Michael O'Sullivan is a Cognitive Behavioural Therapist in the Derbyshire Healthcare Foundation Trust.
There are many “givens” within Cognitive Behavioural Therapy (CBT), one of them is about how long a patient might need in therapy.
Within the NHS the answer is given by what we refer to as NICE guidelines; guidance from the National Institute for Health and Care Excellence which recommends a certain number of sessions for CBT therapists to have with their patients.
"The focus is on achieving those steps that can take us in the right direction rather than complete change".
However, because we as therapists accept the conventional wisdom of NICE we can easily fall into the trap of a self-fulfilling prophecy, believing that this is actually how long we need with a patient. We reinforce this by telling patients "this is the number of therapy sessions we will need" and they will agree with us because, after all, we are the experts.
But how helpful is this one-size-fits-all approach?
All changes are significant
In order to answer this we need to think about the question in the title. The length of time any patient “needs” will be dictated by the changes they make in therapy. The most important changes will be those that reveal they no longer need to come and see a therapist. These changes do not need to be life changing but are nonetheless significant.
When I passed my driving test I was by no stretch of the imagination a competent driver. However, the changes I had experienced through my lessons and the driving test allowed me to take the first steps in becoming that driver.
The changes in therapy may only be those which we need to take us in the right direction. They do not necessarily need to come after a long period of therapy.
If we look at when change occurs, Lambert’s 2013 study (1) suggests that it happens early. If we are to start developing a bespoke rather than one-size-fits-all approach, firstly, we need to think about the approaches we take in therapy. Secondly, we must consider the way in which therapy is organised.
A different model
If change can occur early on in therapy then the approach of Single Session Therapy (SST) from Moshe Talmon (2) may be helpful. SST does not necessarily mean meeting for just one session; rather, it is an approach which uses a variety of focussed techniques such as the Brief Solution Focussed Therapy model of Steve De Shazar (3). As the example of driving lessons suggests, the focus is on achieving those steps that can take us in the right direction rather than complete change. A typical question in SST might be: “If we were only going to meet for one session, what problem would you want to focus on?”
The types of solutions the therapist might negotiate with the client will be more focused. Like domino theory, they will look for the one domino to push to make the others fall down. The solution might be a change of environment, behaviour, or thinking.
- See more: What worked for me? Cognitive Analytical Therapy
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Empowering patients within parameters
Our second consideration would be changing the way that therapy is delivered.
One of the therapies under the CBT umbrella is Methods of Level (MOL) (4). An approach adopted by some MOL therapists states that patients can choose the number, frequency, and duration of sessions they need.
Although this might feel impractical within services constrained by what is available there are potential ways that this system could work: placing a cap on the number of sessions, the frequency on how often the sessions are scheduled, and the length of each session. The research suggests that when this is done, patients will only come to the sessions they want until they feel that they have changed.
Therapy services based around need rather than availability are the ones which are likely to be more empowering for the patient, helping us escape the trap of the one-size-fits-all approach.
(1) Lambert, M.J. (2013) The efficacy and effectiveness of psychotherapy. In m.J Lambbert (Ed.) Bergin and Garfield’s Handbook of Psychotherapy and Behavioural Change (6th ed: pp 169-218)
(2) Talmon, M (1993) Single Session Solutions-A Guide to Practical and Affordable Therapy (New Yor: Addison-Wesley)
(3) De Shazar, S. (1982) Patterns of Brief Family Therapy., New York: Guildford Press
(4) Stiles, W. , Barkham, M. ,Connell., J and Mellor-Clark J. Psychological Medicine (2008), 38, 677–688