When Difference Is Mistaken for Resistance: Why Some Clients Leave Therapy Before It Ever Begins

Lex E Santí, LCSW, DSW-S, Clinical Director of A Key Therapy

Every therapist has experienced it.

A client attends an intake session, perhaps one follow-up, and then disappears. Phone calls go unanswered. Emails receive no reply. The case is closed with a familiar notation: client discontinued treatment.

We often ask why clients leave therapy after they are gone. A more important question may be whether they ever felt understood in the first place.

Research consistently shows that nearly one in five adults who begin psychotherapy terminate treatment before completion (Swift & Greenberg, 2012). Even more striking, most attrition occurs within the first few sessions (Barrett et al., 2008). Traditional explanations frequently focus on client-level factors such as motivation, readiness for change, or symptom severity. While these factors matter, they tell only part of the story.

Understanding Is Not the Same as Agreement

The first therapy session is an act of interpretation.

Clients arrive with stories about grief, fear, trauma, relationships, identity, and hope. Therapists respond by organizing those stories into clinical formulations intended to guide treatment.

Most of the time, this collaborative process helps people feel seen. Sometimes, however, the explanation offered by the therapist does not fit the client’s lived experience.

When that happens, disagreement can become a pivotal moment.

Rather than being understood as valuable feedback, disagreement may be interpreted as denial, resistance, poor insight, or lack of motivation. Once this occurs, the therapeutic relationship can begin to fracture before it has fully formed.

From the therapist’s perspective, the client simply failed to return.

From the client’s perspective, therapy may never have felt like a place where their story could exist.

Not Every Early Exit Is a Failure

Early termination is often viewed as evidence that treatment failed. The evidence is more nuanced.

Barrett and colleagues (2008) found that more than half of clients attending only one or two sessions demonstrated reliable and clinically significant improvement. Some individuals obtain exactly what they needed from a brief encounter.

Others leave for very different reasons.

Recent work by Notaerts and colleagues (2025) suggests that therapists and clients do not always agree about why therapy ended. What clinicians may view as premature termination can sometimes represent clients making informed decisions about whether treatment feels relevant, respectful, or helpful.

The challenge is distinguishing between these very different pathways.

Two Questions Instead of One

Rather than asking only whether clients are motivated, clinicians might consider two separate questions.

Do you want to be here?

This reflects autonomous motivation—the extent to which a person freely chooses treatment rather than attending because of outside pressure. Self-Determination Theory suggests that autonomous motivation predicts stronger engagement and better long-term outcomes than externally controlled motivation (Ryan & Deci, 2000).

The second question is equally important.

Does the explanation you’ve been given fit your experience?

Someone may deeply want help while simultaneously rejecting a diagnosis, interpretation, or conceptualization that feels inaccurate.

Conversely, another person may fully accept the explanation but lack the emotional resources, financial stability, transportation, or support necessary to continue.

Attendance alone cannot distinguish between these realities.

From the Therapy Room to the Larger System

The reasons people disengage from therapy extend far beyond the therapy office.

At the micro level, early impressions may harden into formulations before clients feel fully heard.

At the mezzo level, social isolation, family relationships, transportation, childcare, and community support all influence whether treatment remains possible. Research suggests that loneliness is more strongly associated with relationship quality and social participation than with network size alone (Child & Lawton, 2019).

At the macro level, insurance coverage, appointment availability, transportation, employment demands, and health-care systems shape access to care.

At the meta level, history matters.

Black Americans continue to be diagnosed with schizophrenia-spectrum disorders at disproportionately higher rates than White Americans, reflecting longstanding concerns regarding structural inequities and diagnostic bias (Faber et al., 2023). Earlier research also found higher psychotherapy dropout among racial minority clients and individuals with fewer socioeconomic resources (Wierzbicki & Pekarik, 1993).

These findings should not be interpreted as evidence that marginalized communities are less motivated for treatment. Rather, they remind us that some clients enter therapy carrying histories of invalidation, discrimination, and institutional mistrust that shape how quickly safety can develop.

Asking Better Questions

Social work has long emphasized person-in-environment perspectives. Therapy dropout deserves the same systems thinking.

Instead of asking:

“Why didn’t this client come back?”

Perhaps we should also ask:

• Did they feel understood?

• Did the formulation reflect their lived experience?

• Were disagreement and uncertainty welcomed?

• Were structural barriers mistaken for lack of motivation?

• What happened between the client’s story and the clinical record?

These questions shift our attention away from blaming individuals and toward understanding relationships, institutions, and systems.

Sometimes people leave therapy because treatment worked.

Sometimes they leave because life became overwhelming.

Sometimes they leave because they never felt seen.

Understanding the difference may be one of the most important clinical skills we can develop.

References

Barrett, M. S., Chua, W.-J., Crits-Christoph, P., Gibbons, M. B. C., Thompson, D., & Cucciare, M. A. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy.

Child, S. T., & Lawton, L. (2019). Loneliness and social isolation among young and late middle-age adults: Associations with personal networks and social participation. Aging & Mental Health, 23(2), 196–204.

Faber, S. C., et al. (2023). Racial disparities in schizophrenia-spectrum diagnoses: A systematic review.

Kessler, R. C., et al. (2008). Individual and societal effects of mental disorders on earnings in the United States. American Journal of Psychiatry, 165(6), 703–711.

McMurran, M., et al. (2013). Motivational interviewing and goal setting before treatment to improve engagement.

Notaerts, S., et al. (2025). Therapist and client perspectives on premature termination of psychotherapy.

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78.

Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559.

Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24(2), 190–195.