Monday, January 18, 2016

How Frequently Should Therapy Sessions Be?

When people come to see me, they usually assume I'll be scheduling them for a weekly appointment, probably because this is the norm for psychotherapy these days. But is this really the best format?

When psychotherapy first began, as psychoanalysis, patients attended sessions 4 to 6 days a week. It was thought that this was necessary to allow for the "free association" to reveal the patient's unconscious material. On the other hand, no one came to psychotherapy for 10 years, as happened later. Patients who were suffering wanted to be cured as quickly as possible.The original purpose of treatment was to cure neurosis, and once cured, it was thought it would not re-occur.

As I've outlined in previous posts, these days people come to therapy for a variety of reasons and some  people have personality disorders that are chronic. I believe the format of therapy should fit the individual patient. I see most people weekly, a few people every other week or in rare cases less frequently, and occasionally I have scheduled people for twice weekly sessions. 

I pick the format that seems to fit the individual patient and I expect that therapy could last anywhere from a few sessions to a few years, depending on the individual. 

 I generally start out with weekly sessions because this is usually enough to start therapy and fits most people's schedules. Some people ask to be seen less often and I evaluate this on a case-by-case basis, but I rarely agree to see people less than once a week within the first couple of months. I have found that some persons who ask for infrequent sessions at the start of therapy have intimacy issues or are afraid of making changes. Although fear is to be respected, it may be important to discuss the source of this fear rather than simply acquiescing to it. I've also found that people who request right away to be seen less frequently than once a week are often people who don't want to come to therapy at all but are being pressured by someone else, or for another reason not related to wanting to be in therapy. Change can occur in therapy at any frequency, however.

I have had a few cases in which I moved the patient to twice weekly sessions because I thought we were stuck and weren't getting to something important. Increasing the frequency of sessions can lead to a breakthrough in some cases. Psychoanalysts believe that therapy at least twice a week is necessary to generate something called "transference," which is really just a jargon term for the emotional relationship between the patient and the therapist (although technically it means the patient transfers a relationship from childhood onto the therapist).  I'm not sure this belief is true, as transference can occur in the very first session. But some people may achieve breakthroughs in more frequent therapy because they need the more consistent presence of the therapist to feel safe in making changes or dealing with difficult material.

In a few cases I have reduced the frequency of therapy because I thought the patient felt pressured to make changes he or she wasn't capable of. It's important for the therapist to respect the patient's limits. The more experienced that I have become as a therapist, the more clearly and rapidly I can see a patient's problems, but that doesn't mean the patient is ready to see what I see.

In general, people improve more quickly if they attend therapy sessions more frequently, but it is possible for some people to benefit from infrequent sessions.