Why do therapists keep clients for years?

I practised as a therapist for twenty years, and somewhere around my twelfth year this question stopped leaving me alone. I recorded this episode about it, and later wrote Twenty Years in the Chair to answer it properly. None of what follows is about bad therapists. Most of the people I trained and worked alongside were sincere and skilled. The pull I'm describing works through good people.

A model with no ending built in

The standard model is fifty minutes, once a week, using language as the main tool, inside a framework with no built-in mechanism for completion. Fifty minutes was designed around the therapist's working day. You're intensely connected to someone for fifty minutes and then on your own for the other hundred and sixty-eight hours, and each week the session starts again from the surface.

Nothing in that structure says when you're done. The way in is formal, with intake forms and a plan. The way out mostly isn't. In the book I put it this way: therapy doesn't end, it fades. Many of the long-term clients I saw weren't staying because they needed to. Nobody had told them they could stop.

Two hours on how to stop

In my training, ending therapy was covered in about two hours across a three-year programme. Out of thousands of hours on how to conduct therapy, two were given to how to finish it. I don't think that was unusual. When a profession spends so little time on endings, endings get left to drift.

The money, said once and fairly

Therapists are paid by the session. A client who improves and leaves is a loss of income. A client who stays is a steady one. That doesn't make therapists corrupt. It makes them human, working inside a financial gradient that always slopes the same way. The decision about when therapy should end is a judgement call, and it's made by a person with a financial interest in the answer.

I saw it in my own practice. When I started working deliberately towards endings, around my twelfth year, my income dropped. In the episode I wondered aloud what therapy would look like if it were paid for outcomes instead of sessions, and success meant a client who no longer needed it. It would produce different results. It would also be a very different industry.

The need runs both ways

The money is the part people talk about. The part they talk about less is the relationship. Therapists get attached to clients, and losing them is a real loss, even when the ending is right. Very little in the profession acknowledges that the therapist's own attachment is one of the factors in deciding when to stop.

And the better a therapist is at reflecting, the more the client can come to need the reflection. I was a mirror for a lot of people, and I got good at it. Over time the clarity lived in the room instead of in them. Outside it, the fog came back, so they came back. From the inside that looks like commitment to the work. It can also be a dependency both people are quietly comfortable with.

What long therapy can look like

One woman in the book came to see me for seven years. She had been the one who looked after everyone in her family since she was about eight. After seven years she knew herself better than almost anyone I've sat with, and she could describe her pattern in fine detail. It was still running her life. Her loyalty to the therapy, as I came to see it, was the clearest evidence of what the therapy wasn't doing.

That isn't the only story. For some people a long container is exactly right, and staying is the right call. The question is whether the work is still moving towards something, or has settled into a way of living with the pattern.

What changed in my own practice

In my last years in the room my measure changed. I started asking one question about each client: do they still need me? When someone left because they no longer needed what I offered, that was the success. I came to think the measure of a therapist's work is whether the client can leave it.

With one man who had been coming for nearly four years, I finally asked him directly: what would have to change in your life for you not to need this room anymore?

Questions to take into your next session

1. What would have to change in my life for me not to need this room anymore?
2. What does finished look like for me, and when did we last talk about it?
3. Between sessions, can I do for myself what happens for me in here?
4. If we set an end point, what would we do differently between now and then?

A good therapist will welcome these questions. The structure rarely raises them on its own. If you're wondering whether your own length of time is normal, I've written about therapy that lasts for years and how people know when to stop. If your therapist resists the question, read my therapist won't let me quit therapy.

Where this comes from

Twenty Years in the Chair is my account of the structure of the room, from the inside, and the woman and the man on this page are from it. On The Architect Speaks: Why years of therapy haven't changed anything for you and Why Therapy Stops Working: I sat in that chair for twenty years, then I left (Episode 510).