Why is almost all therapy done as one-hour sessions weekly?

Question

It seems far too spread out to me. Why do we pause mid-conversation and wait seven days?

When my car needed repair after an accident, the bodyshop spent 25 man-hours on repair. They did that over the course of one week, which is good because my car is essential for my life. I can't function without it. But if my car had needed therapy, it would've taken 25 weeks (almost six months) to get fixed. I'd have taken my dangerously broken car to them and had them start checking damage, only to say "times up" an hour later and boot me out the door to use my broken car for another week.

Mental health is more complex and also more immediately essential to a person. Why then do we work on it at such a slow pace?

I've tried researching alternatives, and other than checking into full-time inpatient care, the other option is to find a therapist who can schedule more than one appointment per week, which is very rare. The therapists that have more than one open slot in their schedule at any time are the least well-regarded online. The well-reviewed ones have wait-lists to get a single appointment.

I understand that some therapy is a 'maintenance' model, where the patient only needs to talk about what happened since last session, but what about patients who have a long history to unpack, or are in the middle of a crisis? Why do we apply the weekly appointment model to those cases?

Why have therapists adopted this model? What is the rationale and history that led to it?

Answer 1

Q1 — Your Main Question — Why is almost all therapy done as one-hour sessions weekly?

The studies

Two studies attempted to observe the effects of session frequency in routine practice of psychoanalytic psychotherapy. Both relied on retrospective evaluations by patients after completing therapy, and on naturalistic data regarding session frequency and dose. Each was asked to rate his or her recovery in therapy, including decrease in symptom distress and increasein morale.

Both studies indicated a relationship between the frequency of sessions and patients’ perceptions of recovery, where patients being seen only once a week had less positive perceptions of their experience than patients being seen two times a week or more. In fact, positive perceptions of recovery were incrementally related with the frequency of sessions, with once a week indicating the least amount of recovery, twice a week somewhat more, and three times a week the most recovery in therapy (Freedman, Hoffenber, Vorus, & Frosch, 1999; Sandell et al., 2000). This provides some evidence that patients’ perceptions of their own recovery may be affected positively by increased session frequency.

A follow-up study to Sandell et al. (2000) found an interaction effect in long-term follow-up (i.e., 3 years, with measures taken each year) between duration and frequency, where outcome was better among the low frequency/low duration group and among the high frequency/high duration group (Sandell, Blomberg, & Lazar, 2002). These findings illustrate the potentially complex relationship between session frequency and other parameters, including the number of sessions and duration of the course of treatment; ultimately, they indicate that session frequency seems to be related not only to immediate perception of therapy, but to long-term outcome.

So what is this telling us?

Twice weekly or more sessions may gain quicker results in perception, but in the long term, it is doing the client a disservice.

The frequency of sessions helps balance cost, intensity, and emotional containment (Seeman, n.d.). Therapy can be emotionally intense and someone may learn many things (about themselves and what they are dealing with) in session. More time in session can raise an amount of information which can be difficult to absorb mentally and emotionally, and this is what Sandell, Blomberg, & Lazar (2002) was starting to realise.

High frequency/high duration therapy as indicated by Sandell, Blomberg, & Lazar would be very costly, and, from my experience as a therapist who as part of training has had to undergo therapy too, would not be as beneficial as low frequency/low duration therapy. With high frequency/high duration therapy, the client is not necessarily fully assimilating the information at their own pace, and, the chances are, the therapist is guiding too much on how to interpret the information raised in session. Low frequency/low duration therapy is about pacing your therapy, and the fact that therapy does not just happen in the room.

The time outside the room enables the client to assimilate the information which has been discussed in session at their own pace. Depending on the form of therapy, the therapist may even set some "homework tasks" outside of the session which are optional, but may help with assimilation processes.

Being weekly, it will be recent enough that session continuity will be maintained. Any longer in duration between sessions runs the risk of continuity problems as what was discussed can be hard to remember to a certain degree, and the flow of conversation and therapy can be upset slightly, affecting rapport. There may be times when you may wish to cancel a scheduled appointment with your therapist because you are finding things too difficult. That is fine as long as you give the pre-agreed notice to your therapist. Late cancellations can incur cancellation charges with most therapists.

It is part of therapy in some cases to want to skip a session once in a while, and as long as there are not too many cancellations, your therapist will understand and can pick things up when you return, whilst examining with you what made things difficult. If there are a lot of cancellations, questions will be raised as to whether you are ready for therapy. in order for therapy to work, the client needs to be ready for it

Clients immersed in intense emotional or life changes may see their therapist twice a week or more often to help keep them be emotionally centered and assist them in activating coping skills (Seeman, n.d.)

however, once things have reached a certain point, it is better for the client to revert to once-weekly sessions for reasons already pointed out.

Q2 — Why do we pause mid-conversation and wait seven days?

With the idea of conversations being cut mid-way because of the end of session, a good therapist will manage the session and enable as smooth an ending as possible. Although sessions booked will be an hour long, the typical “therapy hour” is 45 to 50 minutes. In some situations a therapist may offer longer sessions. For instance, a couple in therapy may find themselves just getting into a long-needed conversation. Added time may help them maintain the momentum.

The 10 to 15 minute difference with the "therapy hour" enables therapy to be closed as smoothly as possible giving time for the client to transition from therapy session to life outside the room. When you are approaching the end of the therapy hour, your therapist should be mindful of that and work towards a smooth closure of the session in order for the client not to be "left dangling with no support" after just talking about something very emotional without some kind of closure for the time being.

Further Reading

For tips on how to get the most out of Psychotherapy, see the webpage by Gary Seeman, PhD

For more information about what makes therapy work, see:

Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy. American Psychological Association.
DOI: 10.1037/12075-000

References

Freedman, N., Hoffenberg, J. D., Vorus, N., & Frosch, A. (1999). The effectiveness of psychoanalytic psychotherapy: The role of treatment duration, frequency of sessions, and the therapeutic relationship. Journal of the American Psychoanalytic Association, 47(3), 741-772.
DOI: 10.1177/00030651990470031001

Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Broberg, J., & Schubert, J. (2000). Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: A review of findings in the Stockholm outcome of psychoanalysis and psychotherapy project (STOPP). The International Journal of Psychoanalysis, 81(5), 921-942.
No working DOI available
[Free PDF available at: https://www.researchgate.net/publication/12217712_Varieties_of_long-term_outcome_among_patients_in_psychoanalysis_and_long-term_psychotherapy_-_A_review_of_findings_in_the_Stockholm_Outcome_of_Psychoanalysis_and_Psychotherapy_Project_STOPPP]

Sandell, R., Blomberg, J., & Lazar, A. (2002). Time matters: On temporal interactions in long-term follow-up of long-term psychotherapies. Psychotherapy Research, 12(1), 39-58.
DOI: 10.1080/713869616

Seeman, G. (n.d.). Getting the Most Out of Psychotherapy [Online]
Available at: https://drgaryseeman.com/getting-the-most-out-of-psychotherapy

Answer 2

50 min

"The 50-minute hour was introduced by Freud for pragmatic reasons." (Will, 2015)

Try organizing your work day in 67 minute segments. You'll have a hard time understanding where you are within a given segment when you look at a watch. If you organize your work day in 60 minute segments, the hand of the clock immediately shows you how much time you have left with your current patient.

A therapy session does not last a full hour to give the patient time to leave and the therapist time to answer calls, visit the restroom, and prepare himself mentally for the next patient.

More recent therapy forms have introduced 45 minute sessions (to give the therapist more time for documentation), 90 minute sessions (for group therapy), 30 minute sessions (in hospital contexts), and open sessions without a fixed time span, but all irregular session lengths only work in contexts where the therapist does not treat one patient after another for the whole day each day, as a therapist does in a private practice.

One hour sessions are the most practical in a world where clocks are divided into hours and people think of time in hourly divisions.

weekly

Try to make appointments with patients every four days. You'll find that they will have huge organisational difficulties, because their workplace and their pivate lives are organized in weeks. Try to tell your boss that you need to leave an hour early every four days. It'll be much easier to convince him to leave one hour earlier every Friday.

But the truth is that psychoanalysis requires a frequency of around four sessions per week, and even behavioural therapies often begin with two sessions per week and later reduce the frequency to as far as quarterly visits. Weekly sessions are common, but not in fact the only practice. Frequency is always attuned to the needs of the patient (or should be). In a psychiatric ward patients may have different kinds of psychotherapy multiple times every day.

pace

Behavioral change takes time. Habits – and most problematic behaviour are a kind of "bad" habit – are stored as neuronal structures, and forcing your brain to disconnect a few thousand synapses and connect your neurons differently cannot be done in 25 consecutive hours, especially if the behaviour change is opposed by beliefs (many patients firmly believe that they cannot change), fears (many psychological disorders are in fact easy solutions to difficult problems), and the environment (often the people in the patient's life "support" their psychological problems through their behavior). It's much easier to stop smoking than to stop being depressed because you were sexually abused as a child – and most smokers who want to stop don't even manage that.

• Will, H. Forum Psychoanal (2015) 31: 267. https://doi.org/10.1007/s00451-015-0208-5

Answer 3

Not close enough to the research here to post references to articles for or against it but there is research showing both pros and cons of either side. Once weekly CBT is popular now but this may not always be the case in the future. What I will say is there are a number of therapy types which are designed to be done more than once per week and many many people find these incredibly beneficial for some of the reasons you post in your original question.

Not sure where you live but you could contact the Institute of Psychoanalysis in London. Psychoanalysis (what Freud himself created) and Psychoanalytic Psychotherapy are both done multiple times per week.

As an aside I'm quite surprised by the level of bias in the responses on this post against multiple time per week therapy as there is a wealth of research showing its benefits. My understanding is therapy originally was given multiple times per week (can't quote sources here but I think this is what Freud did) but has been modernised to be once per week. Maybe (my opinion) partly to make it more accessible.