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Longer Sessions; Real Work; Better Results

January 29, 2013

To add to an earlier post about my three-hour counseling sessions, it is important for colleagues and clients alike to understand that this doesn’t come willy-nilly out of thin air. My approach is predicated upon client feedback.

For years I have been asking clients about their experience of my counseling. I have done that at the end of regular meetings, when terminating and by anonymous replies to questionnaires. This is the essence of evidenced based practice: Figure out what you are doing and see if it works. Repeat what does, leave out what doesn’t.

Clients tell me they like the momentum you can achieve within sessions with lengthier meetings.

My analogy is this: I wouldn’t want my surgeon kicking me off the table saying we ran out of time and the scalpel will be removed next week, so similarly, I don’t want to arbitrarily conclude my session on account of time when my client is just beginning to have a therapeutic moment or is upset due to distressing content. Clients appreciate this approach. They feel like we have gotten somewhere before the session has ended and they do not have to leave the session still distraught.

Here is what else my asking questions and reviewing my own practice has taught me: Statistically, 50% of the folks I see is one time only, not because I couldn’t be helpful, but because that was sufficient. Twenty-five percent of the folks I see is only a second time. The remaining 25% may be seen a third or fourth time, rarely a fifth and almost never a 6th.

As per my approach, I also have an expectation that the client leave the session with a plan of action and strategies to do differently with regard to the matter at hand.The social agreement is this: I am responsible for assessing and offering guidance and the client is responsible for implementing the guidance subject to their discretion.

If my client chooses to not do the work that is OK and their decision. However, if the client returns to see me only to reiterate their issues, not having followed the plan, I am quick to terminate service. My view is that I am not here to register their issue, but to help with resolution. If I am not doing so, then ethically, it is inappropriate for me to receive payment for a service not utilized.

I have found that this approach, signaled well in advance as part of an informed consent process, puts an onus of responsibility on the client to collaborate and contribute to their well being. I acknowledge having no magic wand and that change will be the outcome of a partnership between client and counselor.

I know a good many colleagues take the view that maybe the client is still getting some thing from the session even when they do not engage in efforts to effect change outside of the session. Perhaps, but not me. In those circumstances I am more apt to believe the therapist is getting more from the session than the client. I also worry that some colleagues may be keeping their clients in therapy longer than necessary for the client, based on the therapist business or referral needs when clients return session after session without really changing or working.

There is only one reason why people see a counselor – because they are in distress. And when in distress, we all want relief as quickly as possible. Returning week after week whilst the counselor develops rapport and a working knowledge of the person or couples problem only serves to prolong the distress. Further, the likelihood of drop-out is greatest after the first session, so hopefully that first session is meaningfully and leads to relief. Thus the first session is pivotal in relieving client distress.

I am not so naive to not appreciate that the standard 45 to 50 minute hour is also imposed by third party payers. I typically do not accept payment by third party payers for just that reason. However on a very few occasions when I have been approached by third party payers given a demand by the client for my service, I have advised the payer of my approach and received agreement to provide service accordingly. Not always, but sometimes. If the third party payer does not accept my approach I decline the referral.

Please note, that although I always provide 3 hours for each session, I only bill for time used. Thus the session typically ends when most appropriate for the client. As for the unused time, this goes towards clinical notes, report writing, returning phone calls and other administrative functions. This too is valuable time.

Despite all our training with regard to therapeutic theories, approaches and strategies, it is outcomes that matter and from the client perspective that means relief from distress. I encourage my colleagues to ask the hard questions about their own service. We certainly encourage our clients to self-reflect and modify behavior as appropriate. Now it’s our turn. What about our practice or service delivery is most conducive to effecting change and what is not? Please understand, all the above is assuming that therapy is directed at actively making a cognitive, behavioral, attitudinal or affective change. This does not apply to therapy that is supportive in nature as may be provided for psychiatrically or physically impaired persons on a long term basis. However, it still behooves us all to be accountable for our service and determine the effectiveness of our strategies.

Your view?

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7 Comments
  1. Gary, I have found the same in mediation. I schedule two-hour sessions for all initial divorce and family mediation sessions. This is time enough to know if we are going to have a successful resolution…or not. In 90% of my cases, there are no second sessions needed. Success rate is roughly 65-70%.
    And on your most recent post, I agree wholeheartedly.

  2. Of course the sessions are self pay, based on income and not managed care.

  3. Likewise for me Cindy.

    My sliding fee schedule is posted on my website with each service offered. If interested, here is the listing of my services from which you can click on the service to get the details, costs, etc:
    http://www.yoursocialworker.com/contact.htm

    I believe in transparency and I don’t worry who has access to this information. This allows the client to make better informed decisions as to choice of service provider. Some will “shop” on the basis of cost but I always suggest they purchase these services on the basis of experience/competency.

  4. Betsy permalink

    Many to most of what I am reading above, makes my stummick turn.
    Quick fixes,.. in the same piece with counseling.
    Your work sounds to me as Coaching people, or offer them Cognitive Behavior Therapy, perhaps.
    I do get the money part, counseling can be expensive. People wanting to feel better as soon as possible, I get that as well.
    But, for instance, stating that you feel colleagues rob cliënts, – who don’t do their work outside of therapy a.s.a.p.,- from their money, makes me angry.
    And ‘quick to terminate service’ when not doing their ‘work’ outside of the session… ? !
    Seems like you have all the anwsers.And your ‘cliënts’ need to trust you on that. But counseling implies the other person to find strenghts and truths within, so they can learn and trust – not for one particular situation, relationship or problem – but for all to come – to anwser them themselves.
    This makes coaching and counseling different from each other.

    Is it just me, or do people have different ideas of counseling and what counseling people implies?

    • HI Betsy,

      It seems I have hit quite a nerve for you with my post.

      Clearly not for everyone, but again, developed on the basis of client feedback – asking what was most helpful and what wasn’t.

      Interestingly clients have even told me that terminating service was actually very helpful to them in their process as it placed an onus of responsibility on them for change. So the only thing I can say is that my practice is the outcome of personal investigation and my underlying theses is my belief that as practitioners, we should all examine what we do – even when it creates controversy and a diversity of strongly stated opinion.

  5. Hi Gary,

    I like your approach, no I love your approach. I feel that in my personal experience while I was in counseling my one hour sessions often turned into 2. There was no quick, easy, solution yet the good news is that I was in a safe place and allowed myself to ‘go there’, to places I’d never been before. I was living in a ladies recovery house and my counselor never left me ‘wounded’, she would close me back up in the right places and leave some old wounds open so they could heal when I was ready to allow them to.

    It’s refreshing to know there are counselors out there who will make extra time, often times I think that gaining trust is where the first hour is spent and then the service user is done for the week, makes no sense to me.

    Evidence based practice, you are a mighty fine example of this for me, thank you.

  6. Nelda Armour permalink

    I have always found that flexibility in session length worked better, and very few of my appointments are (or ever have been) 50-60 minutes. I think that those parameters are set by the industry to “process” more clients per day and maximize profits rather than for client well-being. Clients very much appreciate a more relaxed and respectful atmosphere, in which they do not have to leave at arbitrary, pre-determined times. I also find that clients may not necessarily follow the action plan agreed upon at our previous session. They may require more time to trust, contemplate or move through the stages of change; or they may change their minds about what they are comfortable doing. I avoid rigidity, and endeavour not to project my values and expectations onto clients. My intake form clearly asks for goals, and they sometimes change as we proceed. One recent client’s goal was simply “To feel listened to.” Most others delineate desired change on their parts. Doing therapy is always a fascinating journey and I am a lifelong learner with no desire to retire.

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