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Nearly all of the clinical benefits of psychotherapy are delivered in the first few sessions. Some studies suggest an inverse correlation between duration and e

Nearly all of the clinical benefits of psychotherapy are delivered in the first few sessions. Some studies suggest an inverse correlation between duration and effect size - people in long-term therapy may have worse outcomes than people who complete a short course of therapy. Psychotherapy is an effective treatment for most common mental health problems, but if you're going to therapy for more than 12-18 weeks, you're doing something other than treating a mental illness. You're likely getting something out of it otherwise you'd stop going, but that thing isn't improving your mental health in any meaningful way and may be actively causing harm. I'd strongly encourage people to try psychotherapy if they're experiencing psychological distress, but I'd also strongly advise them to go in with a clear sense of what they'd like to achieve. If a therapist isn't willing to work with you in the first couple of sessions to create a specific, measurable, achievable, relevant and time-bound plan for your therapy, you should be very wary. Therapists who advocate an open-ended approach that eschews goal-setting and objective outcomes in favour of a nebulous sense of "insight" or "growth" aren't delivering evidence-based care and aren't acting in the interests of their clients. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/duration-of-psychotherapy-has-little-association-with-outcome/CD51BB442A15328952834A5B1FCE7DD0 https://www.cambridge.org/core/journals/the-british-journal-...

nequo 3y ago
The source that you linked points out that there is no experimental data to study this because experiments are designed with a fixed duration. This seems like a serious limitation. Someone who stays in therapy longer might have a more complex issue that they seek to address, resulting in the negative association (that is, correlation) that you mention. But I do agree that having a clear goal is a good idea.
- jdietrich 3y ago
  We have randomised trials comparing long-term with short-term therapy; they show no significant difference in outcomes. https://www.sciencedirect.com/science/article/abs/pii/S0272735811001863?via%3Dihub https://www.sciencedirect.com/science/article/abs/pii/S02727...
derbOac 3y ago
The linked study is interesting and useful and I'm surprised I wasn't aware of it. Thanks for posting. Still, these sorts of things are difficult to interpret because severity of problems are also correlated with length of therapy and inversely correlated with outcome. So it's hard to interpret, even if you try to statistically control for it. It's also something that would be difficult to randomly assign because different lengths of therapy might not be a good match for someone. It's a bit like saying "length of rehab following traumatic accidents aren't correlated with as positive of outcomes". That might or might not be true but if it were it would be difficult to interpret because you could imagine rehab would take longer after serious accidents and also have more difficult outcomes. There's other things to consider with length, like maybe the focus is shifting? Maybe someone continues to benefit from it? Anyway, I agree it's important to try to remain focused in therapy and not use it in the wrong ways, but length is a difficult thing to make sense of sometimes.
- jdietrich 3y ago
  We do have randomised trials to support the argument, but (like most treatments) there's a very obvious dose-response curve. If we take outcome measures after each therapy session, we can see that each additional therapy session has a diminishing marginal benefit. There's a reasonable argument that the most severely affected patients might gain clinically meaningful benefits from very small incremental gains, but that's very difficult to falsify because the effect size is so small. Long-term psychotherapy undoubtedly fails any reasonable cost-benefit test, but even setting that aside, I'd suggest that anyone who isn't satisfied with the results of therapy after 12-18 sessions would be better off trying something else - either a different therapist, a different psychotherapeutic modality, or a biomedical treatment. Anecdotally, the vast majority of people who I encounter who are in long-term psychotherapy aren't severely unwell; obviously that is in large part explained by the barriers to access faced by most severely unwell patients. Many of these people aren't "mentally ill" in any meaningful sense, exhibiting only subclinical symptoms of anxiety or depression even at the point of starting therapy. They don't have clear goals for therapy, or any real sense of when it would make sense for them to finish therapy. If they find therapy to be an enjoyable activity like doing yoga or having a massage then I have no qualms with that, but many of them ascribe benefits to long-term therapy that simply aren't supported by the evidence. https://pubmed.ncbi.nlm.nih.gov/30661486/ https://pubmed.ncbi.nlm.nih.gov/30661486/
ramraj07 3y ago
Good therapists don’t schedule constant weekly checkins for folks who don’t need it. I’ve had times when my therapist said check in after 4 months to see if things are fine. Therapy works for people who need a lot of help to barely get to normal. It also helps a lot for people who would typically be classified as just fine, but they still want to become better people. I’m in that category. I hope none of us believe we are already the best we can ever be, there’s always room for improvement. If that’s the case, why wouldn’t you want to continue working with a professional to try and figure out how that can happen?
- jdietrich 3y ago
  >If that’s the case, why wouldn’t you want to continue working with a professional to try and figure out how that can happen? Because there's essentially no evidence to support it, the cost is very significant and there are very real risks of adverse events. Most developed countries (and America in particular) have a very serious problem of over-medicalisation, over-diagnosis and over-treatment, which greatly inflates healthcare costs for no real benefit. More broadly, what do we mean by "better person"? If we define it in the Californian sense of hyper-optimised self-actualisation, then long-term psychotherapy for clinically healthy people might plausibly deliver on that goal. If we mean a better friend, a better neighbour, a better citizen, then I think you'd be far better off spending an hour and $200 a week doing something towards those aims.
  - faeriechangling 3y ago
    There is an immense IMMENSE bias towards the idea that if something is vaguely a mental health intervention it must be helping. So much of mental health practice especially outside of pharmaceuticals is well well outside the realm of evidence based medicine. If a study shows therapy benefits a specific population it given for a specific period of time, it must benefit all people if you go monthly for ten years. The, what is for most people, massive cost of therapy itself in terms of money but also time is treated as if it has no potential for adverse impact. I’ve been trying to hammer for most people the main cause of poor mental health in the developed world is not lack of access to therapy. It’s poverty.
magicalhippo 3y ago
> If a therapist isn't willing to work with you in the first couple of sessions to create a specific, measurable, achievable, relevant and time-bound plan for your therapy, you should be very wary. I have a friend who's been in therapy for over a decade, due to debilitating anxiety from childhood trauma. Went many years to first before switching to second, same story. I asked "well have you gotten any tasks or tools to help you deal with it?" multiple times, always same answer: "No". Third time lucky it seems. Now seeing a therapist which comes with concrete suggestions and tasks. Things have improved. It's not a trivial problem to solve, but at least there's change now. edit: You may ask, why stay with the therapists that didn't help? Anxiety... didn't want to upset the therapists by suggesting it wasn't helping.
- dyno12345 3y ago
  therapists have a responsibility to act in the best interests of clients who are not able to "manage" therapists well. this doesn't get discussed enough.
- em-bee 3y ago
  a friend of mine who is working as a therapist says she doesn't take any patients for more than half a year. if she can't help them in that time then she probably can't ever. another reason to stay with a therapist is outside pressure. and sometimes talking to someone does help a little bit in that it has a noticeable effect without improving things to the point that help is no longer needed, but that potentially leads to a dependency which is not good either.
rented_mule 3y ago
Please be careful about treating the findings of any study as fundamental, universal truth. Science is messy and yesterday's accepted facts often becomes tomorrow's over simplifications. And when it comes to our understanding of treating mental illness, there are all kinds of exceptions to what we "know". None of this is black and white. This study talks about correlations. What it doesn't (and can't) have is counterfactual evidence to establish causation. Would the people who went longer have had as much success if they didn't go as long? We don't get to rewind and try. My personal experience tells me that going MUCH longer than 12-18 sessions can yield life changing results. Before therapy, I was in a very bad place, having trouble understanding why I should go on living. At one point, I found myself curled up on the sidewalk in a big city, crying in the middle of the night, unsure I'd ever make it home. I needed help and luckily I found it. In my first session, I was very explicit that I didn't want to track any goals - my high pressure job (I led a group that was responsible for a billion dollars a year in annual revenue) already had too many of those for me to handle. I was 50+ sessions and six months in before I was able to observe any benefit from therapy - my therapist could see it much earlier, but I couldn't. Six months later some brutal life events, and my way of internalizing them, put me in a worse state than when I started. I then took months of medical leave from work at the advice of both my therapist and my family doctor. After 150-200 sessions total, over the course of 2.5 years, I finally thought to myself "I feel healthy, do I need to keep going to therapy?" The very next session, before I presented that thought to my therapist, she said "You've made a ton of progress. I'm not sure it's worth your time and money to keep talking regularly. What do you think?" Today I'm 100% clear that life is worth living. And I have a much better understanding of how to recognize when my mind is processing things in an unhealthy way and what to do about it (sometimes an ad-hoc therapy session is part of the answer. Is it possible that I could have changed treatments / practitioners and found success more quickly? Of course! But it's also possible that I could have tried switching, picked something even worse for me, and ended up taking longer or even taking my own life. If we knew the optimal path, we'd take it from the start. But we don't. Medical science around mental health isn't even close to offering that. I'd hate for others to give up on much needed treatment too soon because they aren't seeing success in 12-18 sessions. If they have the capacity to change course, maybe that's the right thing to do. If they don't, then staying the course could be exactly what they need.
deleted 3y ago
[deleted]

nequo 3y ago

The source that you linked points out that there is no experimental data to study this because experiments are designed with a fixed duration. This seems like a serious limitation. Someone who stays in therapy longer might have a more complex issue that they seek to address, resulting in the negative association (that is, correlation) that you mention. But I do agree that having a clear goal is a good idea.

jdietrich 3y ago
We have randomised trials comparing long-term with short-term therapy; they show no significant difference in outcomes. https://www.sciencedirect.com/science/article/abs/pii/S0272735811001863?via%3Dihub https://www.sciencedirect.com/science/article/abs/pii/S02727...

derbOac 3y ago

The linked study is interesting and useful and I'm surprised I wasn't aware of it. Thanks for posting. Still, these sorts of things are difficult to interpret because severity of problems are also correlated with length of therapy and inversely correlated with outcome. So it's hard to interpret, even if you try to statistically control for it. It's also something that would be difficult to randomly assign because different lengths of therapy might not be a good match for someone. It's a bit like saying "length of rehab following traumatic accidents aren't correlated with as positive of outcomes". That might or might not be true but if it were it would be difficult to interpret because you could imagine rehab would take longer after serious accidents and also have more difficult outcomes. There's other things to consider with length, like maybe the focus is shifting? Maybe someone continues to benefit from it? Anyway, I agree it's important to try to remain focused in therapy and not use it in the wrong ways, but length is a difficult thing to make sense of sometimes.

jdietrich 3y ago
We do have randomised trials to support the argument, but (like most treatments) there's a very obvious dose-response curve. If we take outcome measures after each therapy session, we can see that each additional therapy session has a diminishing marginal benefit. There's a reasonable argument that the most severely affected patients might gain clinically meaningful benefits from very small incremental gains, but that's very difficult to falsify because the effect size is so small. Long-term psychotherapy undoubtedly fails any reasonable cost-benefit test, but even setting that aside, I'd suggest that anyone who isn't satisfied with the results of therapy after 12-18 sessions would be better off trying something else - either a different therapist, a different psychotherapeutic modality, or a biomedical treatment. Anecdotally, the vast majority of people who I encounter who are in long-term psychotherapy aren't severely unwell; obviously that is in large part explained by the barriers to access faced by most severely unwell patients. Many of these people aren't "mentally ill" in any meaningful sense, exhibiting only subclinical symptoms of anxiety or depression even at the point of starting therapy. They don't have clear goals for therapy, or any real sense of when it would make sense for them to finish therapy. If they find therapy to be an enjoyable activity like doing yoga or having a massage then I have no qualms with that, but many of them ascribe benefits to long-term therapy that simply aren't supported by the evidence. https://pubmed.ncbi.nlm.nih.gov/30661486/ https://pubmed.ncbi.nlm.nih.gov/30661486/

ramraj07 3y ago

Good therapists don’t schedule constant weekly checkins for folks who don’t need it. I’ve had times when my therapist said check in after 4 months to see if things are fine. Therapy works for people who need a lot of help to barely get to normal. It also helps a lot for people who would typically be classified as just fine, but they still want to become better people. I’m in that category. I hope none of us believe we are already the best we can ever be, there’s always room for improvement. If that’s the case, why wouldn’t you want to continue working with a professional to try and figure out how that can happen?

jdietrich 3y ago
>If that’s the case, why wouldn’t you want to continue working with a professional to try and figure out how that can happen? Because there's essentially no evidence to support it, the cost is very significant and there are very real risks of adverse events. Most developed countries (and America in particular) have a very serious problem of over-medicalisation, over-diagnosis and over-treatment, which greatly inflates healthcare costs for no real benefit. More broadly, what do we mean by "better person"? If we define it in the Californian sense of hyper-optimised self-actualisation, then long-term psychotherapy for clinically healthy people might plausibly deliver on that goal. If we mean a better friend, a better neighbour, a better citizen, then I think you'd be far better off spending an hour and $200 a week doing something towards those aims.
- faeriechangling 3y ago
  There is an immense IMMENSE bias towards the idea that if something is vaguely a mental health intervention it must be helping. So much of mental health practice especially outside of pharmaceuticals is well well outside the realm of evidence based medicine. If a study shows therapy benefits a specific population it given for a specific period of time, it must benefit all people if you go monthly for ten years. The, what is for most people, massive cost of therapy itself in terms of money but also time is treated as if it has no potential for adverse impact. I’ve been trying to hammer for most people the main cause of poor mental health in the developed world is not lack of access to therapy. It’s poverty.

magicalhippo 3y ago

> If a therapist isn't willing to work with you in the first couple of sessions to create a specific, measurable, achievable, relevant and time-bound plan for your therapy, you should be very wary. I have a friend who's been in therapy for over a decade, due to debilitating anxiety from childhood trauma. Went many years to first before switching to second, same story. I asked "well have you gotten any tasks or tools to help you deal with it?" multiple times, always same answer: "No". Third time lucky it seems. Now seeing a therapist which comes with concrete suggestions and tasks. Things have improved. It's not a trivial problem to solve, but at least there's change now. edit: You may ask, why stay with the therapists that didn't help? Anxiety... didn't want to upset the therapists by suggesting it wasn't helping.

dyno12345 3y ago
therapists have a responsibility to act in the best interests of clients who are not able to "manage" therapists well. this doesn't get discussed enough.
em-bee 3y ago
a friend of mine who is working as a therapist says she doesn't take any patients for more than half a year. if she can't help them in that time then she probably can't ever. another reason to stay with a therapist is outside pressure. and sometimes talking to someone does help a little bit in that it has a noticeable effect without improving things to the point that help is no longer needed, but that potentially leads to a dependency which is not good either.

rented_mule 3y ago

Please be careful about treating the findings of any study as fundamental, universal truth. Science is messy and yesterday's accepted facts often becomes tomorrow's over simplifications. And when it comes to our understanding of treating mental illness, there are all kinds of exceptions to what we "know". None of this is black and white. This study talks about correlations. What it doesn't (and can't) have is counterfactual evidence to establish causation. Would the people who went longer have had as much success if they didn't go as long? We don't get to rewind and try. My personal experience tells me that going MUCH longer than 12-18 sessions can yield life changing results. Before therapy, I was in a very bad place, having trouble understanding why I should go on living. At one point, I found myself curled up on the sidewalk in a big city, crying in the middle of the night, unsure I'd ever make it home. I needed help and luckily I found it. In my first session, I was very explicit that I didn't want to track any goals - my high pressure job (I led a group that was responsible for a billion dollars a year in annual revenue) already had too many of those for me to handle. I was 50+ sessions and six months in before I was able to observe any benefit from therapy - my therapist could see it much earlier, but I couldn't. Six months later some brutal life events, and my way of internalizing them, put me in a worse state than when I started. I then took months of medical leave from work at the advice of both my therapist and my family doctor. After 150-200 sessions total, over the course of 2.5 years, I finally thought to myself "I feel healthy, do I need to keep going to therapy?" The very next session, before I presented that thought to my therapist, she said "You've made a ton of progress. I'm not sure it's worth your time and money to keep talking regularly. What do you think?" Today I'm 100% clear that life is worth living. And I have a much better understanding of how to recognize when my mind is processing things in an unhealthy way and what to do about it (sometimes an ad-hoc therapy session is part of the answer. Is it possible that I could have changed treatments / practitioners and found success more quickly? Of course! But it's also possible that I could have tried switching, picked something even worse for me, and ended up taking longer or even taking my own life. If we knew the optimal path, we'd take it from the start. But we don't. Medical science around mental health isn't even close to offering that. I'd hate for others to give up on much needed treatment too soon because they aren't seeing success in 12-18 sessions. If they have the capacity to change course, maybe that's the right thing to do. If they don't, then staying the course could be exactly what they need.

deleted 3y ago

[deleted]