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. 

Why I Don't Make Appointments Via Third Parties

About once a month, someone contacts me to make an appointment for a friend or relative. I no longer respond to these calls, because I don't have time. The fact is I don't take third party referrals, because I know the person won't show up if someone else makes the appointment.

I've pondered whether the person making the call really believes that their relative, friend or significant other will attend an appointment made by someone else. It's occurred to me these individuals making the calls may just want to be able to tell themselves that they tried to help. A better way to help someone is to tell the person what your limits are. If you find someone's behavior to be intolerable, the best thing for you to do is to stop tolerating it. Doing work for them that they could do themselves, such as making a psychotherapy appointment, does not help. If someone won't make a phone call to set up an appointment for treatment, that person definitely is not going to actually go to such an appointment. Going to therapy is a lot harder than making an appointment for therapy.

Why I No Longer Work With Children

I used to work with children in mental health clinics in Brooklyn and the Bronx, from 1997 to 2003. I also worked with children as 50 percent of my private practice from 2001 to 2005. I no longer work with children, however. I decided that since most of the problems I was seeing in the children were caused or exacerbated by their parents, it didn't make sense to treat the children. Psychotherapy was not what they needed.

Of course, some children do have real disorders, but those disorders, such as Attention Deficit Hyperactivity Disorder, Childhood Onset Bipolar Disorder and Childhood Onset Schizophrenia, are neurologically based illnesses that often require medication and frequently don't respond to psychotherapy. Children do develop anxiety and depression, but in most cases, anxiety and depression in children is just a response to a negative environment. Some of the most commonly diagnosed childhood "disorders" such as "Oppositional Defiant Disorder" are just terms used to describe what children do when they are angry about they way adults around them are behaving.

Here's a case that illustrates the pitfalls of diagnosing and treating children: In 2002, when I was working at clinic in the Bronx, I was assigned to work with a 12-year-old boy, whom I'll call as "Jose." He presented with many symptoms of depression and ADHD, including anger, agitation, restlessness and verbalized unhappiness. He was unable to sit still and seemed distracted. He had a history of being abused by his mother, and had been removed from her care and placed with another relative. We agreed I would see him weekly and also that he would be further evaluated by the clinic psychiatrist.

Jose's relative didn't bring him regularly for his scheduled sessions, and after he didn't attend his appointment with the psychiatrist, I called in a report to ACS (the Administration for Children's Services, New York City's child welfare agency). The ACS worker arrived at Jose's home to discover that he wasn't there and his caretaker had no idea where he was. After Jose was found, he was placed with a different relative.

The following week Jose was brought to his therapy appointment by his new guardian. All of his symptoms had miraculously disappeared. He was no longer restless, distracted, or agitated, nor did he appear to be sad. The clinic's receptionist asked me "is Jose taking some new medication?" All of Jose's symptoms had been a reaction to his environment. Because his new caretaker was empathic and genuinely interested in him and his welfare, he adapted to this new environment by acting like the normal boy that he was. I continued to work with him, because of his history of abuse, and he seemed well on his way to a complete recovery when unbelievably, his former caretaker went to court to try to regain custody of him. She'd felt insulted that someone had decided she was not a fit parent. Jose was dragged into a legal situation that re-traumatized him. The situation was eventually resolved, but only after Jose was subjected to further damage.

One could argue that if it hadn't been for my intervention, Jose would have continued to have been neglected and his mental health would have been in serious jeopardy. I would agree, but it doesn't change the fact that most of what I did for him was work that I wasn't paid to do. I worked as a "fee-for-service" therapist at the clinic and was paid only for therapy sessions. This model is extremely common in New York. All the work I did advocating for Jose--calling ACS, attending his court case and making follow-up phone calls--was unpaid.

Our mental health system simply isn't designed for children. In later posts, I'll describe more pitfalls of the system. For my personal well-being, I had to remove myself from working with children. Most children's problems need to be addressed by professional child welfare workers and advocates, not by psychotherapists. But because the system continues to describe children's natural reactions to negative environments as disorders, therapists and other mental health workers are often the persons who end up advocating for children's basic needs.

Five Things Your Therapist Wants You To Know

This is my first post for this blog. I'm a licensed psychotherapist in New York City. You can learn more about my practice at http://www.annerettenberg.com.

As a sole practitioner, I am the receptionist, office manager, billing clerk and quality assurance director for my practice. Most patients don't think about the complexities of running a professional practice, nor should they. But for my first post for this blog, I've decided to be upfront and tell any prospective psychotherapy patients a few things that the therapist they are going to see (me or anyone else) wants them to know BEFORE they call to make the first appointment:

1. We need to know what time you are available to attend a WEEKLY appointment. Psychotherapy isn't a one-shot deal, or an annual visit like a physical exam or dental cleaning. Even if you are "interviewing" several therapists to find the one that's right for you, it doesn't make any sense to schedule even one appointment with a therapist if that person doesn't have a slot that fits your schedule. Instead of saying "Are you taking new patients?" when you call or email, state the times/days that you would be available to attend weekly. "Are you taking new patients?" is a superfluous question, because if we aren't taking new patients, we will let you know.

2. We need to know how you're going to pay. I know this is an unpleasant subject. But if you're going to be attending weekly sessions, you need to know (and we need to know) if you can afford the treatment. Recently I turned away a prospective patient (whom I referred to a clinic) because he had no health insurance and an annual income of $18,000. Putting people into debt only increases their mental health problems. Sadly, our society limits healthcare for people with low incomes. This is a problem that I as an individual cannot solve.

3. We don't know the details of your health insurance plan. This is something every plan member should find out for themselves. Aside from scheduling psychotherapy, you need to know the details of your plan in case you need surgery or hospitalization. (If you want to see some dramatic stories of what happened to people who didn't know how bad their health insurance was, see Michael Moore's documentary film "Sicko.") Every major insurance company sells many different plans. If you have health insurance through your job, your plan may have a custom design.

4. The 6 p.m. slot is usually taken. Most people work 9-5 or 9-6, so many therapists are always booked between 6 and 7 p.m. If you can arrange with your employer to take a long lunch once a week, or you're willing to find something else to do between 6 and 7 p.m. and come to an appointment around 8 p.m., you're more likely to find a therapist who can give you an appointment. Long-term patients sometimes ask if they can be moved to a more convenient time once that timeslot opens up. This is how many therapists fill their 6 p.m. slots.

5. Your problems didn't develop last week. I will see people on an urgent basis (1-2 days) if they have had a recent crisis such as being the victim of a violent crime, or if they are mandated by their job for an assessment. For emergencies such as suicidal intent, I send people to the emergency room of the closest hospital. Most people, however, have problems such as chronic depression or relationship issues. Since these problems developed over months, years or decades, the first appointment for therapy does not need to be this week. If you can't wait one week to start your therapy your difficulty in tolerating a wait may be a pervasive issue in your life and this might be one of the issues you need to address in therapy.