Psychotherapy is a pretty well-understood treatment method used to help people with serious concerns like depression and bipolar disorder, to life adjustment issues like the loss of a significant relationship or one’s job. Therapists and psychologists spend years in classes and training, and generally see patients in modern psychotherapy for one 50-minute session per week.
You know from the outset that a therapist relationship is a professional relationship, and the therapist is running a business. Most therapists, to one degree or another, try to distance themselves from the business aspect of their practice as much as possible. More well-to-do therapists and those who work in a clinic or group practice may even hand off billing and paperwork issues over to a receptionist or secretary. The purpose for this distancing is two-fold — most therapists make horrible business people (and many have trouble even asking for payment due) and many therapists have an uneasy discomfort with the business side of their profession. Business is not the reason most therapists go into the profession and although they want to make a living, they often have a difficult time acknowledging the business component of the professional relationship.
The professional nature of the relationship is set immediately when you get your first orientation with your new therapist. You don’t get an hour with the therapist or psychologist, as you may have been led to believe. Instead you get 50 minutes — what therapists refer to as the “50 minute hour.” Why 50 minutes? Because, the party line goes, the extra 10 minutes gives the therapist time to write up a progress note, deal with any billing issues, take a short bathroom break, and get ready for their next client.
But this whole arrangement is based upon a false assumption — that therapists need every precious minute of their 480 minute work day, because they see (or expect to see) 8 patients every day (or 40 a week). I don’t know of a therapist who sees 40 patients a week, which would be a heavy burden for most therapists. Therapy is an emotionally draining experience not only for the client, but also for the psychotherapist.
Therapists and psychologists could just as well see patients for 60 minutes (you know, an actual full hour), but then they put themselves at greater financial risk. If you schedule 35 patients a week, that means 3 or 4 of them will be no-shows or cancellations every week (for one reason or another). Therapists, therefore, tend to over-schedule a little bit, to try and take into account this rate. This arrangement ensures the professional sees a full weeks’ worth of patients without too much down-time (time for which they’re not getting paid). It’s smart time management, and it’s a careful balancing act that most therapists have learned to juggle fairly well.
I think all of this is well and fine. This is just the way modern psychotherapy works in the U.S., where most therapy is reimbursed by insurance companies and our government Medicaid program, all of which dictate pricing and time standards. But a professional can take this need to manage their time a little too far…
The other day I learned of a practice that made my stomach turn.
A therapist uses an actual kitchen timer to denote their “50 minute hour.” You know, the kind that goes “tick tick tick” and then dings when the time you’ve set is up. Set it and forget it! Fifty minutes later, Ding! Time’s up!
-
The person could be in mid-sentence, relating a horribly traumatic experience of not being heard or listened to by their parents while growing up.
Ding!
Sorry, you’re not going to be heard here either.
The person could be sharing a tender moment of insight of why they feel so reluctant to put themselves out there in a new relationship, for fear of rejection, and…
Ding!
Sorry, your therapist is rejecting your right to some basic dignity.
The person might be wrapping things up and saying, “Hey, I really appreciate your time and not cutting me off like my ex-husband used to–”
Ding!
Sorry, the therapist can cut you off just like anyone else.
I get the need to keep on schedule and help clients keep to the therapist’s schedule (because, after all, it is the therapist’s business), but this is just plain obnoxious.
Worse yet, this sort of behavior reinforces the power differential in the relationship and basically says to the client, “While the time you spend here is valuable, your human dignity is not.”
Most ordinary therapists and psychologists deal with scheduling by simply being aware of the time. Not by clock watching, mind you, but simply sensing when the time is coming to a close. Sure, it may help to glance at a clock every now and again, but most therapists learn this skill as second-nature over time. Some therapists may set their phone or PDA to vibrate to remind them. Others put clocks in strategic places in their office so both client and professional is aware of the time. But such mechanisms are subtle, tactful, and perhaps most importantly, respectful. They don’t denigrate the patient’s experience and humanity with a “Ding! Time’s up!”
Because people are human beings, meant to be treated with dignity and respect. Especially by their therapist.
We’re not turkeys. Well, not most of us anyway.
15 comments
Well said John! I work in a small rural community (less than 10000 people), and there is another psychologist and two therapists in the same office. We are all busy.
And, we all see patients for 60 minutes (not the fifty minute hour). That means immediately going from one patient to the next. Probably 70% of my patients pay out of pocket, and when you have that arrangement, your not going to have a timer that goes Ding! at the end of the session. Folks will spend their hard-earned money elsewhere.
One of the therapists down the hall is the busiest in the office right now (He sees 48 patients a week over 4-12 hour days). Talk about intense! The psychologist down the hall has had to cut back with increasing age from 70 patients a week to 35. There are some out there who see 40+, but outside of the office I work in, I’ve never met any. It takes tremendous energy and focus conducting psychotherapy…and emotional resillience.
I’m guessing the fellow who runs his practice with a timer is not being paid directly by his patients, or if he is, it’s a very small percentage. That kind of thing won’t fly where I come from.
Thanks for the article John.
My therapist never had to cut me off because after he explained the “50-minute hour” to me, I was the one who was overly cognizant of *his* time. But I remember the freedom I felt when I switched to email therapy. We had different time constraints there, but I was never cut off in that situation. It was much more positive than traditional therapy.
I find the comment above distressing. How can you remember who your clients are when you see so many people? This was a problem back in grad school when I saw a university-sponsored therapist. He saw so many people from week to week that he couldn’t remember who I was. It was like starting over each week.
I would also have hated running into other clients in the halls if we were all scheduled back-to-back. The 50-minute hour can prevent you from seeing other clients, which I prefer. But the best thing for me was email therapy.
Jude, you have a point with your distress. Some psychotherapists do get to the point where they are overloaded and overworked. Certain psychotherapists are able to manage a heavy load effectively. Psychologists and therapists have to know their limits so that what happened to you, does not happen to those they work with. As for running into other clients, our offices are set up with two doors. The clients exit through one and enter through another. This minimizes the possibility of running into other clients. However, you do make some good points for others to consider.
The way my therapist worked it when time was running out was he told me, “Time is running out so lets start to wrap it up.” He knows that I have a habit of running on and on and on so he also said, we will start our next session on that topic, and we usually did.
Karel
I’m a part-time therapist with a home-office. I tend to space much time between clients and usually let the client control how long they want to have the session for. (They have a choice to be charged either an hourly rate or by the minute rate.) I have another well paying job and therapy only takes approx. 4 -12 hours per week.
Living and working in Asia, many are polychronic and come from a long distance (even other cities) and may want to spend a couple hours in a session. It may be somewhat”unconventional”, but remember that Freud was most unconventional when he introduced certain theories.
Thanks for the excellent article.
Boy quite a few generalizations here.
Another one: most therapists state up front that they require a 24-hour advance notice of cancellation to avoid being charged for the time the therapist has set aside for the session. So they aren’t necessarily ‘not getting paid’when they have a cancellation.
I think many therapists have fine business skills, but as you said, insurance company paperwork can be quite time-consuming. It’s why many therapists do not accept insurance.
Thanks for an interesting article. Sometimes I think we forget therapists have many concerns within their work with us.
My therapist is pretty good about letting me know when we are running out of time. Then she checks to see if we have any other appointments for future sessions.
I sometimes feel like she sees too many people because her employer is greedy in my book. I have found that she forgets a lot because of all of the people that she talks with in a day. Then she will surprise and remember something. I like to watch her when I leave because she comes into the waiting room and makes eye contact with the next client. Then she smiles at the person like he/she is the only person in the world to her. I love it when she does it with me and I sneak peaks at her when she does with the next person.
I did have one time that annoyed me because she was thanking someone for coming in and then followed me into the waiting room. Then she made a comment like she thought I hadn’t seen her. I replied that I saw her but she was talking to someone.
i agree that the egg timer is a bit harsh, but as a psychiatrist/therapist, i very frequently run into the problem of not being able to get patients out in time, even if i schedule their next appointment, write out prescriptions, and stand up to show them the door. help please!
How interesting, I have been in therapy for 3 years, and my therapist talks about “the relationship” and trust etc, and wonders why I dont “let go” at the sessions, however I find it too formal and not natural to “let go”. I have often been in real distress when she has pushed me to acknowledge something, and then she announces that the time is up, I leave completely disconnected state, but that doesnt seem relivent to the therapist, there is no flow from session to session, it feels disjointed and I think contributes to my sense of being fragmented. I find it impossible to establish this “relationship” due to the formality and time constraints of the sessions.
My therapist is a very astute bussiness woman and when attempts are made to cancel appointments to take a break she wants me to attend to talk about it, i somtimes feel its more about her needs rather than mine. Gosh Ive really let loose in this and think perhaps Ive come to the end of the road with this therapist.
I agree those strict time constraints are repressive. Two hour sessions would work for me. Seems to me longer sessions are better than frequent sessions that leave the client unfulfilled. I never feel really heard in time constrained sessions. I also notice most won’t even file insurance—integrating therapy into my life is hard enough without the added paperwork! Good luck to you, hope you find a therapist that goes beyond the business model!
I’m a therapist who found this article because I’m wondering if I need to use a timer. Now I have more angles to consider, thanks to the comments here.
Here’s what I think about time and therapy:
I think it’s important to start sessions on time–respectful to both parties, professional, and also practical.
It’s often hard to end a session. There are good reasons for this–to end right on the dot at 50 minutes can feel impersonal, rude, abrupt. It’s not how we do things in social relationships, and in therapy too the end of the session can feel like a rude interruption. Compounding this problem, some people only manage to really get into an important topic because they know the end of the session *is* near! Unconsciously, many people tend to have big important revelations or feelings emerge right at the end, making it difficult to stick to the agreed-upon time limit.
Then again, some of my clients value the relative impersonality of ending right on time, because it makes them feel safe from having to feel personally beholden to me.
So, like everything else, there are a lot of ways a person can interpret the 50-minute hour, and promptness about ending.
My own tendency is to stay for a few extra minutes when I sense someone wants that, but it’s not an ideal solution. One, it’s not entirely fair if I spend different amounts of time with different clients. If we both know when we’re going to start and end our meeting, then we both have equal power. (Likewise, if someone really thinks that 50 minutes is not enough for them, I’m very open to negotiating a different session length at a different fee.) If I arbitrarily extend the time for someone, but not for someone else, then I think I’m behaving just a bit more autocratically and unfairly.
And those ten minutes are above all about a therapist’s need to reflect about the previous session before moving on with the day. I know I hate rushing from one session into another, though sometimes I end up doing it that way–but I feel more present and available to my clients when I take care of my own need for quiet, reflective time in between sessions.
And what about my clients’ needs for that kind of time? Fifty minutes is a long time in which to talk. Sometimes it seems to me that the feeling of needing to keep going past fifty minutes has to do with somehow rushing past instead of slowing down to digest and appreciate what’s already been said and felt and put into words.
Interesting article and you made several excellent points in your comment.
I’d happily do a 60 min hour, but then I would still need to schedule breaks. Appointments at 3:10, then 4:20 might be possible, but that seems difficult for both client and therapist to keep track.
I have been to therapists who use timers and it has never bothered me. The key is that they are not ruled by the timer anymore than the clock.
No matter how you keep time, if someone suddenly says “times up, bye” it going to feel abrupt.
My goal is to find a timer with a soft sound, so that it is not jarring, then I can relax instead of watching a clock. Which allows me to be more present with my clients. I am a relatively new therapist, so with practice I may not need a timer anymore.
I agree Joanne and Carol. I have many years experience and I do use an unobtrusive alert set for 48 minutes (soft very brief bell chime) . I explain at the start of therapy that this is to let us both know that we need to start winding up. I never however would abruptly end at that point and clients have told me that they appreciate the chime and how I manage their time. It does for me allow me to be completely focussed on the individual. At times we will go 5-10 minutes beyond this if needed. Having the 50 minute hour enables this option when necessary.
More typically the 50 minute hour allows ime time to reflect, write notes, consider where we are taking the therapy, and recover if needed, to be refreshed and focussed for the next client. I see this as very respectful to ebery client. Respectful boundRies on both sides are important and are a part of life.