Why Therapy Doesn’t Work for Your Client

Therapy has been highly effective for many people but may not work for everyone. Counselors who are new in the profession may take therapeutic failure personally when it may be a reflection of other relationship dynamics. Therapy does not work for many reasons, including a mismatch in personality, client readiness for treatment, financial issues, or cultural misunderstandings. 

What increases the likelihood of a good match for therapeutic work is when counselors are matched with client issues they have experience with or specialize in. Counselors who have a passion for the work they do are more invested. This shows in the therapy room. 

When counselors have the competency or skill to work with a certain population or diagnosis, this can lead to a good match therapeutically. A 2019 study from JAMA Psychiatry in which a two-arm, double-blind, randomized clinical trial included 48 therapists and 218 outpatients found, “Matching patients with therapists based on therapists’ performance strengths can improve mental health care outcomes.” 

Personalities, regardless of your profession, can mesh well or clash. This can be due to differing views, opinions, or behaviors. The majority of behavior occurs on a nonverbal level. Some of what is unconsciously communicated as a counselor may be a turn-off for a potential client. When this is not acknowledged, it can cause therapeutic failure. At times, these differences are addressed and can be worked through. When the discord cannot be overcome, the counselor must transfer the client to a different counselor.

Building Rapport & Trust

Rapport-building begins at the initial counseling session and continues as the counselor builds a strong foundation for all future therapeutic work. Along with building trust, this part of the process is not to be rushed or forced. Rapport is a two-way street between counselor and client. The therapeutic relationship will break down if either party is not invested in building rapport and trust. Koole and Tschacher’s (2016) description of the Interpersonal Synchrony Model of Psychotherapy states,

The more tightly the patient and therapist’s brains are coupled, the better the alliance. Of course, the patient and therapist’s brains do not communicate directly. Their coupling can thus be achieved only indirectly, through the mutual coordination of the patient and therapist’s behavior and experiences. This mutual coordination is achieved through synchronous activities of the patient and therapist. Synchrony thus helps to establish the alliance, which in turn promotes adaptive emotion regulation in the patient, and thereby good therapeutic outcomes.

Sometimes, the counselor will have the competency and skills to work with a client, but there is a lack of harmony or emotional connection in the relationship and rapport is not built. This is okay and may happen at some point in your career. This is not a failure of the counselor but rather a reflection of human relationships.

Discuss with the client if the counselor and client are not connecting by the third or fourth session. It is important to not assume. Sometimes, clients feel more emotionally connected than they appear outwardly or can express verbally. Clients who have experienced abuse or trauma may need more time to open up and build trust with a counselor.

If the client does not feel comfortable with the connection, consider a referral to another provider. When the client asks for a change in providers, the counselor needs to look into a transfer for that client. It is essential for counselors not to take this request personally when a client chooses or asks to go to another therapist.

Client Readiness for Treatment

Another reason for therapeutic failure is the client may not be ready for therapy at this time. Often, clients don’t know how to verbalize readiness for treatment, but the counselor will witness certain client behaviors that indicate resistance. Therapy requires willingness and a commitment to work for the client and the counselor. If the client comes to the session and has not completed homework or has not tried therapeutic suggestions, it is worth having a conversation about what the client’s expectations of therapy are. 

Clients may show their ambivalence toward therapy when they become inconsistent with treatment. Clients routinely canceling or showing up late creates a barrier to achieving their therapeutic goals. This is often a sign that the client is not ready for treatment.

As a counselor, you will want to discuss these situations with your supervisor first. Some of these situations can be resolved through open communication with the client and a review of the therapeutic goals. If the goals for treatment do not accurately reflect where your client is, it may be time to revise the current goals. If you have attempted open communication, supervision, and goal review, consider an alternative type of treatment.

Clients may not be honest about what is going on in their life. This can be exhibited consciously or subconsciously. There could be hidden abuse or addictions the client is actively engaged in. If a client shows up intoxicated, the client will require more treatment than outpatient counseling. There are many times counseling alone is not enough. This is not a failure on the part of the counselor or the client. Consider the client for a brief hospitalization, detoxification program, or a day treatment program, where more structure is given.

Assumptions about Counseling

Clients come to therapy with different expectations about counseling. One of these is treatment duration. Instead of twelve sessions, clients may expect to feel better in six or eight sessions. These mismatched expectancies can lead clients to drop out of treatment early. Communication is essential at the beginning and throughout treatment concerning the methods used to make progress and the estimated goal completion time.

Starting at the initial evaluation, ask your client about their treatment expectations, specifically regarding the length and effectiveness of counseling concerning their symptom presentation. How will they know they are better? Do they have the support of family, friends, and their community? What are their beliefs about how a therapist should act or their role in helping them achieve their goals?

As you listen, be open, accepting, and curious. Once the counselor has this information, they can work to clarify any misconceptions, biases, or concerns the client has. Invite the client to continue these questions throughout treatment.

Child Care, Transportation & Costs

In the past, all therapy was handled in person. Today, many counselors can use virtual platforms to conduct therapy sessions. This can be useful to decrease dropout due to transportation availability or costs.

Some clients who have children can find it challenging to schedule therapy sessions. If the counselor can offer session availability when children attend school, it can decrease some issues with attendance. Clients with older children can ask them to play in another room while they attend sessions. Other clients may find therapy too challenging to invest their time and energy in when they have babies or young children who are at home with them. Hiring someone for child care and paying treatment costs can be a barrier to treatment for some clients.

Cultural Differences and Similarities

Cultural differences do not have to end a therapeutic relationship. When counselors are open to learning about their client’s culture and how it shapes their beliefs, they can know how this affects specific interventions. Counseling failure occurs when counselors do not consider their client’s culture or a counselor over-identifies with their client.

It is essential to address racial/ethnic minority concerns during the initial counseling evaluation. As counselors, it is wise to get comfortable taking responsibility for your limitations and be willing to grow. Being authentic and honest with clients helps build rapport. Hook et al., 2017 states,

Cultural differences may cause struggles or misunderstandings with your clients, or they may lead to an enriched therapeutic relationship that results in increased growth. Likewise, cultural similarities may lead to overidentification with your clients, or they may result in a close bond. The main theme is this: learn to get comfortable with acknowledging your limitations, owning them, and viewing them as opportunities to grow and connect with your clients at a deeper level. Becoming a better therapist is not an end state to be achieved through striving, but rather a continued process of growth in humility, openness, interest, and flexibility.

Ask for Feedback

Counselors must be open to feedback and keep the lines of communication open throughout therapy. When clients leave prematurely, it is an opportunity to review your own treatment style. Look at what you are doing well as a counselor and the areas you need to improve. It can be helpful to ask your supervisor or other colleagues what they see about your style of therapy and communication. Ask your clients what went well with their treatment and if any areas could be improved. 

Once you hear the feedback, be open to learning, growing, and acting upon those suggestions. Feedback can sometimes be challenging to hear, but the more open you are to receiving it, the better you will be as a counselor.

Lisa Hutchison, LMHC

Lisa Hutchison, LMHC

Writer & Contributing Expert

Lisa Hutchison, LMHC, is a licensed mental health counselor for the Commonwealth of Massachusetts. She works for professionals who want to treat and prevent compassion fatigue. With over 20 years of psychotherapy experience, she helps her clients assert themselves, set boundaries, and increase their coping skills. Her specialty is decreasing stress, anxiety, and depression while increasing realistic methods of self-care for those who help others. Ms. Hutchison’s psychological advice has been featured in Reader’s Digest and the Huffington Post. Her articles have been published in numerous magazines, including Grief Digest and Today’s Caregiver.

Lisa is the bestselling author of I Fill My Cup: A Journal for Compassionate Helpers and a faculty member writer for NetCE. Her latest continuing education unit publication is “Setting Ethical Limits for Caring and Competent Professionals.” She has taught creative writing in colleges and presented on boundaries for the compassionate helper; the use of expressive art to heal grief, anxiety, and depression; inspirational and motivational topics; and creative writing techniques.