working longer term

Author: Ann Lowe

(Please note that in this article we use the terms therapy/counselling and therapist/counsellor interchangeably)
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If you want to build up a private practice that can provide you with a living wage, you are going to need some long-term clients.  This is a simple matter of mathematics - if you need 18 clients per week to give you the income you need, and your clients stay for 6 sessions on average, you will need to find 3 new clients each and every working week. Apart from the fact that this is very difficult to achieve by your own marketing, it can quickly lead to you burning out too.

​read more> so how do you get long-term clients?

So how you you get long term clients?

There is a myth, which seems to have arisen in the early days of counselling, that six sessions is the “right” length of time for therapy. It still pervades the public sector and the EAP (employee assistance programme) world, where clients will be “sent” for six sessions of counselling, whether or not this is right for the client. Under exceptional circumstances, this might be extended to 12.

The consequence of this limit, is that counsellors and therapists start to work to this norm, and can start to feel that they are not good enough if they don’t get results in that time. A therapist with this mindset will start to give off subtle signs to their client that will bring about the ending after six sessions, whether or not this is the right time for the client to end.  It may be that some counsellors are best suited to short-term work, and that is fine, but you will need an agency that can supply you with a constant stream of new clients, such as the public sector or a charity to sustain a private practice this way. 

If you would prefer to work with long-term clients, here are a few points to ponder that can help you to shake off what you may have learned in your training or other work in the counselling sector so far, which may be blocking you from working with clients over a longer period of time:

1.  The six session norm is nothing to do with the good of the client, it is to do with getting as many people treated within a limited budget. Long-term therapy is expensive, and not many agencies are willing to fund it.

2.  To divert attention from the limited budget, one of the justifications used for short-term therapy is avoiding dependency. The argument goes that if a client stays too long they become dependent on the therapist, and this is a bad thing.  To answer this in depth is beyond the scope of this article, I will just point you to the Freudian or Psychodynamic approach, in which a certain amount of dependency on the therapist is encouraged, but it is then worked through so that the client comes out the other side much stronger and more independent. I believe that every therapist should have enough knowledge of these ideas to be able to work comfortably with their client’s dependency needs, because they are at the core of therapeutic change.

3. Linked to this is your willingness to engage in a close working relationship with your client. Six sessions is barely enough to develop a therapeutic alliance, and the longer you have, the deeper the relationship can become. Developing a professional form of intimacy with a client is part of the reward of providing long-term therapy, but if you are not comfortable with this it will feel threatening. And please note that this is not something you can hide from a client.

4. The best way I know to prepare yourself for the challenges of working long-term is to have long-term therapy yourself.  Many counselling training courses only require their therapists to have six sessions of personal counselling, and some other modalities don’t require any at all. I know personal therapy is expensive, but it pays off when you start to consider long term-work. There is a principle in therapy that you can’t take a client somewhere that you haven’t been yourself, so if you have no experience of therapy lasting more than six sessions you will find it hard to keep clients longer than that.

5. Returning to money for a moment, it’s worth looking at your own beliefs and conditioning around this difficult topic. Many therapists struggle to ask for money, and worry that in extending the length of the therapy they are exploiting the client. This is not helped by the way therapy can be portrayed in the media - the money-making “shrink”. Another way to look at this is to ask yourself how much it has cost your client to have their mental illness or psychological problem.  What has it cost them financially in divorces, lost jobs, failed businesses, alcohol consumed, time spent in hospital or prison?  What has it cost them in failing to fulfil their potential, which may not be measurable in terms of money, but in happiness and satisfaction?  What will it continue to cost them if you limit their recovery by cutting the therapy short?

How is long-term therapy different?

Each therapist who works long term will have their own ideas on this, and so here are a few of my observations:

Short-term work basically deals with providing coping strategies, information and relief of symptoms. Sometimes this is enough, and if a client gains a fresh insight into the origin of their problem this may be all they need to move on. 

Beyond that comes behaviour change, such as learning to replace drinking too much alcohol with a different form of stress relief. This is going to take longer, as replacing one habit with another requires time for the neural pathways to become rewired. Eventually the old habit withers away as the new one becomes established. You may be able to achieve this in six sessions, but the chances of a relapse must be high. The risk is that if the client feels they have failed, they may not give therapy another chance, and that is a lost opportunity for healing.

Beyond behaviour change is personality change, where we are looking at traumas, patterns and conditioning that may have been hanging around for a lifetime. I sometimes compare the personality to a tangled, knotted ball of wool, and the treatment to the careful, patient, teasing apart of the knots which is done by client and therapist in co-operation. There is no way this can be done in a hurry, as often when one knot is released the next one immediately appears.

Beyond personality change we enter a realm which is psycho-spiritual, as the client can start to allow their ego to relax and the higher self to emerge. To facilitate this as a therapist you definitely have to have trodden the path yourself, but even if you haven’t it’s worth knowing that the possibility is there, so that you can recognise it in your clients and refer them on to someone who can help. Spiritual awakening can look like mental illness to those who are not aware of it, and this can lead to a lot of suffering for the client before they find the right support.
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To summarise, finding long term clients starts with working on yourself, overcoming limiting beliefs about what therapy is and the ethics of working long-term, preparing yourself for the emotional challenges of working more deeply with clients, and broadening your knowledge of the field.

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