Is Longer Really Better?

I recently got into a discussion with some therapists in a networking group that I'm a part of about how we all tended to have the same beliefs concerning how often and how long treatment sessions should be. For example, most of us adhered to what's commonly referred to as the “50 minute hour”, which splits a typical session into 50 minutes of contact time and leaves 10 or so minutes for recording case notes. Ideally, these sessions were being held at regular intervals. A weekly or twice monthly frequency was most common. For clients who could afford the luxury, or perhaps in the event of a crisis, twice weekly sessions were not uncommon. At the other end of the spectrum, when therapists were busy and schedules get blocked in, the frequency of sessions could slow to once every three or four weeks, and sometimes even longer. Behind all of this lurked a key set of beliefs that can be summarized as follows: In an ideal world, most therapists would have an hour for every session, meet with each clients every week or two, and continue with sessions for as long as it took to get symptoms down to “normal” levels. 

Given that everyone seemed to be struggling with the same questions that I was facing when it comes to how often and how long treatment sessions should be, I offered to dig a little deeper to see if we were missing something. To accomplish this, I performed a quality assurance review in one of the clinics I worked at. I started with a large group of records for adult clients in therapy. The available data included the mental health diagnosis, whether the client was taking any medication, how frequently they were being seen, and how long treatment lasted. I compared this information with session-by-session records of symptom severity, thanks to the clinic’s routine use of Myndplan’s mood monitors. What I discovered surprised everyone, and was consistent with some findings that were emerging in recent academic research studies. Here are 5 of the most important findings that emerged:

Real Clients Are Different Than Research Participants

Unlike the type of client in research studies that typically suffer from just one discrete problem, such as major depressive disorder, nearly all of the clients I looked at described a mixture of both anxiety and depression, and many had additional diagnoses, like opiate addiction or alcohol dependence. I also discovered that most were already taking some form of antidepressant medication to treat their symptoms when they were referred. This meant that therapists were seeing clients with more complex issues than those who populate most treatment research studies, not to mention that we were trying to treat people who were probably not getting an ideal response from medication. In other words, the problems facing the typical client that most therapists work with are much more complex than the ones that research studies base their findings on when looking at things like treatment effectiveness. 

Initial Symptom Level Matters

Based on my file review I was pleased to learn that despite how serious their problems were, on the whole many of the clients were improving significantly with respect to their life satisfaction and key symptoms of depression and anxiety. Even when I controlled for the passage of time, which in itself can bring about healing, therapy proved to be having some beneficial effects. However, there were a number of surprises. For example, I discovered that the symptom levels described at the start of therapy were very relevant to outcomes. People who started therapy with more severe symptoms and lower ratings of life satisfaction in comparison to other clients tended to end treatment with lower life satisfaction and higher symptom distress. But they also showed the same degree of improvement. In other words, people who start off worse finish worse, but improve just as much. 

Different People Show Different Rates of Change

I also learned that regardless of how severe a person’s symptoms were at the start of therapy, different people experienced different rates of change. Some clients improved quite dramatically from one session to the next, whereas others seemed to improve more slowly. Furthermore, some very specific client characteristics predicted this rate of change. When taken together with our finding about symptom severity, this means that with the right tools it should be possible to identify not only how quickly a client is likely to respond to therapy, but also how many sessions they will require in order to achieve the same relative improvement. 

Some Clients are More Variable Than Others

When I looked at clients’ mood monitor scores more closely, I also found some interesting things. Most importantly, while many people getting therapy demonstrated slower or faster rates of improvement over time, some were far more changeable with respect to their day-to-day mood states. Perhaps this was because they were in more stressful or more desperate circumstances, or were more sensitive to the effects of everyday stress than the average person. Regardless, it seemed that more of this variability, particularly in the case of anxiety, corresponded to both the severity of symptoms at the outset of treatment and the rate of response over time. This type of person was far more likely to do better with more frequent sessions than if they were left with large blocks of time between sessions. 

Fewer is Better

A final insight proved remarkably counter-intuitive. This involved the results when I looked more closely at the number of sessions that clients were attending over the course of therapy. Contrary to the assumption that more is better, I was surprised to discover that clients who had more sessions showed less improvement, and in some cases their condition even deteriorated! While you might be tempted to point out that this was probably a function of more severe symptoms, or reflected a slower response to therapy, neither of these explanations seemed to account for the difference. For example, when I looked at first session monitor scores they were unrelated to the duration of therapy. I also found no significant relationship between the passage of time and outcomes. Most of the difference in outcomes seemed to be based on the actual number of sessions. This suggested that grouping fewer therapy sessions close together in time may be just as good, or even better, than more sessions spread out over time. 

What Does Current Research Say About This?

It will probably come as no surprise to you that these findings are consistent with some of the more recent published research on the topic of session frequency and duration. For example, Erekson et al (1) looked at the relationship between session frequency and psychotherapy outcomes in over 21,000 clients who were treated at university counseling centres and found clinically significant gains were achieved faster for weekly sessions than for twice monthly sessions. Cuijpers et al looked at 70 randomized treatment trials that included data on session frequency and duration, and found that neither the total number of sessions nor the number of weeks in therapy had a significant impact on outcomes. Furthermore, the length of sessions was found to have no impact. It turns out that the only significant effect that made a difference in outcomes for this study was session frequency (2). 

Another study by Storch et al (3) revealed that daily treatment sessions for 14 days was as effective as weekly treatment sessions for 14 weeks, with no difference observed on follow-up. These findings, and the results of my own quality assurance work are consistent with Bohni et al’s proposal that exposure is an essential piece of any effective psychotherapy method (4). Whether a therapist is trying to get someone with phobic anxiety or panic attacks to face a feared situation or object, convince someone with depression to ignore negative thoughts or get out socially, or persuade someone with anger issues to keep calm and carry on, the most effective therapy encourages people to practice behavior change every day that puts them in uncomfortable situations and encourages them to ride it out. 

Why is this important?

Psychotherapy is meant to help reduce the suffering that goes with mental health problems by dialing down the severity of symptoms, increasing adaptive behaviours, and improving a person’s quality of life. In addition to using the right methods, it appears that something as simple as the frequency and duration of treatment sessions can have a big influence on these goals. For example, session length may be less important than most therapists and their clients would like to believe. Plus, severity scores at the outset of treatment may be more useful for determining realistic goals than for estimating how long a person will be in therapy.

These results may seem counterintuitive, but in the end, the best outcomes may come from fewer sessions, shorter sessions, and more frequent sessions. This may defy tradition, but evidence seems to be mounting that how therapists deliver treatment, not just what they deliver, may reduce suffering in addition to saving time and money. 

Equally important here is the fact that if therapists and clients are not measuring symptom levels or keeping track of progress, it will be more difficult for them to set appropriate goals in the first place, determine if progress is within normal limits, sort out whether there are any signs indicating that a change in tactics is required, and know when to start tapering sessions. 

References:

Erekson, D.M., Lambert, M.J., Eggett, D.L.(2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. J. Cons. Psychol. 83(6), 1097-1107

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. J Aff Dis. 149, 1-13. DOI: 10.1016/j.jad.2013.02.030 

Storch, E.A., Merlo, L.J., Lehmkuhl, H., Geffken, G.R., Jacob, M., Ricketts, E., Murphy, T.K., & Goodman, W.K. (2008). Cognitive-behavioral therapy for obsessive-compulsive disorder: A non-randomized comparison of intensive and weekly approaches. J Anx Dis. 22(7),1146-58. DOI:10.1016/j.janxdis.2007.12.001

Bohni, M.K., Spindler, H., Arendt, M., Hougaard, E., & Rosenberg, N.K. (2009). A randomized study of massed three-week cognitive behavioral therapy schedule for panic disorder. Acta Psychiatri Scand. 120, 187-95. DOI: 10.1111/j.1600-0447.2009.01358.x