The big issue: Time to flex?
Therapy Today, February 2023

It was during a recent supervision session that I realised that none of my therapy clients now come weekly – my one remaining weekly client had transitioned to fortnightly. When I later mentioned this at my local private practice network group, I discovered I wasn’t the only one whose practice had evolved this way. Biweekly, it seems, has become the timing of choice for many clients, making ongoing therapy more sustainable both financially and time wise. But if the fortnightly session is becoming mainstream, have we fully considered the long-term impact of agreeing to work this way, on us, our clients and our profession? And in our efforts to accommodate client preferences and make therapy remain viable in a challenging market, are we inadvertently making it less sustainable for ourselves?

The question of whether we should take a more flexible approach to therapy isn’t new – in a 1975 interview, Carl Rogers was reported to have said that if he were to go back to individual therapy, he would take a more flexible approach: ‘I don’t know what I would do, but I would experiment with various things... I think I would try various things depending on the client and try and keep my own time as flexible as possible. I think I would try to have the client share with me the responsibility of determining how much time to spend.’¹

Many of the psychoanalytic masters were also open to a flexible approach. The French psychoanalyst Jacques Lacan was known to refuse to offer appointments – instead, clients turned up and waited to be summoned by Lacan for a session that may have lasted hours or, if he felt the client was wasting time, was abruptly ended after just a few minutes.² Freud meanwhile famously conducted a four-hour session in 1910 with the composer Mahler walking around the city of Leiden.³

There is also no evidence to suggest Freud offered 50-minute sessions, despite the origins of the therapeutic hour being widely attributed to him. ‘Archival evidence suggests that Freud conducted sessions of 55 minutes, rather than 50 minutes,’ says Professor Brett Kahr, Senior Fellow at the Tavistock Institute of Medical Psychology in London, and an Honorary Fellow as well as Honorary Director of Research at the Freud Museum London. ‘It remains unclear when and where, precisely, the more universal 50-minute session first emerged. But this has now become the standard length of the classical psychoanalytical session in the United Kingdom, whereas in the US, many psychoanalysts offer 45-minute sessions.’

Research

What’s most likely is that the 50-minute hour evolved for pragmatic reasons, allowing sessions to start on the hour, with a 10-minute break between clients. But there is limited research into whether 50 minutes is the most effective duration for therapy, or whether clients would do just as well or better with shorter or, conversely, longer sessions. A 1976 study (into brief emotive psychotherapy) compared client outcomes from being seen for either 30 minutes twice a week, 60 minutes once a week, or 120 minutes biweekly. It found there was no relationship between length and frequency of sessions and outcomes, although clients reported preferring having more time to talk.⁴ Similarly, a study carried out by Turner and colleagues in the 1990s that compared groups who were given eight sessions of either 30- or 50-minute therapy found that session length did not determine client satisfaction or outcome – researchers concluded that ‘the ability of the therapist to be present and empathic with the client may be more influential than the length of the treatment hour’.⁵

In the US, the differing duration of session offerings, most notably seen in platforms such as TalkSpace and BetterHelp, aligns with the ‘codes’ that therapy can be billed under for health insurance purposes – 90832 for therapy lasting 30 minutes; 90834 for 45 minutes; and 90837 for 60 minutes. And with the global expansion of these therapy platforms, UK therapists who choose to work for them are now having to adapt to 45-minute or even 30-minute sessions. It’s not always an easy transition – many report feeling they are cheating clients by stopping at 45 minutes, so top up sessions to their normal 50- or 60-minute hour, even though they will only be paid for 45 minutes (members’ concerns about this and other aspects of the new platforms are currently under review by BACP’s Professional Standards team). For some UK therapists, the solution is indicating on their platform profile that they don’t offer 30-minute sessions, although others say they can be useful for ‘emergency’ sessions, fitted into a busy day.

Thirty-minute sessions

Thirty-minute sessions may also make therapy accessible for clients who wouldn’t normally engage with therapy, says Jodie Cariss, founder of London-based Self Space (www.theselfspace.com), marketed as ‘the world’s first on-demand mental health service on the high street’. ‘There are some clients for whom 50 minutes feels completely overwhelming, whereas 30 minutes feels like more of a kind of introduction, or a hello. And we found people would often cross the line more easily into therapy with a 30-minute session, and the retention was then good. After they’d had a couple of sessions at 30 minutes, they would say, “Oh, this isn’t enough time” or “Gosh, that’s gone quickly”, and perhaps then opt for 50-minute sessions. Thirty-minute sessions also appeal to other clients who might just want to come quickly in their lunch break, or come back for a check-in after therapy has ended. It’s also often students and younger people who book the 30s – which might be due to financial reasons, but it might also be because they’re time pressured, or perhaps because their brains are working in that way. And I think it provides people with choice.’

Self Space operates a flexible model – as well as session length, clients can choose when and how often they come, by booking directly through the website. ‘They can also book a double, two 50-minute sessions, which clients have done if they feel they need more time. Then they may take a couple of weeks before their next session, to process that,’ says Cariss. ‘That wouldn’t be possible in traditional therapy, but for us client autonomy is key. I have personally experienced the frustration of having to pay for sessions that I can’t make as I’m on holiday, or having to go to a session when I feel I have nothing to say.’

Although it seems clear the 30-minute session has appeal for some clients, it’s not without its drawbacks for therapists. One of the conclusions of the Turner study was that clients didn’t suffer much from having their sessions restricted to 30 minutes but therapists did – most reported finding seeing two clients in an hour without a break increased stress. ‘It’s very rare that I look in the diary and see therapists with back-to-back 30-minute sessions booked in – they are intense,’ says Cariss. There are other considerations for practitioners before booking a 30-minute session for a client, she says: ‘I think as clinicians we have to be particularly careful that we don’t collude with avoidance. We always have to ask what is actually happening in the room here, and is this the best format for the client?’

Biweekly

While the 30-minute session is still relatively rare, the biweekly session seems well on the way to being normalised – not a prospect that all therapists welcome. Private practitioner Avril Scott says she only agrees to fortnightly sessions if the client has worked weekly for some time, ‘once a therapeutic relationship has been established’. She also points out it doesn’t suit all clients. ‘I had one client who was considering going fortnightly so we trialled it over the summer when we ended up working that way due to the way my breaks and their breaks fell, but afterwards they asked to revert back to weekly as they preferred it. Working biweekly can’t be simply a practical consideration about time and money – we also need to think about what else may be going on and whether clients are trying to reject the therapy but actually still engage with it on some level.’

Working flexibly can be a difficult transition for those trained psychodynamically, like therapist and coach Charlotte Braithwaite: ‘In the early days of starting in private practice, I had a client ask me if we could go fortnightly after we’d been working together for five months because their financial situation had changed. My immediate response was to say no, because it would be breaking the therapeutic framework, but they said that they couldn’t afford to carry on. I took it to my supervisor, and she was surprised I’d said no, and we had a long discussion about it. I realised I still had the mindset of a trainee, following “the rules”. I went back to my client and opened a discussion about biweekly, and they stayed and continued to do good work. It made me realise that the psychodynamic model is my roots, but I need to grow different branches. And some of those branches have enabled clients to continue their journey both therapeutically and ethically.’

But for some therapists, such as Ellis Johnson who also trained in psychodynamic therapy but now works integratively, weekly sessions are the key to working at depth. ‘In my experience, working fortnightly means too much of sessions is spent “catching up” with what’s happened. I make it clear on my website that I only offer weekly therapy so clients are aware of that when they approach me. The feedback is that clients appreciate our sessions becoming part of their weekly routine, always there at the same time. Even changing a session time by an hour if that has to be done one week feels disruptive. Continuity is very important in therapy – I make sure the room always looks the same, right down to details like always using the same glass if I have a drink of water next to me. If there have been times due to breaks that we’ve had longer between sessions, I sense a kind of drift in the client away from the therapy when they come back.’

Johnson counters the argument for ‘client autonomy’ by stressing that it’s our role to hold the client, and the frame of the work: ‘I would rather a client had six months of weekly therapy than a year of fortnightly sessions as I think they will just see better results that way. Of course, we have to acknowledge that not everyone is privileged enough to be able to afford once a week therapy. But if it’s financially challenging, I will discuss that with clients, and give options such as paying monthly in arrears on their pay day.’

Time pressure

The biweekly option is not always a financial choice – many therapists and clients say fortnightly sessions also fit in better with our ‘busy lives’. Many therapists like myself endeavour to book fortnightly clients into alternating slots, so my allocated therapy days are always full. But others say the space in between fortnightly sessions can create welcome ‘less intense’ weeks that allow time to work on other work projects, for CPD or just for self-care. That sense of ‘opening up space’ also works for clients coming biweekly, says Sarah Worley-James, who works both as a private practitioner and for the University of Cardiff’s student counselling service. ‘I have some clients who start weekly but most prefer fortnightly, and I think that actually works best, because weekly sessions don’t allow enough time for clients to really think about what we’ve worked on or what has come up, especially if there are any ideas, strategies, techniques or different ways that they’re going to be trying out. They need a bit of time and some opportunities to do that.’

Worley-James also believes in offering clients a level of autonomy in choosing their session frequency: ‘Sometimes a weekly client might feel, whoa, a lot came out today, I need a bit of space to get my head around these things that have emerged. That means they may ask for a longer gap between sessions. Or conversely, it may be that a fortnightly client will say, there is so much that’s come up today, can we have a session sooner, because I want to keep moving forward. So in responding, it’s respecting that client’s autonomy, trusting what they might need. I think being human and being flexible are more important to me than being rigid and only offering the client the same weekly session. It’s also quality, not quantity that works – isn’t the quality of the work with a client more important than the number of minutes spent with them?’

Client autonomy

Although the research to date shows little difference between outcomes in the frequency and duration of therapy, giving client autonomy over their sessions does seem to make a difference to client satisfaction with the process.⁶

The positive effect of giving clients autonomy over booking their sessions was also confirmed by a study by Professor Timothy Carey on NHS clients in Scotland.^7,8 His study aimed to explore what might happen if clients, rather than therapists, took control of appointment scheduling: ‘I established systems so that clients could book their own appointments at the clinics where I worked [in the NHS in Scotland]... Essentially, clients made appointments to see me in the same way they would make an appointment to see their GP. We informed clients they could come four times a week if they wanted to, or once a week, or whatever they thought was appropriate. If clients thought that a one-hour appointment was too brief, they could schedule two appointments in a row to give themselves more time. The data indicate that clients appreciate the increased choice and flexibility. One of the fundamental differences with this method of therapy provision is that the number of non-attended appointments reduces dramatically.’

He concedes however that a patient-led approach can be ‘messy’ – therapists are never certain as to when clients will return for subsequent appointments. Some therapists also become concerned about clients who did not attend for as much therapy as the therapist thought the client should have. ‘From a pluralistic perspective, however, if we are to genuinely embrace the agency of the client then this must include respecting clients’ decisions about how much therapy they need. Even if they get that decision wrong, it is their right to do so,’ he says.

One reservation of an ad hoc approach for therapists working relationally may be the impact on the developing relationship. Research has shown that the likelihood of relational depth developing, from the point of view of both therapists and clients, is increased with frequent sessions, says Mick Cooper, Professor of Counselling Psychology at Roehampton University. ‘But the standard 50-minute, weekly, in-person sessions are not necessarily the only way to create relational depth. Certainly qualitative studies have shown that relational depth can develop fairly quickly and it is there in short-term work. However, that raises the prospect of a deep connection being made and then ending quite abruptly, leaving clients feeling that loss, which needs to be carefully managed.’

While Cooper says that sharing responsibility for booking sessions with clients is ‘a good thing’, he also says that ‘one risk may be consistent avoidance when the client has something painful or difficult coming up. When therapy is regular, it may encourage clients to use the time to address things that happen that they may find difficult to talk about, which if they didn’t have that regular space, I can imagine some people might avoid.’

Baby and bathwater

The past three years have presented an opportunity for us to demonstrate our ability as a profession to be flexible and adapt to the needs of our clients, with many of us pivoting to offering remote sessions within days of the first COVID lockdown. But in our eagerness to respond to client needs, are we in danger of sacrificing our own? There are also many practical downsides for therapists of working flexibly – with fortnightly sessions, unless you can alternate two clients in the same slot, you may have a session every other week that doesn’t earn you any money. You also need to manage the potential ruptures caused by the way that holidays fall, leaving some clients with a month between sessions. ‘There’s no doubt that more flexibility means more financial instability for us,’ says Worley-James. ‘We want to give clients autonomy but we also want to think about our needs. We have to be business people as well as therapists because we have to make a living.’

I also wonder whether, by embracing flexibility, we are potentially in danger of ‘throwing the baby out with the bathwater’, diluting some of the most important elements of therapy, such as holding, routine and structure. ‘Whether we provide 50-minute sessions or 55-minute sessions as Freud had done, or even 60-minute sessions, I believe the majority of practitioners would underscore that reliability and predictability of timing constitute one of the most important features of our work,’ says Brett Kahr. ‘In view of the fact that most of our patients could not rely upon the trust of their caregivers during infancy and childhood, having a psychotherapist who practises in a hugely consistent manner offers great comfort and reassurance and, ultimately, healing. I would hesitate to practise psychotherapy in a session shorter than 50 minutes.’

Not every practitioner is in a position to offer a flexible approach. Says Charlotte Braithwaite. ‘If I was renting a room, I think it would be a lot trickier for me – I would be wanting to slot people in every other biweekly slot to maximise the time I had in that room, to make it financially viable. Working from home means I am more willing to make things flexible with clients, although it still has to work for me. And I know that my clients are very appreciative of that.’

Despite that, she still feels a sense of taboo around working flexibly. ‘Considering how many of us are working biweekly, it’s surprising how few of us are open about it. Whenever I’ve talked about it, there’s a really healthy curiosity, but there is still this underlying taboo, a worry about being shamed by fellow therapists. But considering the way the world is right now, I see being flexible as a sign of our profession evolving as a response to that. And I think the more we can hold reality in a relational way, the better for clients.’