems to be discussed” with their child in therapy sessions this is usually because parents have a preconceived expectation that their child will primarily be talking in therapy sessions about everything that the parent thinks is going wrong or is concerned about this is often not the case, and when caregivers learn that their child might be playing or engaging in activities in therapy, they might draw inaccurate conclusions about the efficacy of such treatment unless they are otherwise informed if a child has previously been in therapy, it may be helpful to initially explore with the parent what went well and what they wished had been different in that therapeutic relationship doing so allows you to learn alot about what the parent might be expecting for their child’s sessions with you and give you an opportunity to address anything that you foresee as problematic caregivers rely on you as the expert to tell them what they need to know, and taking time during your intake session with caregivers to briefly explain how child therapy works can be extremely helpful for proactively mitigating issues of unmet expectations by helping caregivers understand what a typical session looks like and why the sessions function the way they do, caregivers have the opportunity to align their expectations accurately and appropriately communicating how child therapy works to caregivers does not need to be complicated, and it can be as simple as showing them the short introducing andrew video during the initial parent call ☑️ communicate expectations based on the stages of therapy clinicians have the opportunity to establish rapport by briefly covering the stages of therapy with caregivers during the preliminary intake session (see “stages in play therapy” link for reference) healing progress is not a steady incline, and even less than neutral reactions to therapy such as resistance are completely normal in fact, the resistance stage of therapy is often a key indicator of a client’s growth however, if caregivers are unaware of the stages of therapy, they may (understandably) negatively interpret their child’s reaction and assume that the treatment is not working, leading to prematurely ending therapy and “no shows ” this misunderstanding can be circumvented by educating caregivers on what to expect as treatment progresses ☑️ communicate your obligation to confidentiality especially for adolescent talk therapists, taking the time to ensure caregivers are crystal clear regarding confidentiality obligations is essential caregivers may have the expectation that you can and will tell them everything, but as clinicians well know, there are limitations to what can be shared even if confidentiality limitations are spelled out in paperwork, it is best to ensure that caregivers understand the limitations of what you are permitted to share by verbally addressing this topic with them upfront this discussion may happen many times over the course of the child’s treatment, including at intake, parent check ins, and when parent’s inquire about what their child might have said about a particular topic be prepared to explain the reasons behind confidentiality limitations so that the caregivers understand how a certain degree of privacy benefits the therapeutic relationship and ultimately helps the adolescent progress in therapy to be sure, an alliance between clinician and caregiver is crucial, however limitations, such as upholding confidentiality and not interviewing immediately following a session, must be taken seriously ☑️ communicate how you will communicate with caregivers between sessions from the beginning, caregivers need to understand their involvement and how you plan to include them some therapists meet with parents at the beginning and/or end of every session, while others prefer to schedule regular caregiver follow ups for progress updates and debriefing, such as after every 4th session with the child whatever your preferred structure, be upfront during your initial consultation and intake about your expectations as you communicate the extent of caregiver involvement that will be needed ☑️ communicate format nuances to pre emptively address any technical or scheduling issues that may disrupt the routine it is important to proactively acknowledge financial issues and the challenges of telehealth versus in person treatment and provide caregivers with a plan for how such nuances will be addressed for example have a protocol in place for what to do if a session needs to be rescheduled have a structure for how caregivers can reschedule an appointment specify what accommodations are available or unavailable if an appointment does not begin promptly on time for virtual therapy sessions, it may be helpful to provide a back up plan in case technical issues are encountered remind parents of the notice required for canceling sessions and the financial consequences stated in their agreement for no shows or late cancellations during the intake ☑️ provide clear communication for progress tracking calling attention to progress and taking the time to notice the strengths of the patient and their caregiver is a proven way to build rapport and encourage retention, however the onus is on the clinician to track and communicate progress to this end, caregivers might need your help to identify and understand what true progress looks like, since the progress achieved may not match the expected progress the caregiver imagined especially for caregivers who may be experiencing parental burnout and may be too overwhelmed to even notice progress, it is paramount for clinicians to take the time to communicate the ways in which progress is identifiable and trackable when identifying and tracking progress, the value of progress over perfection must be communicated for example, suppose a client, johnny, was getting negative reports every day from school when he started therapy, but now he is only getting one or two a week from the caregiver’s perspective, johnny is “still getting negative reports,” but the reality is that progress has been achieved and thus should be positively reinforced not only does calling attention to progress set the stage for progressive treatment solutions, but in some cases, it may also signal that a decrease in frequency and/or duration of treatment may be appropriate (hopscotch providers will soon be able to track and share progress through child and adolescent assessment tools within the platform) time for reflection we know this is a lot to communicate to families take time to consider the best ways for the families you work with to receive and digest this information what are your strategies to help your families know what they need to know as you begin your work together? what fits your practice and personal style? will you spread it out over multiple sessions or cover it all in your intake and repeat again? will you create a handout? do you need to write it down and keep a checklist for yourself? do you need to polish up a verbal run through? rapport & retention method #2 become an expert in your client’s motivation for many reasons, we recommend focusing on understanding the various motivations during the client intake during this first session, the emphasis should be dually focused on identifying and managing the separate motivations of both the child/adolescent and the caregiver children and adolescents are typically the ones being labeled as the “identified client” and potentially seen by others (school, family, after school programs, etc ) as the problem as such, the child/adolescent may not be happy about being brought in for therapeutic treatment the child may also view therapy as a punishment for their challenging behavior if it was presented by an adult as a consequence taking the time to understand both the caregiver’s and the child/adolescent’s motivation for therapy can have a powerful influence on how receptive the child/adolescent is to treatment, and it also provides the relevant context necessary for cultivating engagement within each session be mindful that both the children/adolescents and their caregivers want to feel seen and heard, and when the duality of motivations are in opposition, acknowledgment and empathy for both perspectives is needed gaining a deep understanding of what your client’s motivations are will ensure all parties involved are on the same page and working towards the same objective keep in mind that even if caregivers don’t know how to verbalize their motivations, they certainly still have a motivation and a reason for seeking therapy for their child/adolescent it is important that you address this motivation by asking the right questions, and when you do this upfront, you can build strong rapport from the beginning for example, you could ask, “i’m wondering what led you to seek therapy for johnny at this time ” the motivational discovery conversation is a good time to re communicate your commitment to confidentiality obligations, because doing so can help correct inaccurate preconceived expectations additionally, in some instances, communicating the limitations of what will be kept in confidence can have a profound influence on the motivation for attending therapy, and in some cases, once a child/adolescent understands that they are to receive a degree a confidentiality, any motivations they may have for not wanting to attend therapy may be neutralized caregivers have a right to be kept informed on their child’s treatment, and a caregiver’s involvement can be very helpful there are times, however, when a caregiver’s motivation may inadvertently contribute to the child/adolescent’s problem due to a misaligned or inaccurate understanding of the problem itself in order for a caregiver to see the positive changes they desire, there may need to be a willingness to adopt parenting techniques that support therapeutic treatment principles to this end, a clinician might provide parents with homework or suggest parent therapy to support at home adoption of in session principles and activities time for reflection think of your client’s motivations as possible variables that you have some, though not all, influence over how can you go about assessing their motivation from session to session? what will be some of your “go to” strategies to jump start motivation for a child, for an adolescent, or for a parent? rapport & retention method #3 assert yourself confidently no discussion about client retention is complete without acknowledging the self sabotaging effect imposter syndrome can have on client retention imposter syndrome is a psychological tendency for an individual to doubt their ability, skill, or worthiness, and those who struggle with imposter syndrome may cope with a persistent, internalized fear of being a fraud imposter syndrome does not discriminate, and even fully qualified therapists may struggle at times to feel like the experts they are nevertheless, a therapist’s confidence in their own abilities has a strong influence on client retention, and thus it is important to take steps to overcome imposter syndrome and respectfully assert yourself with confidence keep in mind that one of the reasons why so many therapists struggle with confidence and imposter syndrome, is because therapists are some of the most open minded and compassionate people you understand so well just how nuanced people and situations can be, and this humility and compassion is precisely what makes you exceptional and qualified 3 ways to respectfully assert yourself to retain clients with confidence \#1 focus on patient retention by securing several appointments in advance as a pediatric counselor, many families will look to you for your expert guidance on whether to continue sessions over the summer, decrease their frequency or pause them with their child while spending time together and engaging in recreational activities are important, a lot of children may still benefit from regular therapy sessions over the summer to maintain their progress and continue moving forward in their treatment parents may not realize the importance of maintaining continuity without you bringing up the topic and sharing your recommendations with new and current clients, take time before summer and the holidays to initiate this discussion with families and proactively manage your schedule here’s an example of what you could say to a parent/caregiver "as we look ahead to the summer months, i would like to discuss scheduling with you given that both of us may have some time off and johnny may have some summer plans, i think it would be beneficial to schedule regular check ins (or “booster” sessions) every other week (or once a month, etc ) to ensure that johnny continues to make progress in therapy and to address any new parenting challenges that may arise what are your thoughts on this? (pausing for feedback) it would be helpful for us to schedule the next 4 sessions in advance to ensure that i have availability if something comes up, just let me know at least 24 hours in advance so we can reschedule let's take a look at our calendars and book these appointments together ” \#2 take initiative on discerning whether or not a client is going to be a good fit discerning client fit is a decision only the clinician and the client can make, and since you are the expert, it is both acceptable and even encouraged for you to take initiative on determining fit if, in your judgment, the client is not a good fit for you and your services, it is appropriate and expected for you as the clinician to make the necessary referrals at any time during the therapeutic relationship you may want to utilize peer consultation to determine if there are any other options besides referrals before you speak to the parent about this possibility participation in peer consultation groups and/or your own therapy can be helpful in identifying any other issues impacting the reason for referral and provide opportunities for professional growth \#3 embrace learning curves the world of psychology is full of learning curves, and the ability to learn quickly can serve your practice well whether you are needing to learn more about a presenting issue one of your clients is exhibiting or requiring support with setting your practice up for telehealth, take confident initiative and reach out for help if needed hopscotch offers complimentary peer consultation groups, and our director of community, michelle rigg, is available to provide individual support schedule a consultation with michelle \#4 ask for the next appointment! being proactive and encouraging caregivers to set up more than one appointment in advance is helpful for all parties involved either before or following a session, you could simply say, “schedules fill up quickly, and in order to ensure we maintain momentum, why don’t we go ahead and schedule our next three or four weekly sessions and a parent check in?” is retention and ongoing scheduling a struggle? talk with parents at the beginning or end of sessions about scheduling it can also be helpful to schedule more than one week in advance taking initiative on requesting future appointments takes confidence, but since retention is contingent upon those future appointments, finding the confidence is well worth the effort confident follow ups are important both for building rapport and retention, and checking in with caregivers following a canceled or missed appointment is part of schedule management responsibly handling your bookings with confidence is an ongoing process, and having a plan in place for reminding clients to schedule sessions is highly recommended utilizing hopscotch’s easy scheduling system can also help provide tremendous confidence with scheduling continuing sessions if you or your clients need help with implementing or utilizing the easy scheduling feature, please visit hopscotch’s help library or contact a support team member time for reflection take a moment to look back and assess how things have gone when you have asserted yourself confidently vs times when that has not been the case as you utilize some of the above strategies, make note of your efforts and reflect on the outcomes what is working? what is not working? what may need to change? use this information to improve your therapy process moving forward am i using easy scheduling? if not, could this benefit my practice and have a positive impact on my retention efforts? need help retaining clients? hopscotch loves to help providers grow their private practice! if you have questions about scheduling or retaining clients, or anything else related to practice building, schedule your 1 1 consultation with michelle rigg, hopscotch director of community