4 June 2012

Counselling - The Frequency of Therapy and the Question of Client Autonomy


I had a discussion with my partner yesterday morning about whether it is right to ask clients to commit to weekly sessions and/or to specify a duration of therapy. He suggested that it would be a good concept for me to explore and blog about.  I had spent the previous day at Exeter Respect Festival, with the Therapy@GandySt stall. We were tucked away in the Healing Zone – pretty much hidden from most of the park and consequently, we weren’t getting much traffic. So yesterday I decided to stray away from the Healing Zone and present a question to the festival goers.  This seemed like a great opportunity to do some real learning based on what people actually want, rather than basing my stance on personal preferences.

At the agency where I work clients are expected to commit to weekly sessions of 10 weeks, or weekly sessions of an undetermined duration. The “open-ended” contract is to be reviewed periodically but the expectation is that the client will come along at the same time, on the same day on a weekly basis, except for pre-agreed holidays. Allowance is made for emergencies and illness but generally speaking, cancelled sessions are expected to be paid for. One of the justifications for this is that the agency can only charge such low costs for counselling based on regular client attendance. Also, that the clients needs to show commitment to their therapy.

In my private practice, I have tended to leave the duration and regularity of therapy entirely up to the client. This may have something to do with the fact that my therapist, whom I saw throughout my training and beyond, does not bring up the issue of frequency or ever ask if I want to book the next session. I have always liked this lack of pressure and the fact that the decision is left entirely to me. It suits my personality and I had assumed that everybody would share this appreciation.

It was in discussing this with a colleague, who takes a different stance, that I first started to really question this assumption. My colleague told me that when he embarks on private practice he intends to ask clients to commit to weekly sessions of a particular duration. I asked him what his therapist’s stance had been and, low and behold, his therapist had had the same requirements. My colleague said that this was what he needed, that he had benefited from this contract and wanted to give his clients the same.

What also came up was the fact that clients committing to coming along weekly for a set duration is much more handy for the therapist than sporadic attendance. This issue of convenience is something that jars with me and I firmly believe that this is not a good enough reason to insist on weekly sessions.

So, I wanted to find out more about what people actually want out of their therapist with regards to pushing for regular attendance.

I have never done any market research before, or anything that involves approaching strangers and asking them questions. So the first thing I did to make life easier on myself to was to make sure that I only had one question to ask. It seemed much more likely to get a result if I asked “Please could I ask you just one question?”. Of course I had to think of the question and I was conscious that the power of semantics in the choices I was posing to people could heavily influence the outcome. I settled on:

Asking verbally: If you were to choose to have some counselling or psychotherapy which would be your preference?

Then showing the two possible choices on a sheet whilst simultaneously reading them out:



A: The therapist requires you to commit to weekly sessions of a particular duration e.g. 6 or 10 weeks


or



B: The frequency of therapy is your choice




I did make some prior assumptions as to how the results would turn out, but I was genuinely open-minded and curious as to what they would be.

Do you have an assumption as to what they might be?




So, I asked 119 people in all. Only one person declined to answer – he said it would never be relevant to him, but did point out that his companion had had counselling so he could answer! (he did). On the whole, I was surprised at how forthcoming some people were about their therapy history and I very much valued the time people took to really consider this issue.

I did not keep a tally of ages or gender but I consciously alternated men with women and targeted differing age groups, going from a-level students up to elderly folk  in their 70’s or 80’s. They were mainly white British but with some ethnic variation of around 10% (a rough estimate).

9 of the people I asked are therapists.

It took about 4 hours in total. the majority of people were happy to just give their answer and move on, others wanted to ponder for a while. Some gave a few words by way of explanation of their choice and there were some individuals and groups that I approached that were intrigued and asked more questions and contributed to a discussion about the topic of client autonomy and other counselling related issues.  It was a wonderful experience and I really felt that there was real learning potential for me in this, and hopefully others who may read this blog.

On to the results. Of the 119 people I asked the question:


  •  51 people chose A (42.9%)
  • 60 people chose B ( 50.4%)
  •  1 person declined to answer (0.8%)
  •   1 person said that they had no preference (0.8%)
  •    2 people said that it would depend on the situation (1.7%)
  •    4 people said they would like a mixture of the two i.e. be given the option of structure but given the choice of whether to adhere to it or not, or to start with A and progress to B (3.4%)


From these 119,  the 9 therapists I asked:

  • 6 chose B
  • 1 chose A (but reckoned that clients would choose B)
  • 2 chose a mixture of the two



Some people commented on their choice.

People that chose A said (comments from those that are therapists marked T):

  1. As a client I would want the commitment (T)
  2. I trust their (the therapist’s) judgment
  3. I wish I had had more guidance. Therapy can open you up and leave you raw and without the agreement it could leave people floundering. You can’t sort your head out in one hour.
  4. I would go by what they said
  5. I can’t be trusted
  6. Better being disciplined – it suits my personality
  7. It would be structure and I’m not structured
  8. If you’re going to go on a journey you need to stick to it
  9. I’d like a bit of order
  10. I would have thought that if you needed therapy you would need A
  11. If it wasn’t A I probably wouldn’t bother
  12. Commitment is important – it gives the incentive to keep going even when the going gets tough
  13. If you were told that you had to do it weekly you would be more likely to go
  14. It would be easier for me, I like routine
  15. I would know that that time with the therapist was safe
  16. I would want it weekly, but not for a particular length of time
  17. Would need A to be effective
  18. We assume the therapist knows better than we do.
  19. My judgment may be impaired
  20. A – otherwise I wouldn’t go
  21. I need structure
  22. People need structure, particularly those with addictions



People that chose B said:

  1. It would feel restrictive going weekly
  2. Some clients only want one session (T)
  3. Definitely B – you can’t tell how long it’s going to take somebody to clear (T)
  4. B, but with organised contact e.g. weekly telephone call
  5. I can’t tell what mood I’m going to be in
  6. People are busy, and you might get better
  7. B, but endings are important (T)





Given that these are all the comments made in relation to their choices, it is clear that those that chose A were much more likely to choose to justify their stance (43%) than those that chose B (12%).

What I learned from this is that I have potentially been doing a disservice to some clients based on my assumptions that people would, like me, prefer choice on the frequency of sessions. I intend to use this information during the initial consultation with clients to ascertain what their preference is with regards to this issue, and to make provision for those that want or need the structure of committing to scheduled counselling sessions, or that would like guidance from me. That is an issue in itself – why the client needs guidance from me – which could lead to important work.

I am hoping that this offering will promote discussion and debate on this topic and I appreciate all comments and contributions, regardless of compatibility with my way of thinking.

UPDATE April 2016 - I now only take on clients who can commit to weekly sessions as I have come to learn that the client's commitment to therapy is one of the most important factors in having a successful outcome. I believe that infrequent sessions are not cost effective as the disjointed nature means that the therapy can be inefficient. I have also now had the experience of a couple of years of weekly therapy (with breaks) and found it to be much more effective at getting to core issues.

Amanda Williamson is a professional counsellor working privately in central Exeter, Devon.


5 comments:

Laura said...

This is a really interesting survey Amanda. Good to see the results laid out so clearly too. You're right that it's a question worth asking because otherwise I think we'd just go along with one approach or the other without really knowing which is more appropriate for the individual.

I've experienced both approaches and something somewhere in between. The first time I sought counselling it was set times weekly for a number of months (although I chickened out and left early because it was too much to deal with at the time). The CBT I was offered was to be on which ever weeks I could fit it in. Which seems to defeat the object of regular analysis etc. But I didn't get on with it so only attended a couple of sessions. Psychology dept at hospital saw me fortnightly for a few set number of sessions as an outpatient.
Latest sessions should have been limited at 6-8 but somehow it wasn't mentioned. It's very irregular because the service is so overstretched, can be anything up to 8weeks between sessions. At the end of each session she asks whether I'd like to come back to see her. It's the hardest question every time. I want to say no, but I know I need to keep working at things if anything is really going to change.

After all that I'm still not sure what I prefer.
Probably some kind of set day for sessions and in this case maybe it's best not to set an end date as such because it's the first time I've ever been able to trust someone enough to be truly honest.

Enough rambling from me as usual!
Good work on the survey again though! Take care.

Cathy Helmers said...

Interesting question. I think it depends on the individual and the individual's make up and issues. When I was in therapy 30 years ago, I definitely needed the structure to be defined for me. As a pretty unaware 20-something, I had no idea what my issues were, really, or what I needed. I definitely left it up to my therapist to set those parameters. Now back in therapy as a 50-something, I know myself better, know what I need to sort out and at what pace. I'm fortunate to have a therapist who allows me to set the parameters as I move along. We recently moved from weekly meetings to every other week at my suggestion. I feel like I've seen the core issues in our weekly sessions and am now in the transformation phase. I feel the need to just touch base: talk about how I've made strides or back-pedaled regarding my issues in specific situations. It gives me the clarity I need while in this phase.

I do believe that some sort of regularity is critical, though, for therapy to be effective. Otherwise, it feels like rambling, at least to me.

Here in the US, the health care system pretty much decides the longevity for you, unfortunately. They only pay for so many sessions and then you have lull in therapy while you wait for them to approve more. If they don't, you're pretty much on your own in terms of paying for it. So, unless you are really committed and choose to continue on your own, that decision is made for you.

Sarah67 said...

Very thought provoking!
When I first started therapy, I was given a starting point of six weeks weekly. It very soon became clear that this was not going to be sufficient and I was lucky enough to be with a therapist who was able to give me unlimited weekly sessions. I was able to explain to the therapist that in myself I would know when I was 'done'.

The part that I find interesting is this assumption from people that you have talked to, that they assume the therapist knows best. Why should they know best? Its the client's mind we are talking about here. How can the therapist know the client's mind. The therapist has a bag of tools, they can offer the client the knowledge of the tool and how to use it but ultimately the know-how is up to the client surely? How can a client sit in session expecting the therapist to know best? How can the therapist know best? - something I find difficult to come to terms with: is it not for the client to use the tools that the therpist has to offer, and for the therpist to steer away from fulfilling the idea that they know best?

Sarah67 said...

Very thought provoking!
When I first started therapy, I was given a starting point of six weeks weekly. It very soon became clear that this was not going to be sufficient and I was lucky enough to be with a therapist who was able to give me unlimited weekly sessions. I was able to explain to the therapist that in myself I would know when I was 'done'.

The part that I find interesting is this assumption from people that you have talked to, that they assume the therapist knows best. Why should they know best? Its the client's mind we are talking about here. How can the therapist know the client's mind. The therapist has a bag of tools, they can offer the client the knowledge of the tool and how to use it but ultimately the know-how is up to the client surely? How can a client sit in session expecting the therapist to know best? How can the therapist know best? - something I find difficult to come to terms with: is it not for the client to use the tools that the therpist has to offer, and for the therpist to steer away from fulfilling the idea that they know best?

Amanda Williamson said...

Thank you for your input. I agree with you, Sarah, that the fact that a client assumes that the therapist knows what is best for him or her, is something to work on in the session.

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