Real Psychotherapy Has to Happen at Least Once a Week

Photo by Manasvita S on Unsplash

There are many reasons clients request attending sessions every other week or once a month. The reasons are built on misconceptions about what therapy is and how it works. Therapists might very well agree to this frequency of sessions, but most likely with reservations. I will lay out here some of the reasons clients might want to attend less frequently than weekly, and why that is less than ideal. Besides making an argument for clients about why once a week matters, I will also use this blog post to support therapists about how to discuss this with clients.

From the Beginning

Sometimes when clients start therapy, they suggest meeting every other week, or sometimes even once a month. This is often driven by financial or time constraints. It is surely a daunting thought to make the kind of financial and time commitment therapy requires, especially if you have never been in therapy before. Entering psychotherapy is one of the most impactful steps we can take to transform our lives. While it is well worth the investment, surely it is hard to trust that without a prior experience.

Another reason clients new to therapy might suggest a bi-monthly or monthly schedule is simply an unfamiliarity with therapy. There are plenty of misconceptions about therapy that reduce the experience to a sounding board for thinking through life’s dilemmas, or a shoulder to cry on. Surely we all hope for a place where we will be well listened to and supported, but this is only the very tip of a significantly more complex iceberg.

Misconception: Psychotherapy is about dealing with external dramas

Psychotherapy isn’t a place to unpack the drama of the week. Or at least not exclusively. 

When people first come into therapy, they typically come with a specific issue they need to talk about, which we refer to as the presenting issue. It may be a recent loss, through death, or divorce, or kids leaving home. It may be a decision they are trying to make, about a relationship, or a job, or possible move. It may be a mood or behavior that have been unable to change. In the first weeks and even months of therapy, the events of the week are used to explore the issues at hand.

A misconception about psychotherapy is that it is just about having a place to think about your issues out loud, a sounding board, or a shoulder to cry on. People unfamiliar with therapy imagine therapists are just kind, warm, good listeners. A neighbor of mine used to say she was surprised people need so much schooling to say “tch tch, there there, it will all be better in the morning”.

It is true that good listening is a must. But curiosity is our superpower. Good listening means hearing more than what the client is saying. If someone is talking about feeling consistently invalidated by a partner for instance, we are going to be curious about the role validation and invalidation played in their childhood. If a client is struggling with a co-worker who they feel competitive with, we are going to want to explore issues of sibling rivalry. If a client finds themselves consistently having conflicts with bosses and other authority figures, we are going to look for similarities in their relationships with their parents.

To be clear, we don’t just randomly dig around in childhood. It has to surface organically in ways that are directly related to the issues at hand. But we are not just trying to help our clients resolve the issue at hand. We are wanting to help clients make links to the ways those issues are larger themes and patterns that will continue to surface until they are resolved at the core, from their first incarnation.

A Few Months In

Sometimes a few months into therapy, clients suggest a reduction in frequency of meetings. There are three experiences that typically trigger this consideration for the client.

The first often occurs after there has been a sufficient resolution of the original crises or issue that brought them into therapy. They decide to suggest it after one or a handful of sessions where they weren’t sure what to discuss in their session. Because something isn’t immediately apparent to them as a needed topic of exploration, clients either figure they are done, or they feel unable to manage the anxiety of not knowing, and so offer up every other week therapy as a solution, imagining issues will likely come up every other week that are worth discussing in sessions moving forward.

Another experience that can trigger a wish to reduce the frequency is related to the session the week before the request happens. That session may have included an exchange that left the client feeling hurt, angry, misunderstood, invalidated, or otherwise upset, consciously or unconsciously. The request to reduce frequency in this circumstance is a protection of sorts, again, conscious or unconscious, but ultimately meaning to alert the therapist to the problem, or at a minimum, to act out against them. This may sound petty or extreme or defensive, but so much of what happens in therapy happens though unconscious nuance. Expressing anger and disappointment at a therapist can be hard, so digging at the therapist a bit, by essential saying the therapy is no longer viable enough for weekly therapy, is a common occurrence.

The other thing that might have happened in the prior session is a meaningful break-though, or epiphany, or moment of access to uncovered sadness, or perhaps gratitude for the therapy. Sometimes, when a session has gone incredibly well, or results in a client feeling particularly vulnerable, or exposed, or moved, the unconscious becomes threatened by things to come and tries to shut it all down. We call this a negative therapeutic reaction; when something that is clearly forward moving in therapy results in a negative reaction to stop future progress.

Misconception:  Your Conscious Mind Knows It All

People typically explore in therapy issues they have struggled with one way or another for years. Clients are often at a loss to understand why they feel so stuck, or so entrenched in certain moods or behaviors or patterns. The good therapist doesn’t magically understand why a client does what they do, or feels what they feel. We have to investigate. We have to search for clues. And the clues are going to be sent to us by the clients unconscious. We are going to notice what seems like random associations but that point us to a deeper understanding of an issue. We are going to notice discrepancies or inconsistencies in how our client talks about certain issues, or changes in their affect during part of their story. We are going to notice the use of an interesting word, that our client only used one other time when talking about an issue that will illuminate the current topic. We may get lucky and have a Freudian slip or a dream to help point us in the right direction.

Part of why we concentrate sessions into a brief specific time period, 45, 50 or 60 minutes, is that it helps the client focus on what they most want to tell us. That is why if a client spends the first 5 minutes to talk about the traffic on their way to therapy, we will spend the rest of the session listening for themes of emotional congestion, imagining that the clients’ unconscious also has information they are eager to share with the therapist. If the client has a standing appointment, say 1:30 every Thursday, that time will literally appear in the clients dreams to alert them to dreams about therapy. 

Our unconscious is also the client and it will happily bring issues, or elements of issues into sessions for the therapist to unpack. Sessions when our conscious self doesn’t know what to talk about are great opportunities for a therapist to help us open to thoughts lurking below the surface.

The richness of therapy lies in the works we do about the internal drama of our lives. For instance, what is the language we used to talk to ourselves, especially when we make mistakes? That language came from somewhere and we don’t have to carry that soundtrack with us the rest of our lives. If the only thing someone did in therapy week after week is discuss the language they used to berate themselves in the week, real transformation could happen. If we routinely find ourselves getting defensive with people who insist they aren’t attacking us, then we are defending an old injury or fear. We don’t have to leave that injury to fester the rest of our lives. If we live with a kind of negativity, or unrealistic optimism, or feelings of persecution, they came from somewhere. We can figure out where and how that world view was built and deconstruct it to choose a new perspective on ourselves and life and others.

To believe there is nothing we have to work on in therapy is to say we are perfectly content with how we experience ourselves, how we manage our most intimate relationships, how we feel when we think about the past and the future, our view of others and the world. Therapy is the place to explore the fears that keep us up at night, the thoughts that surface when we feel lonely or scared or angry or hurt. It is so easy to believe that who and how we are is just fact. In reality, our life, particularly our early years, has shaped us and we can reshape ourselves. Therapy is the perfect venue to do so.

Months or Years into Treatment

Sometimes clients indicate an interest in reducing to every other week therapy when in truth, it is time to consider ending treatment. They have done great work, are doing much better, have a strong working relationship with their therapist, but in earnest, just don’t have any meaningful work they need to be doing in their lives at that moment in time.

Misconception: Your Therapist Will Be Hurt or Insulted if You No Longer Need Them

Because therapy has maternal and paternal elements, clients can sometimes worry that a therapist is going to respond to a wish to end therapy as a rejection of the therapist and their usefulness. It is true that parents sometimes feel a loss of purpose whether kids no longer need them. Therapists however entered a field whose goal is to help people increase their self-knowledge and relational skills so that they are better positioned to craft the lives we want. A timely termination is the ultimate success.

There are many different ways to use therapy. As a therapist, it is my experience that most of the best work happens like a wave, that must be ridden. We have periods in our lives when our themes surface, either because of external circumstances or internal readiness. When the work surfaces, we can choose to try to ignore it, but if we decide to instead try to ride that wave, psychotherapy is a great place to do that work. Sometimes it is a very long wave, sometimes it is a wave that is quickly followed by another and then another. But frequently a moment comes when we have ridden all the current waves. Sure, we could dig up internal junk to work on, but the work is much harder if it hasn’t surfaced on its own, and truthfully, if it isn’t causing active problems in our internal or external lives, why work on it?

Therapists know this. We are not actually interested in continuing with a therapy past its relevance. Often when a client suggests moving to every other week at this point in the treatment, the therapist has also started to sense that the work might be coming to an end. If they haven’t, hopefully this will alert them to begin the conversation about termination. 

Therapists handle termination in different ways. Most of us want 2 to 6 sessions to discuss the termination itself, depending of the length of treatment. They may want to spread these sessions out a bit to allow the client’s feelings about the termination to surface. Some therapists will support a client coming in for occasional sessions post termination, when an issue surfaces for the client they need some help with. Some therapists will suggest some themes that they see on the horizon that they are open to working with the client in the future should a new wave surface for the client that they would like to use therapy to help ride.

A Note to Therapists

There are two primary barriers to therapists discussing with clients the decision to move to a bi-monthly or monthly schedule. Allowing these barriers to stop us from having these crucial conversations is a disservice to our client.

First, we can worry that clients are going to see us as encouraging weekly sessions for our own financial reasons. While surely having clients come weekly is a better work and financial model, no therapist is interested in doing work in a frame that is pointless, redundant, or unnecessary. We need to trust our own intentions and know that even if losing a client would financially suck, we well know it sucks way more to have a client in session who is not ready or interested or in need of real work.

Another barrier is an insufficient amount of confidence in either ourselves or therapy. Therapy is an outrageously awesome tool for offering deep meaning and creating lasting change in people’s lives. We may have hit a rock in sessions, or be in a part of the process that feels confusing, or dreary, or even pointless, so when our client suggests session frequency be reduced, we may even be a bit relieved. But that is short-sighted. Yes, sometimes therapy is meandering and we aren’t really sure where we are going or how to get there. That is not because therapy sucks or because we suck. Ok, well, therapy does suck, when it sucks, but abandoning ship isn’t the right move. 

When a client requests a decrease in frequency of treatment, it is a signal that we both have some things we need to be thinking and talking about. Short answers to our questions will not do. The first thing we should think about is the prior week’s session. What happened in it? Was it particularly great, or potentially horrible for the client? Might they be angry or hurt or confused by something that happened in the session? If we can identify things about the last session that might be upsetting or threatening to the client, that is the conversation to be had.

When the client says it is for financial reasons, we must ask why that is an issue this week and not two months ago. Finances are almost always a burden as relates to therapy. But at an unconscious level, money does not exist; but feeling “tapped out” or “resource-poor” or having the feeling that we can’t “afford” something, can be symbolic for emotional burden and overwhelmedness. I am not suggesting we dismiss financial concerns, but it benefits our clients for us to see if there is something else burdening them.

When a client tells us they don’t know what to talk about in therapy, we need to trust the process. Psychotherapy is about the realm of the unconscious. Absolutely nothing needs to be going on in the client’s external world for their internal world to be filled with the drama of their early object relations. When the loud drama of external crises subside, we have a chance to explore the unconscious world that drives our experience of ourselves, our relationships and our world.

 

Smith is an analytically oriented psychotherapist with 25 years in practice. She is additionally the  Founder/Director of Full Living: A Psychotherapy Practice, which specializes in matching clients with seasoned clinicians in the Greater Philadelphia Area.

If you are interested in therapy and live in Philadelphia or the Greater Philadelphia Area, please let Full Living: A Psychotherapy Practicematch you with a skilled, experienced psychotherapist based on needs and issues as well as personality and style. Request an Appointment Today.

 

If you would like to read more about issues related to this topic, please check out some of these blog posts. 

What Should I Talk about in Therapy Today?

Psychotherapists are like Dance Archeologists

Attending to the Unconscious in a Psychotherapy Session

Myths about Psychotherapy





Author
Full Living Founder and Director Karen L. Smith MSS, LCSW Karen L. Smith MSS LCSW Karen is the founder and director of Full Living: A Psychotherapy Practice, which provides thoughtful matches for clients seeking therapists in the Philadelphia Area. She provides analytically oriented psychotherapy, and offers education for other therapists seeking to deepen and enriching their work with object relation concepts.

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