One Size Doesn't Fit All
Working with
Client-Determined Session Length
Clive
Perraton Mountford
Published
in Counselling and Psychotherapy Journal,
vol. 16 no. 5, June 2005 and New Zealand Association of Counsellors Newsletter, Vol. 26 No. 2 December 2005.
____________________________________________________________________________
I think that if I were going back into individual therapy now, I would be far more flexible than I was at that time in regard to time. I don’t know what I would do, but I would experiment with various things. I have always worked with a fifty minute hour and met once, twice, three times a week—but that was about it. 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. I don’t know. I think there would be lots of things I would try to do.
Carl Rogers in Kim
C. Francis (1975), Questions and Answers:
Two Hours with Carl Rogers, Department of Education Services
That was
1975. Thirty years later, most counselling services proffer the standard fifty
or sixty minute counselling hour. Most training programmes prepare students to
work within fifty or sixty minutes and convey a sense that it is inappropriate
or unprofessional to go beyond this ‘boundary’.
Why? Was
Carl’s desire to experiment and to explore more flexible time allocations
misguided? Has it been shown that the fifty or sixty minute counselling hour is
the most effective way to do therapy?
I don’t
have a definitive answer to these questions, but I think they need an answer because, like some of my
colleagues and students, I have been experimenting. After all, if rumour is
correct, the standard counselling hour only came into being because Sigmund
Freud found that it fitted his schedule.
Four Questions and a Challenge
My ‘experiments’
with session length began when I was a counselling trainee. There was sometimes
an hour or more between clients, and one day a client—call her Jean—wasn’t
ready to finish just because the big hand had reached twelve. By mutual
consent, we kept going, and Jean seemed to move a lot further and deeper in
consequence of that extra half-an-hour. Next session, she confirmed that the
extra time had really seemed to help her. Again, we worked for about an hour
and a half, by which time it felt that Jean had naturally reached a place where
she wanted to stop.
For several
weeks, there was no opportunity to work longer, but we did fit in another three
extended sessions before Jean’s therapy ended a couple of months later. Each lasted
an extra half-an-hour or so, and each time it seemed to both of us that Jean
had reached a natural stopping place.
When
scheduling permitted, I offered extra time to another client who seemed to find
fifty or sixty minutes constraining. We had three extended sessions together,
and each seemed to involve more movement and depth than two or three of the
shorter sessions.
This
impressed me greatly, as did the negative response of some of the course
trainers. I was asked why I needed to work longer sessions, and I didn’t have a
ready answer... I didn’t think I did need to work longer sessions, but it
seemed to be helpful to two of my clients, and I didn’t know why. Here was
something to explore:
1. Why did these two clients seem to benefit so much from the longer sessions?
And that started a chain of questions and reasoning:
2. What was my sense of a natural stopping place all about?
3. Why was I, a supposedly person-centred counsellor, purporting to tell any client how long their counselling session should be?
4. What would happen if I didn’t establish session lengths for my clients, but encouraged them to determine what worked best for them?
With
hindsight, these questions look pretty tame, but as the training programme
ended it felt that I was planning to do something a bit radical. I think that
speaks for the power of the counselling-hour paradigm.
An Experiment in the Marketplace
Two material
circumstances helped me. First, the supervisor who had accompanied me through
the training programme and knew my empirical ways agreed to continue.
Eventually, it was she who provided the material I quoted from Carl Rogers. And
when that supervisory arrangement ceased, I found my way to someone else who
thought that flexibility, experimentation, and counselling go together. The
second material circumstance was that nobody wanted to give me a placement in
an agency which would wed me to the ‘Standard Counselling Hour’. Instead, I
went to work at a private practice where I had all the freedom I needed.
Or maybe
that bit about freedom isn’t quit true. After a ten-month training programme
and a little over a hundred hours of experience, I was in the marketplace
selling my services. I needed to provide what people would pay for and speak
well of; therefore, I really needed to be customer, i.e. client, led. I
determined to begin my counselling career by disavowing fixed-length sessions
and beginning the experiment implied by the last of my four questions. I
discussed both session length and payment as early in each counselling
relationship as seemed reasonable. I explained that I would charge like a taxi,
for the time actually spent with me, based upon an agreed hourly rate. And I
quickly learned to schedule a two hour slot for first sessions because the only
people who seemed to want a bare hour were those who had already received
significant counselling elsewhere. Even some of the experienced clients changed
their preference over time. (I saw a new client recently who was certain that
she wanted one hour sessions. Our first session lasted ninety minutes, the
second lasted one hundred and twenty.)
Over the
next few years, my experiment became a central feature of the way I work and of
the counselling practice I had by now inherited. What I found, and am still
finding after 2,500 hours, is that few clients favour the fifty minute or sixty
minute session. I’ve had one client who liked forty to forty-five minute
sessions, a handful of experienced clients who have stuck with sixty minute
sessions, and the large majority whose preferred session length is between
seventy five and a hundred and fifty minutes. The modal session length is
ninety minutes. Session length varies initially, but after a few weeks, clients
establish their own session length and by and large stick to it. Clients who
have no prior experience of counselling are shocked that sessions should be
time-limited by the counsellor; most clients who do have prior experience
celebrate their new found freedom.
Since my
second year in private practice, my wife and business partner has worked
alongside me and offers a similar service. She, too, has about 2,500 hours
experience, and her findings are the same.
In sum,
and referring back to my questions, the answer to number three is that I
stopped trying to tell my clients how long their counselling sessions should be
when I completed the training programme, and I don’t ever want to do that again.
Instead, I work with clients to figure out what is best for them. When one does
that—and this is also the short answer to question four—clients establish their
own pattern of time use.
A Natural Process Length?
Working on
up my list of questions, number two asks why counselling sessions which are not
timed-out seem to have a natural end-point. And subsequent experience raises
the related question why clients quickly establish a consistent session length.
For some
clients, money is a consideration that affects session length, but this is not
true of all clients, and anyway, my partner and I try to negotiate hourly rates
which allow for each client’s needs. (No, you don’t get rich working this way,
but you can stay in business.) The obvious non-financial explanation is that
there is some kind of consistent and natural process which determines the length of sessions, but what does that
really mean? At present, I don’t know, but my best guess is that each of us—or
at least each counselling relationship—has a process which defines optimal
session length.
Experiential
focusing lends credence to this suggestion. In a focusing session which isn’t
curtailed, there is always an ending or rest point. One either reaches a place
of inner stillness and tranquility or a place where it is recognised there is
nothing more to be done right now. Most people achieve this in around twenty
minutes. I am thinking that counselling sessions have similar natural endings
when they are not artificially curtailed but that the time involved varies from
person to person, or relationship to relationship, more than it does when focusing.
Some Reasons Why
I shall move
on to question one. It has probably exercised me the most because seeing that
something works is not the same as understanding why or how it works. Here are
some reasons why allowing clients to determine the length of their own sessions
might facilitate therapeutic process. (Perhaps they also begin to explain why
sessions do have a natural length.) The list is a consequence of discussion and
collaboration with several clients and colleagues. The quotations are from
clients.
Arrival and Departure
¨
When an incongruent or defended
way of being is necessitated by their environment, clients will need time to ‘arrive’
or ‘land’. Initially, and for some clients, this can take the better part of a standard
counselling hour:
My experience of my early counselling was
that it took me at least an hour to actually find myself. The person I was when I arrived was a version
of me I’d adapted and been to survive my environment outside counselling. An
hour session, or fifty minutes wouldn’t have been enough for me to become aware
of those defences I’d built.
¨
Before returning to a less
acceptant, more threatening environment clients also need time to gird their
loins and make preparation:
The transition from where I was when I
arrived to the undefended me was way too long to be given a fifty minute time
limit. I would probably have chosen not to go there because the transition to
and back from this place under the pressure of a time limit would have been too
frightening. I wouldn’t have felt safe. Formatted time would have left emotions
I was scared of unexplored because of my fear of where I’d be at the end of my
allotted time.
Power and Relationship
¨ Making the session-length decision a mutual one puts power in the client's hands and emphasises their personal worth and uniqueness:
Time limits seem to me to be the opposite of what this kind of therapy is offering. They seem to devalue the person’s experiencing. I’ve experienced these kind of counselling relationships as devaluing of me because I immediately assume that the person I’m with is the authority figure who I’m paying because they’re skilled enough to fix me. Maybe the most empowering part of my counselling now has been the ‘choice’ I’ve been given as to when I am ready to end. That choice has told me that I am important and valued, and I’m the one who’s responsible for me, not the person in front of me.
¨
This also helps to de-professionalize
the relationship; visiting one's therapist becomes a little more like visiting
a friend and a little less like an appointment with authority. Is that such a
good thing? I find that clients consider it so:
Relationships are scary to me. If I’m going to have a relationship with my therapist as a friend/person/human being, fifty minutes a week just isn’t enough. I don’t think I could see them as a human being.
¨
Some clients will start out asking
for relatively short sessions. As they experience acceptance, relationship, and
opportunity to be themselves, they begin to unfold and experience their needs. They
need more of this good stuff and seek longer, or longer and more frequent
sessions. To refuse is to jeopardise their developing sense of their worth and
power.
¨ Those who offer client/person-centred counselling provide what can be conceived of as a therapy of acceptance or as a therapy of love. In both cases, and especially when it is love that is required and offered, clients would find it contradictory to ration them in a way that makes no reference to their own needs and wishes:
Being someone who has found it hard to
value my own experiencing, I know that timed sessions wouldn’t have worked for
me. I would have found it hard to begin to value and listen to my experiencing
if it had been given a time limit, especially as it’s been hard to be even be
with it at times.
¨
To make a less partisan but
similar point, if it is broadly accepted that relationship as perceived by the
client is an essential ingredient in effective therapy, why would the
counsellor dole out that relationship in rigid fifty or sixty minute parcels?
Fragile and Difficult Process
¨ Because it is essential to follow the client's moves towards or away from depth, or here and now experiencing, and allow time for slow development, fragile process requires an expansive and flexible use of therapeutic time:
I feel that if it had been a one hour
session initially, at the beginning of my therapy, I could control my
relationship with Clive. I wanted to see it as a client/therapist relationship.
Part of the control is me talking, me setting the agenda. After an hour and a
half I run out of ‘agenda setting material’ and then at that point I’d be
confronted by feelings of the moment. I think that in a fifty minute session I
would very rarely get to that point, if at all. In some ways that’s almost the
point of acceptance; that I don’t have to set the agenda and I can just sit
there with him.
There may be several movements over the course of the session, and it is important not to end in what for the client is the middle of things and block their process.
¨ At least in the early stages of therapy, some clients don't process between sessions; they only process in the safety of their therapist’s company. Other clients find that their therapist’s office is the only place they can experience their authentic selves and find relationship. In both cases, they are probably going to need more than a standard counselling hour.
¨ Clients who cannot or are afraid to make decisions are encouraged and held while they make at least one decision, namely how long and how often, and this does seem to get help their ball rolling. They begin to reconceive themselves.
¨
Clients who have learned to use
a fifty or sixty minute time limit to avoid material may find that taking responsibility
for the length of the sessions helps them to acknowledge that there are things they need to avoid and to do
so in full awareness.
Relationship Work
¨
Couples and small groups like
families need longer sessions because of the multiple processes involved.
There
isn’t space here to try to imagine or respond to objections; instead, here are
some concluding thoughts.
First, colleagues
and I have seen some very fast process, and it may be that overall counselling
time is reduced by working longer sessions. (‘Proving’ that would take a
research project.) Personally, I think I see an overall time reduction achieved
by very wounded clients, but it is measured in years rather than weeks.
Second, an
agency or institutional service could move towards accommodating longer or—when
needed—shorter sessions by planning around the modal ninety minute session and
splitting it in two for short sessions. If longer sessions make for more
effective therapy and faster process, then the time spent on those sessions
will be recouped later.
Third, I am
often asked if it isn’t really very hard on the counsellor to offer long
sessions. I guess my answer is that counselling
is very hard on the counsellor. I find it easier to see four clients in a day
and offer them, say, eight hours of counselling between them than see eight
clients for fifty minutes. What’s more, because I am allowing room for
relationship to evolve in an unhurried way, and because I am allowing sufficient
space for process, I find the longer sessions a more satisfying way to work.