Attendance vs. Retention: Why One Leads the Other

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If you’ve been around these blog posts for a while, you’ve heard us hammer away at “Teach your clients to attend.” It might sound weirdly obvious, like, of course, you want them to show up, right? But the more we dig into the data (and yes, the dreaded Excel spreadsheets), the clearer it becomes: Focus on attendance and retention naturally follows.

First, a Quick Recap

We’ve spent a good chunk of time talking about:

• First-session conversations: Setting client expectations from day one.
• Barriers to attendance: Money issues, scheduling conflicts, “I feel better now, so I’m out,” or just plain ghosting.
• Active client follow-up: Understanding who discharged whom and why.

All of these threads come together in our another push: retention. But here’s the kicker:

“Retention is a byproduct of client attendance.”

You heard it here (or maybe you heard it from me before). Translation? When clients consistently show up and do the work, they get clinical outcomes.  When they’re sporadic or don’t have the right frequency, your “retention” number tanks.

Understanding Attendance vs. Retention

Attendance (the “BETTER” KPI)

Attendance is measured by how many booked sessions a client actually attends. If you schedule 100 sessions in a month, and 80 are attended, you’ve got 80% client attendance. That’s a big deal! Why? 

1. It Reflects Engagement
   If clients value the therapeutic relationship, they honour their bookings.
2. It Minimises Cancellations & Reschedules
   You’re not stuck playing Tetris with your calendar.
3. It Tells a Clinical Story
   If your attendance percentage is low, something’s off: maybe your approach, maybe their readiness, maybe you’re not setting the right boundaries.

Retention (the Byproduct)

Retention is how many sessions clients collectively stay for, on average. For instance, if you’ve got 10 clients who total 100 attended sessions in six months, that’s an average of 10 sessions per client. Handy, but it’s also context-dependent:

• If you do short-term, solution-focused therapy, 10 sessions might be perfect.
• If you’re working with complex trauma or couples following a particular model (like Gottman or DBT), you might need 14–100 sessions or even more.
• If half your clients are severely depressed and can only front up for 1–2 sessions before ghosting, your “retention” might look dismally low. Even if you’re a fantastic clinician.

The reason we don’t fixate on retention alone? It’s easily skewed by a handful of long-term clients or by an influx of “one-and-dones.” Attendance, however, highlights immediate engagement. No matter how many sessions they should have, are they actually showing up?

“Time Under Tension Builds Muscle” (…Even in Therapy)

One of my favourite phrases from my trainer is: “Time under tension builds muscle.” Think of therapy as a muscle, if you don’t hold clients (and yourself) through the challenging, tense conversations, you never develop that therapeutic muscle strength. When you hold what is difficult (as the expert you’re meant to be), it:

• Builds Resilience for the Client: They learn to repair relationships rather than ghost the moment it gets uncomfortable.
• Develops Your Clinical Grit: You learn to handle tough feedback, set boundaries, and push for deeper work.

If a client wants to bail the instant the “ick” factor appears, active follow-up helps you re-engage them. You’re essentially saying, “Yes, therapy is uncomfortable sometimes. But that’s where real change happens. Let’s sit with this and work it out.”

How to Improve Attendance (So Retention Happens Naturally)

1. Nail the First-Session(s) Conversation

We keep banging on about it, but it’s vital. Slowing down therapy in those initial sessions to cover:

• What the journey typically looks like.
• What does your expert advice suggest for frequency and duration for their goals (yes, I called you an expert.  Why? Because you are a specialist (yes, I said specialist) 
• Why you need a final session (no ghosting, thanks!).
• How you’ll handle future cancellations, follow-ups, or even fee adjustments if finances get tight.

Clients can’t read your mind.  If you never say it, they won’t know.

2. Address Barriers Head-On

If you sense a money barrier by session two, don’t wait until the client is disengaged to discuss how they’ll fund further sessions. If your approach requires 14–16 sessions (like couples therapy might), let them know early and help them understand how they will get the best use of what sessions they can attend. You don’t want them bailing at session four, saying, “We can’t afford this.”

3. Own Your Authority in the Room

You are the specialist in the therapeutic process. If they’re showing up with “I’m not sure I need this,” or “I’m just here because my partner/GP told me to come,” it’s your job to educate them. Show them why therapy is more than a box to tick. When you establish trust and authority, attendance soars (retention follows and eventually so do client outcomes).

4. Follow Up Actively

When a client misses a session, check in. Show you care about their journey; not just your diary. Ask if they’re struggling with you or how you work or doubting the process. Remind them of the bigger goals you set.

• Use the method they prefer (text, phone, email).
• When you establish at the start that you’ll be following up - you’ve made it clear you’re not “hassling” them for a sale; you’re honouring your shared plan for their health.

5. Embrace Rupture & Repair

You will have tension in therapy. If they’re upset, show them how to talk about it in session instead of disengaging.  That’s real therapeutic growth and ironically (maybe? Am I using that right?), it boosts revenue. People trust you more when you can handle conflict.

Why Underserving Helps Nobody

Research shows that most clinicians will underservice out of a fear of over-servicing.  So on a final note: therapists in Australia don’t get stuck on the 10-session Medicare limit. This can lead to underserving, hastily wrapping up therapy because, “Welp, that’s all Medicare covers.” But does the client truly feel resolved? You are doing a disservice to your profession (and that elusive fight for your 20 sessions covered under Medicare). 

• If best practice says they might need weekly sessions for two years, talk about bridging the gap. Could they pay out of pocket for five? Could you space them out more? Offer a reduced fee if that’s clinically justified?
• Never assume they can’t or won’t find a way. If they see the value, they will surprise you.

When word of mouth spreads that you’re good at what you do (not just you saying “I’m worth this fee”, people often rise to the occasion. You’ll see it in your attendance numbers and, ultimately, in your retention.

Homework: Dig Deeper

1. Review Your Discharges
   Check who left therapy in the last six months. Did they self-discharge, or did you do it? Was it a ghost situation? Symptom reduction?
2. Add a Script
   In your next first-session conversations, mention your expectations for the last session, how you handle discharge, and what is the best consistency and frequency for the presenting issue.

Key Takeaway

Focus on attendance: the day-to-day showing up. Because that’s where the real clinical relationship is forged. Retention will grow as a natural outcome of consistent engagement. If you see a mismatch in your attendance stats, revisit your first-session chats, your boundary-setting, and your follow-up approach.

Remember: You can’t magically wave a wand to get perfect attendance. But by nailing the fundamentals, teaching clients to attend, addressing barriers, following up actively, and harnessing that “time under tension” you give them (and yourself) the best chance to create lasting change.

At Private Practice Alliance, we guide allied health practitioners to merge strong clinical skills with savvy business strategies. Ready to transform your approach to client engagement, attendance, and retention? Join our Practice To Profit 90-Day Profitability Challenge Waitlist.