267 Is there an optimum length of time for clients to be in therapy for effective therapy outcomes?

Welcome everybody to the uh episode 267 of the therapy show with me Simon Bailey and the wonderful Mr. Bob Cook. You >> good to see you. >> It's good to see you Bob. Um the uh the title of the the of the session today is is there an optimum length of time for clients to be in therapy for effective therapy outcomes. >> Very good title. >> It's a good good title. I wonder who thought this title up. >> Me. >> Absolutely. And uh I think all the podcast listeners um I'd like you to think or reflect yourself on whether whether you what you think about this subject matter and also whether you are working in the world of problem solution problem focus where you might only work with people eight to 10 sessions. You might be in an organization where there's only six to seven sessions. You might be in private practice where it could be four or five years. Um it'd be [clears throat] good for you to reflect what you think about that and perhaps put it in the drop bar below. I can I'll start with what I think though. So um when I first started therapy many many many moons ago um I was determined very much by the contract. >> Okay. So I was trained as a transaction analyst and Erburn who was the originator transaction an analyst came from the point of view that you get a contract or a goal if you like with the client at the beginning of therapy and once that's goal has been achieved you may end the therapy process and that could be one session six sessions 10 sessions 15 sessions 20 sessions or whatever. Um and it's the opposite of psychoanalytical world which he came from which is more like 4 6 8 10 years where you're much more interested in um allowing the deep unconscious processes and repeated patterns play out rather than uh having a contract and uh looking at goal change. So I started off that way uh getting a contract looking at uh you know when the clients achieved their contract whe they wanted to renew it or have a different contract or end. >> Okay. >> But now >> now uh I don't know when it all started to change. I think when I got very much more interested in long-term psychotherapy and developmental way of thinking >> terms of repeated patterns and reparative therapy and letting the unconscious processes and transferences emerge so the person can really understand themselves of a deeper level. I think I started to change that when I started to uh move into a different type of psychotherapy myself and also had a mentor who thought developmentally. >> Okay. So my me my trainings changed the therapy changed I was in my way of thinking changed and um certainly for the last 20 years of my uh therapy experience as a therapist I was known as a long-term psychotherapist I wouldn't work with people under three years >> okay three years >> all my clients were four five six seven eight nine years in length >> right >> where it was much more about allowing the unconscious processes to come out, the transferences to emerge, looking at the what's underneath the processes of the real self, looking at detachment issues, looking at repeated patterns over time. So I was that's how I was seen and how it's what I said to people. >> I would take a step back though. So my question is what is the purpose? What is the point of therapy here? >> Okay, tell me what tell me what you think. >> Well, it's about change, isn't it? >> Uh, is it that's a really interesting question? So, that's So, is it about change? >> Yeah, we Yes. Yes and no. So, yes, but a bigger question is what what is change? So, so I agree with you in one level, but then what what you might mean by change and what somebody else might mean by change and certainly how you get to that outcome >> or could be very different. >> So that was my my first question. What is the point of therapy? >> Okay, >> it's change. Okay, so what do I want? So this is my assumption. Okay, >> let's go with this then. Okay, >> so what do I want to change? Do I want to change the way I deal with my neighbors? Do I want to change the way I deal with the bullies at school? Do I want to change the way that every time somebody uses a particular word, I go into I have a panic attack? At what level are we changing? What is it? Is it a a social level? Is it a short behavioral level? Or is it a more fundamental level? because they all for me they all feed into the length of time that therapy is undertaken for. I was going to say it takes but is undertaken. >> I understand your thinking and in my experience I've had very little >> few clients have come into my therapy room knowing what they want to change. >> Okay. In fact, somebody came to Derby uh to the assessment only five weeks ago and I said, "What have you come for?" And she said, "Because I'm lonely. There's nothing to do with change." >> Right. >> In therapeutic sense, in the therapeutic sense, >> okay, >> the way we look at change, >> it was you are correct. I do think there was a change because she actually came in the first place. But when I and often people come to therapy, they don't know what they want to change or or they say, "Well, I don't really know why I'm here, but um I've just my life's pretty got a high level of discomfort, so I just want to explore that." Now, you could call that's a change in itself. Um, but I understand where you're coming from because when somebody comes into therapy, if they simp if you Well, I think it's I think your training will determine, Simon, it's like what you see as uh behavioral or what you see as what's underneath the behaviors will determine how you think or how long a person might stay in psychotherapy. So you know you might work in an organization or I can think of many uh or placements I can think of many where they only get 10 sessions. So it's very short term. I know beacon for example around here uh who deal with placements it's six sessions. So it's very shortterm >> focused psychotherapy. And I I think that's a ve that's a completely different type of style of psychotherapy needed when working in that short length of time. >> Yeah. >> And then you can get people who work in private practice or come from a different frame of reference where they may spend years with somebody. >> Yes. Oh. Yes. Yes. >> And so it's it's horses for courses. Um and I I think a lot of people um so for example I I talk to people who work for EAPs um employment assistant programs or medical providers and they are required to work for six sessions with a solution focused uh modality and the frustrations that they have. But also it it it it works sometimes. It's it's adequate depending on what the client is bringing in. >> Yeah, absolutely it does. And I will be the worst worst worst psychotherapist working in that way. >> Okay. >> I couldn't work in that way only because I always look at what's underneath the behavior rather than what should be happening. SH's an odd word, but I think it' be problem focused perhaps. Uh looking at how to help somebody with behavioral change. >> Yes. Yes. Yes. Of course. So people see it very differently, don't they, Simon? So that's because we're trained I know you did a developmental relational training. I did a developmental relational training. So, but [snorts] you get people who are, you know, trained in CBT, for example, going to the NHS, they may think things very different in terms of cognitive behavioral therapy, like mood homework or uh thought change homework. Uh, and they may think, well, you know, Eric, I think Eric Burn came from this point of view when he left psychoanalysis. Let's try and cure people in one session. >> And I he often said that And uh there's I I'm just thinking of Adrien Lee who's a well-known psychotherapist in the tear world who wrote that article about one session cure which he's very proud of and I think if we you know perhaps that could be one aim you know let's let's instead of baffing around in somebody's history for three four five six years and everything else goes with it let's Let's just focus on changing a person as quick as possible. >> Yes. But these the the the situations in which those kind of therapies work tend to be uh apologies for my overgeneralization. Single single issue things um particular anxieties uh >> like phobias >> phobias and uh panic attacks and >> yeah or hypnotherapy >> and and they and they and they work and they're very effective. But what you and I do is then we want to look at what's behind them, what's underneath that. >> Yeah. And that's why I'm saying I would be the world's worst. I wasn't trained in solution focused psychotherapy at all. So I was trained in the in the way you're talking and uh I think there's a place for both actually. >> Oh, I agree. I agree. >> And sometimes um clients vote with their feet. In other words, they they want to look at they want the behavioral cognitive route and they may not want the route that you and I may think about the way we've just been describing it. Um, and they don't want to stay in therapy for months or weeks or sorry, months or years. Um, so they may vote for the vote in a different way. But I do think that you and I trained in a way of think about developmental attachment, what's beneath the behavioral processes, an emphasis on the relationship being the uh therapeutic agent of cure. So it's very personally for me it it's very hard it would be very hard to just work for one specific thing like you're talking about. >> I feel I I feel enormously lucky that I we have the time the the space in which to work long term with people. I have colleagues who work with they do great work. They do trauma focused CBT or or short-term stuff with either in the in the national h you know in the health service or with the police. Um and they do great work and I think but I think that and I think that has to be acknowledged when we're talking about about therapy. Now they're dealing with trauma. the the the policeman's found a dead body and he's been traumatized by it. >> Um but another policeman hasn't. >> He's seen the same dead body. He hasn't. So my curiosity would be why one and not the other. And then that's when I would go down a more therapeutic. >> Yeah. >> And I see a distinct change uh in the psychop psychotherrapeutic world in the last 10 years. And maybe I think I'll be even more specific than that in the last three years, four years. >> Okay, I think I know where you're going. Go on. >> Where am I going then, Simon? You're >> Well, I think you're talking about the the the the way that um capitalism has invaded the therapeutic world and the these agencies that, you know, you can have a different counselor or therapist every week and we'll get you sorted in six weeks time. Well, no I wasn't. But that's an interesting thing like in the ballpark of where I am going. >> Okay. >> Which is to do with money. >> No, that's what I'm saying. That's what I'm saying. It's in the same ballpark. >> Yeah. >> But yeah, I wasn't thinking of capitalism so much. I was thinking about >> in very simplistic terms. >> There isn't as much money around. >> Okay. you know there's an actual uh crisis if you want cash flow crisis or people can't afford therapy they would say so what what how people try to get around that we see the emergency the emergency no it is an emergency but the emergence uh of what often therapists come to me about where people won't stay one week they won't come fortnightly because they haven't got the money And even though I might say things are postless, there is a common economic factor here that you know we are the population is much more short of money. Now that I hear about capitalism, I I studied politics so I can certainly talk about it. Um and uh well I I actually Bob I would challenge that a little bit because I don't think it's that people are the the money is tight for everybody of course but I think that the the market has expanded and that includes people who are prepared to to come weekly and but there's al there is al also more people who who've who are aware of the need for therapy, but they feel they can only do it fortnightly. It's not that it's people have moved to fortnightly, it's that there are more people in in the in the market. >> I think it's both. >> Okay, then you think it's both. I mean, I seriously do. I think I definitely do and I I agree what I agree with what you're saying. The market's widened. I'm not disputing that. um think people have a cash flow problem as well which determines the way they think and that's I mean in 19 when I came when I I started to do my own therapy in 1984 my god you know a completely different world in terms of how people saw therapy you're right the market was shorter to smaller I do agree with you in that um but but you know there lot of people who who might come for long-term psychotherapy and say, "Oh, yes, I know it'll take a longer time. We want to look behind it all." But a lot of people say they can't afford it >> or they're only they're only going to come fortnightly or they're only going to come for 6 months or we're going to have host of host of reasons. there's a change in the air and that might be also to do with the what you've just said in terms of the size of the market >> and what I said earlier about TV commercials saying we can we can sort you out in six sessions >> and I don't think that's realistic >> but it's heavily marketed. Oh yes. And and uh we've got the development of art artificial intelligence. >> Okay. >> Got the development of um Zoom psychotherapy. >> Mhm. >> We've got the development of text therapy even. They're all short term. Is are they more effective? I don't think so. But some people might argue that it is. Well, they may be short they may be effective for specific those specific well- definfined >> areas the phobia the panic attack or although panic attacks usually symptom of something much more serious um so they may fix that fix that >> also zoom therapy >> I think zoom therapy for example the huge amount of therapists that work on zoom now with clients that's much more short-lived >> because there's no face to face interaction. It's not that attachment. It's a different type of attachment. Put it that way. So, it's a different world I live in or inhabit in terms of psychotherapy from the mid80s. So, that's one way of looking the subject we're talking about. And then of course there's the the there's there's the attack on long-term psychotherapy or at least put it another way a lot of negative criticism which is about you know long-term psychotherapy fosters infantilization or it fosters dependency ex xxx and uh I think they're real things to think about >> and and is dependency a bad thing? Well, but mo most people, most psychoanalysts would say yes or would argue that it could be. >> It could be. And what do you say? >> Well, of course it I think of it this way. Yes. I think if a client becomes dependent, well, here's another one. If you're a long-term circa therapist, especially the way I work, you get clients that can get heavily dependent and attached to you. >> Yeah. >> And never want to end therapy. >> Okay. And then I get a I get a therapist that come and says, you know, um Joan, I'm making names up here. Joan's been with me eight years. And uh we have great problems finishing, you know. So when somebody does get to a level what might be termed as dependence, at least needs to be looked at, I think, and see what we're talking about here. Then I don't think effective change has necessarily happened. In fact, maybe there's some sense of infantilization or some sense of >> right >> lack of uh ownership of the self. >> Yes. Yes. Um my feeling is I don't mind dependency as as long as it's not indefinite. I I'd rather people be dependent on me than on a bottle of whiskey or a bottle of gin or on some other thing and then work on that to that relationship that therapeutic relationship to strengthen the adult and get them out of child and the things that we that we mentioned that we talk about the therapeutic process. Yeah, I I'm with you in many ways, but and I also am aware of the criticism, you know, of long-term psychotherapy and dependency is often one of the big criticisms, you know, because it's like the the sense the argument be oh that the person gives up their sense of self. There's no real agency. the therapist becomes the person who does the work or whatever way you want to look at it, not the not the client. So, I'm with you though. By the way, I I I I rather change the word depend dependency to dependability. >> Okay, good. >> So, I I would follow the way you think. It's just something to be aware of if we're thinking of long-term psychotherapy and and is that effective. I I think it can be very very effective, but I do think they're important things to think about and endings particularly. >> Well, we'll come on to Yeah, maybe deal with endings later, but um we come back to the purpose of the therapy >> and I said it's change. It's about building resilience. It's about understanding what's going on for themselves. It's about uh having techniques. It's having skills to soothing techniques to to to manage themselves and ultimately change themselves and the way that they interact change in in relationships and relationship with themsel. Well, there's often, you know, one thing I often learned as a TA therapist was I I went along, especially as a supervisor. Um, that TA therapist often like contracts and like goals. They call them contracts. And quite often, you know, the contract the therapist thought they had with the client was completely different than what the client thought they had. >> Okay? >> And when you're talking, I often think that way. It's like it's like oh you know it's like therapists often have a a view of what change is and it might be completely different from what the actual client thinks they're working towards. So all the things you said I agree but it doesn't mean that the client's there >> and and when you when when you discuss contracts with clients and you say to them well what do you want from therapy? >> How do you ever know? >> What do they say? I don't know. >> I want to be happy. >> They say I don't know, Simon. >> Oh, I I find that they say I want to be happy. >> They say that you'll say, "What do you mean by happy?" >> What does that look like? >> I when I went into therapy myself, I didn't know what I wanted >> or I might say to some I remember saying to my therapist, "So, what you want?" Oh, I don't know what I want. Oh, well, how come you're here then? Oh, because uh my life is such a level of discomfort. I I just need that. If you're talking about change, I'd like to find out why that's that way. Okay. >> Or whatever it is. So if you got an experienced therapist who can like what you're talking about here I think but you can get many therapists think that's so vague that they never really nailed down what change is and it's quite I think contracting is a real art by the way >> there are books written about it >> yeah you know you you trained in it I was trained in it both I probably write we did it. I just think of the many clients though I've said assessment and I said, "What are you here for?" I don't really know. I just feel miserable or like you've just said or I'm not happy. >> Yeah. >> Or, you know, um but they never really thought about a further goal than that or they might not. Is there any advice that you would give to a client before you pass them on, you know, hypothetically before you pass them on to a therapist to say you'll know when your therapy is complete when you feel or when you are? >> Well, I don't have advice, but I know what I'd ask. >> Go on. I say, "I'm going to pass you to X, but I just want to check you're motivated." See, and you want to be here in the first place. >> Yeah. >> Because unless you've got motivation for change, nothing's going to happen. In terms of advice or tips, I may say something like, "Yeah, I'd like you to, you know, if I could give you one tip afterwards, I've done this myself. Just be as honest as you can and as authentic as you can and share as much as you can. in therapy and if you can do that you won't go far wild >> and and the respon their response would be well how do I know I've got where I want to get to >> I've never had that Simon >> no oh no I'm I'm just talking hypothetically >> oh no usually what happens when I say something like that >> they'll say something well I'll try and do that and I'll say great and >> I hope it goes well >> or something like that I don't if somebody said what I haven't said What was that you said? If they say what? What did you say, Simon? >> If they were to say, how will I know when I'm I'm I'm complete. I've completed my therapy. >> Oh, I say I say back to them, well, how do you think you might know that? I wouldn't, you know, I'm not God. I wouldn't be able to go down that line. I say, well, I'd say back to them, what do you think? How do you think you might know them? H you see behind every question is a statement in my books. So I'll ask them what you know. Well, how would you know then? Well, I'll feel better. Oh, great. Well, if you feel better, then tell your therapist. I put it back to them. Tell your therapist. Monitor yourself. Do you still get Do you still look forward to coming to therapy? Do you feel Do you feel resilient? Do you still behave? Do you still respond in the same way that you used to? >> I quite agree, Simon. And do you think anybody ever looks forward to go to therapy? >> Oh, yes. >> I'm not so sure, by the way. >> No, there are there there are those who come and then there are those who say, "I didn't want to come this morning." You see, I think that when you're looking at defenses, I don't think it's a I think it's a hard road because it's an uncomfortable one. >> It is. And it's a bit like Pilates. I do I do Pilates every Friday morning except when she's away and I'm away. And and she says after the hours, Pilates, how do you feel then? And I think I think how do I feel? Yeah. So sometimes, but if I'm working really in the the areas of stretching or whatever it is which are comfortable, it's actually not a particularly energizing session for me because I'm going to areas which have been difficult and I think that about therapy. It's not meant to be cozy and if it's cozy something's wrong. So you I think some people are eager to understand themselves so might look forward to therapy from that point of view. Um, but it's an interesting I smiled when he said looking forward. It's just an interesting It's the same with my Pilates teacher. I think she says, "Do you look forward to coming bob sometimes?" I said, "No, actually I don't sometimes." You know, so it's just interesting. But you're right. I think Simon that people have a great thirst for understanding themselves. They may look forward to therapy and they might look forward to coming to see you. you know that furthering of a relationship. Well, when we talk about um how long is effective for how long is effectful therapy, >> how often do we have clients with whom we've fulfilled our contract >> and their life has changed and they're okay >> and yet they still want to come because of that relationship they've built with with us. and there's really no one else they can talk about. >> And would you call that dependency then about what's going on in Simon? >> Would you then call that dependency? >> What an interesting question. Um >> only because we were talking about dependency. >> No no that's an no interesting point. >> Yeah. >> Um um um shuffle shuffle >> only because you know Eric Burn talked a lot. Not that I I I'm not that I'm a what you and of course TA changed my life in many ways behind a TA therapist and I believe in the model in many different ways. There's a lot of things he said which are quite contradictory, but he he was very much into the contract and having a contract which is specific, observable, and behavioral. And so you would know when you've made that change and then that's when therapy ends unless you have a different contract. And if that different contract is vague and unc would say they are if you can't get a specific behaviorable observable finish it will contract >> then therapy doesn't begin. >> Yeah. Okay. Yeah. You your comment about is that dependency I'll have to have to take take that away and think about it. >> It's an interesting one isn't it because I often think about it by the way. Uh are they just coming because there's some level of dependency really? >> Yes. >> Rather than any real changes happening. >> Yeah. On that note, Bob, um I wouldn't like us to be too dependent on each other here. [laughter] >> Simon, I love being dependent on you sometime. You brighten my day. >> I know. I know. I know. Your wife pays me to do it as well. Yeah. >> [laughter] >> Um, next week, uh, I know Bob's wife. She's great. All right. Um, next week we'll be talking about notetaking. >> Oh, why now? Another one of my favorites. I must pick these titles. I must pick them >> because I like that subject. That is a wonderful subject for podcast. >> So, what Bob? Bob, it makes the titles and it gives me a long list and then I choose the ones that I like to talk about. [laughter] >> Let's be transparent with this. >> Yeah. Yeah. Yeah. Yeah. Yeah. It's interesting though, isn't it? That's an interesting title though. Seriously, about note takingaking. >> Is it important for therapists or counselors to make notes during the therapy session? >> Yeah. Yeah. Because the people listening to this, I am sure will say it's vital. But and there will be those who say, "But my trainer said I should never make notes." >> I'm going to leave these nuggets of pearls of wisdoms and stories to to that podcast. >> We will come we will deal with this next time we meet. >> We'll deal >> again everybody from Thank you very much for listening to us today from from myself Simon Bailey and the most wonderful Bob Cook. >> Yeah. Yeah. Thank you very much. And I've enjoyed I've enjoyed talking about this area and I hope the people listening have found it useful. >> Yeah. Thank you very much everybody. >> Yeah. Bye-bye. >> Bye. >> You've been listening to the Therapy Show Behind Closed Doors podcast. We hope you enjoyed the show. Don't forget to subscribe [music] and leave us a review. We'll be back next week with another episode.