How do I know how much and how long I need therapy?
If you’ve been reading my posts, you may realize by now that I tend to take a different perspective than the ‘standard’ on many things. This one is no different. When it comes to making choices about the logistics of therapy, many assumptions enter in about what therapy is. These assumptions give a potentially false impression about needs, and therefore, control. I will try to use my experiences discussing this with people here to help you think this through as well.
“What do I need, doc?” Therapy and the disease model
Western therapy has gotten drawn into the medical disease model, but there has always been a schism. Early psychoanalysis saw itself as both identifying neurological disorders coming from individual deficits; and also, exploring meaning, power, and purpose in how to live as individuals in a fraught, complex society. Early behaviorism identified universal mechanisms of learning and their impacts, while it also presumed that some groups are “naturally” better than others at these (behaviorists no longer believe this, but the bias persists in many of the mechanisms of what and how information is gathered).
Illness model and capitalism
Though this tension has never left, we live in a capitalist country. People need to be paid. Payment comes from billing, and billing is tied to the disease model: clinicians are paid for treating illness. What does this have to do with treatment planning? The disease model creates a story of a specific, identifiable disorder, that therefore has specific, identifiable mechanisms to get rid of. Along the lines of, I have a bacterial infection with a certain severity, I take a specific dose of antibiotic for a specific length of time, and this eliminates the bacteria. There are problems with this even when it comes to bacteria, but largely this model is helpful for infections. However, when it comes to psychological challenges, the fit is highly suspect. What exactly is being eliminated? Where is the problem even located?
For example, if I have major work and relationship stressors, and I avoid them by drinking 5 beers a day, this is likely to create a whole host of additional problems. Do I “need” to eliminate the alcohol? What if I reduce to 2 beers a day? Or 1? Has that even addressed the problem? And if the problem is more about work and romantic relationships, then isn’t the problem socially shared? (Not necessarily evenly, of course. But how we determine responsibility has more to do with what society we want to create than some ‘truth’ about dysfunction.)
All to say, that when someone I’m working with in therapy asks me about how much therapy they need, I immediately want to shift the perspective from seeing this as something they need to something that we (mostly they) build.
“You’re the expert!”
Built into the idea that there can be pre-set expectations of how many meetings and how frequent, is the idea of expertise. This idea sounds something like this. I have read the research on how many sessions maximize outcome effects; I have read the research on different doses of therapy (session length, session frequency) to maximize outcome effects. The research breaks this down further, by diagnosis, by treatment method, by symptom severity, and sometimes by demographic factors as well. Great! According to the research, for your diagnosis and severity, the best effect comes from 12 weekly meetings of 45-60 minutes each, with a booster session 1 month later. All set, right?
Sorry. There are many reasons why this data is only marginally helpful.
Problems with individualizing group data
First, there are many factors these studies do not address. These studies track perhaps half-a-dozen important elements. But what about education level? Economic status? Whether you are in a city, suburb, town, or rural setting? Your spiritual/religious perspective? Not to mention a host of factors that may be directly related the problem. Your specific set of these factors may make your expectations different from the group.
Second is who we’ve collected the data on. For psychological research as of 2010, 68% of subjects were from the US and 96% from Western countries, comprising only 12% of the world’s population. And they were studied by Western universities (99%; data compiled in Henrich, Heine, and Norenzayan, 2010). For many people reading this, you may be represented. But most of the world is not. There have been efforts to improve this skew in the past decade, but more recent data suggests very slight improvements so far.
Measurement: What do the studies actually say?
Third, measurement issues. These are big. Researchers design studies to find positive results. They want to say, hey look! It works! This means trying to reduce variability. They want people who only have the target diagnosis. In the real world, multiple diagnoses are the rule, not the exception, making those who qualify for the study somewhat unusual. Studies often cut out people at the extremes of severity, where symptoms are below the cutoff for official diagnosis, or where symptoms are so severe the person may be in the hospital or have certain immediate risks.
Also, people qualify based on a diagnosis. Diagnoses have little evidence of real-world validity (i.e., meaning; diagnoses even struggle with reliability, or consistency of diagnosis across diagnosers and diagnosees). They do not necessarily match the variation present across people. The set of issues may overlap but not correspond to yours. Good treatments are tailored to you, not to an abstract somewhat-you.
Also regarding measurement, there is the question of outcome. What outcomes are important? Typically, studies address diagnoses (see previous paragraph). Therefore, outcomes are generally based on not having the diagnosis anymore. Sometimes they are slightly more specific: such as, how much did your level of depressive symptoms go down on the Beck Depression Inventory. But is this meaningful? I might feel less depressed, be sleeping better, and enjoying the time I spend playing mindless games and doom-scrolling social media. But if I’m still spending most of my time at home doing very little that connects with others, does that mean very much?
Nails in the coffin of the data-based expert decider
And finally, the most fundamental problem with these studies: grouped data. Researchers find an effect by washing out variability. As long as all the variation that comes from all the above issues is averaged to be smaller than the difference between how the treatment group did and how the various control groups did, the researcher deems the results significant.
Now if I were to mash all of us together into a human stew, this might be fine. But that’s not how it works. We are people, not ChatGPT. For each of us, we retain our individual unique mix of everything. All those factors that were not assessed, or that make you different from the 12%, or that make what you are looking for different from what the research puts as its outcomes: these mean nothing to the “gold-standard” randomized controlled trial. But they mean everything to you.
Therapy as supporting power and self-/community-determination
The final point I would like to highlight is about the purpose of therapy in the first place. Through the language of diagnosis, we think of therapy as about recovery, treatment, feeling better, getting rid of illness. People speak of “healing,” implying that they are somehow injured, or broken, or defective. Through this lens, we might base how much and how long for therapy on what it takes to get patched up or improved, and ready to take care of things. When we have a cold, we tend to stay home from work/school while feeling unwell, and then return not when 100% but when good enough, able to function adequately.
All of this is very mechanical. Bringing ourselves into the shop to be fixed and sent back out to do our job.
Responsibilities are, indeed, important. We have many responsibilities: to ourselves, to each other, to our communities. When someone comes to therapy, it is a sign that something isn’t working. But just like our responsibilities are not just to ourselves, when things aren’t working, it’s not just about us as individuals. We are strands of an intricate, dynamic fabric. Whether a strand is fraying has as much to do with how tension is handled across the fabric as it does with the properties of that strand.
When you look at the individual as an interconnected strand of this larger fabric, you can understand that parts of what may not be working cannot be solved in therapy meetings. No matter how many.
Therapy’s multidimensional purpose
Figuring out how much therapy therefore involves looking inward and outward. Some work is done in meetings, others through “homework” assignments throughout the person’s days. Yet other work involves figuring out how to position each of us as allies with each other to tackle bigger problems.
This outward look means helping people find their voice and their power.
Doing therapy: How much?
So coming back to the initial questions – how often should I meet? Putting all the above together, I often approach this fairly pragmatically. The help I can provide fits into a much larger puzzle of resources (including money, social support, environmental supports), time, energy, and immediate and long-range goals. Some of those factors may be more important at one time, and less important at others. As the person explores and grows, priorities and resources will shift. Ideally, the frequency of therapy can shift in harmony with these changes.
You might be surprised to hear that I think meeting length (how many minutes per session) is fairly straightforward. We need enough time to enter fully into the topic, help people step back from assumptions and preset ways of understanding it, try new ways, discuss what just happened, and consider where to take it next. There are also individual factors, such as how skilled the person is at being able to look at these things and keep their attention going. And content factors: some things are simple and quick to approach, others way more complex or slow to work through. I’ve found in a minority of situations, perhaps 10%, 30 minutes is indeed adequate. In a majority, perhaps 70%, 40-50 minutes is quite nice for this arc. And then in the final 20%, more would be beneficial.
How much: real world
Briefly stepping down from the clouds and bringing things into the real world: most people do not have access to these options. Particularly if wanting more frequent meetings. Most therapists are social workers in clinics where they are expected to be meeting with nearly 100 people. You do the math. Most people only have access to seeing a therapist for 30 minutes, every other week. Unless the person is in a crisis, therapists cannot even consider the above factors. (And think about the consequences of making it so that you only get the support you are looking for when you are in a crisis.)
Doing therapy: How long?
Again putting all of the above together, I have become very fluid on the question of how long a person should be in therapy for. Goals may be very specific, in which case you can monitor how it is going, make adjustments, and end once those goals are complete. Goals may be more fluid or complex. Often, goals change as the person grows and understands more about what they are trying to cultivate. This is not to say their initial goal was wrong. Just because the goals of a 40 year-old are different from the goals of a 20 year-old does not make the 20 year-old’s wrong. We are constantly changing and our goals change with us.
I’ve heard therapists say you should commit to a certain number of sessions from the start, to “give it a chance.” I disagree. I find people are fully committed to what they see as why they are meeting, from the start. If this doesn’t look like what I believe, that’s on me. When I show people that I’m with them on this journey, no matter how that looks, that gives them the space to make meaningful decisions for themselves. If they leave meeting 1 understanding what this is about and thinking, “This isn’t the time” or “That’s not what I’m looking for right now,” great! I value giving that clarity to shape their lives positively, even if it means no next session. “No” can be a powerful action.
Summary: Therapy logistics, trust, and power
Think about diet as a parallel. Sometimes we have the time to plan out nutritious meals. Sometimes we have time to make changes to routines to be healthier. Other times we don’t. Sometimes what we’re putting into our bodies is top priority, other times it is less so. Does each meal have impact? Of course. But if this month, while dealing with work responsibilities, family responsibilities, bills, chores, etc., I decide I’m going to work on sleep and let meals fall out how they will, or hey, not work on anything additional at all, that’s okay. I’m not a machine. I can trust myself to care about my health and set priorities and goals as I can.
I trust the people I work with in therapy to do the same. (Many times, more than they trust themselves!)
Some of you may have been reading this, hoping for answers. I know this post does not do that. Instead, I’ll leave you with this: the answers, as much as there are answers, are (or will be) in you.