The Fifty Minute Hour and Closure

I received some interesting questions via email about the practice of psychotherapy, and thought I'd respond to some of them.

How many clients do you have and how often do they come and see you?
The number of clients I have tends to fluctuate. At the moment I have 27 clients, and they include couples, families and individuals. This is about as many clients as I can see in any given week. If my practice is full and the potential client is not an emergency, I compile a wait list. If the length of time a client must wait is more than one month, I keep a referral list of other therapists that I recommend to potential clients. In the event of a client needing therapy immediately, I refer to other therapists as soon as I receive the call. Of this 27 clients about half are couples, with one or two families. The remainder are individuals. I generally work Tuesday through Friday. 25-30 hours of my work week is spent with clients face-to-face. I spend 5-10 hours per week attending professional meetings; I have peer supervision with colleagues and paid supervision with other experienced professionals; I conduct research into areas where my education is lacking; I talk with "collateral" agencies (this means other professionals who are involved in clients' lives, such as psychiatrists, other therapists, social workers, teachers, etc.); I market my clinical practice; I do my book-keeping and answer/return phone calls. When I started my private practice, I was determined not to burn myself out and decided that a four day work week was a more humane and reasonable approach to working. I pride myself on being a very conscientious therapist and spend a lot of time reading and researching on different issues that clients raise. This might mean educating myself about other cultures, religions or spiritual practices, learning about the stressors attached to various professions that clients have, consulting with other clinicians with a particular expertise, etc.

Most clients come to see me once each week for a therapy "hour" which is generally, but not always, 50 minutes long. For busy couples, especially those with children and the accompanying headache of finding regular babysitters, I usually suggest that they attend a 2 hour session every other week. Clients in crisis will often request extra sessions during the week, although unless the client is in an emotional crisis or is very depressed I usually suggest that they only come in once a week. While coming to therapy can be very helpful for people, and building a good relationship with your therapist enhances the quality of your therapy, becoming dependent on your therapist is not advisable. Encouraging clients to build supports into their lives in the form of friendships, communities, support groups and/or 12 step programs is a valuable adjunct to working in therapy. It doesn't take a whole village just to raise a child - adults need villages of caring support also.

Why do therapists have a 50 minute hour?
This is a fairly common question. The answer is that therapists, including myself, often need to have ten minutes before the next client. This allows time to jot down any notes that we need to remember, check messages and return any urgent calls and clear our heads before the next client comes in to the office. While a 50 minute hour works best for the therapist, in practical terms I will often allow more time if a client is dealing with a particularly challenging time in their life and would really benefit from an extra 10 minutes on the end of their “hour.”

How long do people stay in therapy?
There are as many reasons for people to attend therapy as there are people on the planet. Some people come and see me with a specific goal in mind: a parenting challenge; the death of a parent; a sexual problem; a miscarriage, etc. These people may spend 3-6 months in therapy and leave. Often they will come back in for a "refresher" later on, or they will return to therapy if another issue comes up that they think I could help them with.

Some people come in with bigger challenges: long-term depression; a marital crisis that has come about as a result of years and years of marital neglect and estrangement; families recovering from the effects of a family member's long-term alcoholism and new sobriety; people with a lifetime of struggle, who are just beginning to realize how much they have been affected by the family they grew up in and want to learn how to make different choices for themselves; men and women with histories of sexual abuse who want to learn different ways of being in the world. These issues are often more long term. I have some clients who have been meeting with me for 4+ years. Others stay for a year or more and then leave, possibly returning later if they feel it would help them.

Sometimes people come in to therapy and are not yet ready to do the work. I always leave the door open for these people to return. I know from personal experience that it can take time to pluck up the courage to sit and face your demons.

How do you know when you are done with therapy? Is it really necessary to have “closure” when finishing therapy?
In the best of all possible worlds, a client’s decision to terminate therapy would be because the problems or issues facing them at the outset of therapy are no longer present in their life. However, in reality a client’s decision to leave therapy may be simple or more complex: they may feel that the piece of work they came into therapy to focus on has been adequately examined and explored; they may not feel that they are benefiting from therapy; they may not feel that they are a “fit” with a particular therapist; they may have come face-to-face with some challenging feelings that they are scared to bring up with the therapist and see abrupt termination as a way out of that fearful place.

If it is the therapist who is driving the termination of therapy, they may suggest termination if the client is either unable or refuses to pay for therapy services; sometimes the therapist decides that the problems facing the client are outside of their particular expertise or competence; sometimes, despite a therapist’s best efforts, they can tell that a client is not benefiting from the treatment; sometimes the reverse is true and the client improves dramatically over time and is no longer in need of therapeutic services, leading the therapist to suggest termination; and there are times when a therapist is unable or unwilling to continue to provide clinical services, either due to illness, need for prolonged absence, or some other appropriate reason. Unless the client’s quality of life has improved to the point where they no longer need services and have decided, after discussion with their therapist, to terminate the therapy relationship, the therapist is at all times responsible for attempting to ensure that clients have access to other clinical referrals.

Therapists often disagree about the benefits of taking time to “close out” a therapy relationship. Some therapists prefer that several sessions be devoted to the termination of therapy. Others don’t see the necessity of a lengthy termination procedure, and still others, like myself, think that it really depends on the client, how long they were in therapy, what kinds of issues they were working on, and how invested they appeared to be in the process. If a client comes to therapy wishing only to work on a short-term goal, the issue of closure is less important. However, in the event of a long-term relationship between therapist and client, the issue of taking time to say goodbye to the relationship takes center stage in the final treatment sessions. Few of us have had the opportunity to say a proper goodbye to a relationship, and that opportunity is enshrined in the closure sessions between client and therapist. This is the chance to “do it right.”

The manner of terminating therapy is one of the most crucial aspects of therapy. All relationships should have a good ending and a good beginning and therapeutic relationships are no different in that respect. While licensed psychotherapists are bound by the ethical standards of their professions to follow appropriate termination procedures with their clients, clients are not bound by the same rules and ethics. I always hope that my clients will terminate therapy with me in an honest and straightforward fashion, but this is not always the case. Some people would rather drink drain cleaner than say goodbye! This shows in the way they terminate the relationships. For example, refusing to answer a therapist’s phone calls is not terminating therapy. That is hiding out from therapy and is not an honest approach to closure. Getting “too busy” in your personal life and not having time to attend therapy is also not closure. That is running off and is not the same as taking time to say goodbye. If a client is furious and/or upset with their therapist and is too scared to tell them, leaving therapy rather than dealing with their feelings that is not closure – that too is running.

On balance, the most effective way to terminate therapy is to talk about it. It is an opportunity to review where you are in your recovery path and to understand, with some perspective, where you have come from, where you stand and where you still might need to go in the coming years. Even a short term therapeutic relationship can benefit from one such session. It is a great opportunity to take stock of strengths and to pat yourself on the back for your hard work (both therapist and client!)