What Keeps Clients Coming Back in Psychotherapy: Insights from Chicago - Based Authors

The journey of psychotherapy is often described as a partnership—a collaborative process between therapist and client that unfolds over time. Yet, in a world of competing demands and limited resources, what motivates clients to return to therapy week after week, sometimes for months or even years? This question has been the focus of extensive research and clinical reflection, particularly among mental health professionals in Chicago and across Illinois. Drawing on the work of influential authors and researchers from this region, this post explores the key factors that foster client retention in psychotherapy, weaving together empirical findings, clinical wisdom, and the unique cultural context of Illinois.

The Therapeutic Alliance: Foundation of Retention

At the heart of client retention lies the therapeutic alliance—the collaborative and affective bond between therapist and client. Edward Bordin, who spent part of his career at the University of Illinois at Chicago, is widely credited with conceptualizing the working alliance as comprising three essential elements: agreement on goals, assignment of tasks, and the development of a personal bond (Bordin, 1979). Bordin’s model, which has been foundational in psychotherapy research, suggests that clients are more likely to return when they feel aligned with their therapist on what they are working toward, how they are working, and when they experience a sense of trust and connection.

Research from the University of Illinois at Urbana-Champaign and other local institutions has consistently validated the centrality of the alliance. Horvath and Bedi (2002), in their chapter for Psychotherapy Relationships That Work, highlight that a strong alliance predicts not only lower dropout rates but also greater client satisfaction and better outcomes. This finding holds true across therapeutic modalities, client populations, and presenting problems, underscoring the universality of the alliance as a retention factor.

Judith Lewis Herman, a psychiatrist and trauma expert who trained at Harvard but has deep professional ties to Chicago, further emphasizes the importance of safety, trust, and collaboration in her influential work, Trauma and Recovery (Herman, 1992). Herman’s framework, widely adopted by Chicago-area clinicians, underscores that clients are more likely to return when they feel understood, respected, and empowered within the therapeutic relationship. For clients with histories of trauma, the predictability and reliability of the therapist become especially crucial, as these qualities help to repair ruptured trust and foster a sense of security.

Cultural Competence and Community Connection

Chicago’s rich diversity has inspired local clinicians to prioritize cultural competence and humility in their practice. Derald Wing Sue, who has lectured extensively in Illinois and whose work is widely cited in Chicago’s training programs, argues in Counseling the Culturally Diverse that therapists who demonstrate cultural awareness and adapt their approaches to clients’ backgrounds foster greater trust and engagement (Sue et al., 2009). In a city where clients may face systemic barriers, discrimination, or acculturative stress, therapists who acknowledge and address these realities are more likely to retain clients.

Community mental health centers in Chicago, such as the Community Counseling Centers of Chicago (C4), have long recognized the importance of hiring clinicians who reflect the communities they serve and who are trained in culturally responsive care. This approach not only enhances the therapeutic alliance but also signals to clients that their identities and experiences are valued. Research from the Illinois Department of Human Services has shown that culturally competent care is associated with higher rates of client engagement and lower rates of premature termination.

Flexibility and Accessibility: Meeting Clients Where They Are

Practical barriers—such as transportation, cost, and scheduling—can significantly impact whether clients continue in therapy. Therapists in Illinois, particularly in Chicago’s community mental health centers, have pioneered flexible approaches to care. Judith Cook, a professor at the University of Illinois at Chicago, has published extensively on the importance of accessible services, including evening hours, sliding scale fees, and teletherapy options (Cook et al., 2013). Cook’s research demonstrates that when therapy is logistically accessible, clients are more likely to continue attending sessions.

The COVID-19 pandemic accelerated the adoption of teletherapy across Illinois, breaking down longstanding barriers for clients who previously struggled to attend in-person sessions. Many Chicago-based clinicians report that offering virtual appointments has increased retention, particularly among clients with demanding work schedules, caregiving responsibilities, or mobility challenges. The flexibility to choose between in-person and virtual sessions allows clients to fit therapy into their lives, rather than the other way around.

Evidence-Based Practice and Outcome Monitoring

Clients are more likely to return when they perceive therapy as effective and relevant to their needs. John Norcross, who has collaborated with Illinois-based researchers, notes in Psychotherapy Relationships That Work that therapists who regularly solicit feedback and adjust their methods based on client progress see higher retention rates. The Feedback-Informed Treatment (FIT) model, implemented in several Chicago clinics, involves routine outcome monitoring and has been shown to reduce dropout rates (Miller et al., 2005).

FIT encourages therapists to check in with clients about their experience of therapy and their progress toward goals. This collaborative approach not only empowers clients but also allows therapists to make timely adjustments, such as shifting therapeutic strategies or addressing ruptures in the alliance. Research from the University of Illinois at Urbana-Champaign supports the use of outcome monitoring as a means of enhancing client engagement and reducing premature termination.

Empathy and Authenticity: The Legacy of Carl Rogers

Carl Rogers, who spent formative years at the University of Chicago, revolutionized psychotherapy with his emphasis on empathy, unconditional positive regard, and genuineness. Rogers’ client-centered approach, detailed in On Becoming a Person (1961), remains foundational in Illinois training programs and clinical practice. Clients consistently report that feeling genuinely cared for and accepted by their therapist is a primary reason for continuing therapy.

Rogers’ influence is evident in the work of many Chicago-based clinicians, who strive to create a therapeutic environment characterized by warmth, openness, and authenticity. This humanistic stance not only fosters trust but also encourages clients to explore difficult emotions and experiences, knowing that they will be met with compassion rather than judgment. The enduring relevance of Rogers’ principles speaks to the timeless importance of the therapist’s presence and attitude in client retention.

The Role of Hope and Meaning

Beyond the technical aspects of therapy, clients are often drawn back by the sense of hope and meaning that therapy provides. Chicago-based psychologist Dan Tomasulo, who has taught at Columbia College Chicago, emphasizes the importance of instilling hope in clients, particularly those struggling with depression or trauma. In his work on positive psychology and group therapy, Tomasulo argues that therapists who help clients envision a better future and find meaning in their struggles are more likely to retain clients over time.

This perspective is echoed in the work of Viktor Frankl, whose existential approach has influenced many Illinois clinicians. By helping clients connect with their values and sense of purpose, therapists can foster resilience and motivation to continue the therapeutic journey, even when progress feels slow or setbacks occur.

Systemic and Organizational Factors

While much of the literature focuses on the therapist-client dyad, systemic and organizational factors also play a role in client retention. Chicago’s robust network of community mental health agencies, university clinics, and private practices offers clients a range of options and resources. Agencies that prioritize staff training, supervision, and self-care are better equipped to support therapists in building strong alliances and managing the challenges of clinical work.

Moreover, Illinois’ commitment to mental health parity and Medicaid expansion has increased access to care for many underserved populations. Policy initiatives that reduce financial barriers and support integrated care models contribute to higher rates of client engagement and retention.

Conclusion

What keeps clients coming back in psychotherapy is a complex interplay of factors: a strong therapeutic alliance, cultural competence, accessibility, evidence-based practice, therapist authenticity, and the instillation of hope and meaning. Illinois-based authors and researchers have made significant contributions to understanding and implementing these principles, shaping the practice of psychotherapy both locally and nationally. By integrating these insights, therapists can foster lasting, meaningful therapeutic relationships that support client growth and well-being.

References

• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260.

• Cook, J. A., Copeland, M. E., Hamilton, M. M., et al. (2013). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services, 60(2), 246–249.

• Herman, J. L. (1992). Trauma and Recovery. Basic Books.

• Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 37–69). Oxford University Press.

• Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The Partners for Change Outcome Management System. Journal of Clinical Psychology, 61(2), 199–208.

• Rogers, C. R. (1961). On Becoming a Person. Houghton Mifflin.

• Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2009). Counseling the Culturally Diverse: Theory and Practice. Wiley.