How long does therapy take?
This is a difficult question, but in this article, I will shed light on this from various angles. How much time is it reasonable to assume therapy takes for common problems? When should therapy be concluded? What does the research say?
The amount of therapy needed is obviously related to the type of problems one seeks help with and the goal of therapy for the individual. Therapy can vary from just a few hours to several years. Short-term therapies, i.e., under 20 hours, are suitable for addressing specific issues, while longer-term therapy can focus on larger and more profound patterns in the individual. An example of a short therapy could be a patient seeking help for being stuck with an uncomfortable obsessive thought. In just one or a few hours with the therapist, the person can gain sufficient understanding of the obsessive thoughts to feel more secure and better equipped to handle the issue.
However, most people seeking help have more ingrained patterns causing symptoms in various areas of life. The patient who came in for the obsessive thoughts may return to therapy shortly when new or different problems arise, such as troublesome physical symptoms that doctors can't figure out, low self-esteem, relational problems, and a growing awareness that, being honest with oneself, there is more to work on.
It's not the case that all therapy works; in fact, it has been documented that, on average, about 10% of therapy actually makes things worse, as documented by Jørgen Flor. If therapy is not helpful, or worse, harmful, it is necessary to address these issues or terminate therapy as soon as possible. But assuming that a therapy is helpful and effective, and acknowledging significant variation between patients and therapists, how many sessions does it usually take before it starts to help and before one can end the therapy?
Jonathan Shedler and Enrico Gnaulati have written well on the importance of the duration of therapy in their article 'The Tyranny of Time'. They cast a light on it from three different perspectives: what patients report, what experienced psychologists report, and what more objective measures suggest. The studies they rely on are based on data from real patients who have received treatment from various providers.
Experiences from 4,000 American patients who had received treatment in the last three years suggested that meaningful change typically began after about 6 months, and those in therapy for over a year reported greater benefits, with even greater benefits for those in therapy for over 2 years. Those with only 10 hours of therapy reported the least benefit. This suggests a 'dose-response relationship,' meaning that the response to therapy increases with the amount of therapy.
When examining what therapists reported, in this case, 270 experienced therapists with an average of 18 years of experience, they reported that meaningful change occurred around 16-20 hours, and therapy was completed after about 52 hours for panic-attacks and 75 hours for depression. Again, the findings align with a dose-response relationship.
But can we fully trust what therapists and patients say? A psychological phenomenon that is important to be aware of is cognitive dissonance. This makes it more painful to realize that the more resources you invest in something, the more painful it is to realize that your investment did not yield as much as you wanted. This means that the longer therapy has persisted, the greater the internal pressure to justify that it was a good investment. Therefore, we cannot rely solely on what patients and therapists say; we need some more objective measures.
To do this, we use another variant of self-report data. Instead of asking patients what they think of therapy, we ask them to fill out a carefully developed questionnaire for symptoms and issues that has been tested on a large number of people and found to be good enough to provide a measure of therapy outcomes. This is filled out regularly, for example, every week while patients are in therapy. A study based on this obtained data from 10,000 patients. The results were that, on average, it took 21 hours before 50% had achieved a clinically significant change. This number increased to 75% after 40 hours. A clinically significant change here means that the measure of symptoms had fallen sufficiently to consider them actually reduced, i.e., not a result of chance. This does not necessarily mean that individual patients feel 'cured,' but that at the group level, there is a trend towards recovery.
In summary, this research suggests that there is generally a dose-response relationship in therapy outcomes. That is, those who benefit from therapy seem to benefit more when they have more sessions. But when should therapy be concluded?
As I see it, therapy is a goal-directed process: when you reach your goals, therapy should be concluded, or new goals should be set. There are two pitfalls here: one is dropping out of therapy before reaping its potential benefits, and the other is staying in therapy either without effect or after the effect has already been achieved. I believe the former is far more common than the latter, but both are problematic. Shedler and Gnaulati refer to an American study of 30,000 patients that found 40% had dropped out after two sessions, and 80% after 10 sessions. Only 9% had more than 20 sessions. With respect to the research we have looked at, it suggests that very few of those seeking therapy got enough sessions for most to harvest the potential of therapy.
At the same time, it is important to acknowledge that patients may have good reasons for dropping out. In short, I emphasize four reasons to terminate psychotherapy before reaching your goals:
- You do not have sufficient personal chemistry with the therapist.
- You and your therapist lack a good common understanding of the goals of therapy.
- You and your therapist lack a good common understanding of how to work towards your goals.
- Your therapists violates ethical and professional expectations.
So what can we learn from this? Therapy tends to take time, often around 16-21 sessions before meaningful change is observed, and it can be several times this before therapy is finished depending on the goals. The standard for psychotherapy is weekly sessions, and there is reason to assume that with less frequent sessions, the total duration of therapy also increases. How long does it take before you see a change? Well, 21 sessions of therapy will take about 6 months with weekly sessions or about 1 year with sessions every other week. Regarding the 270 experienced therapists we referred to earlier, they used an average of 52 sessions to treat panic-attacks and 75 sessions for depression, respectively over a year of weekly sessions for anxiety or 1.5 years of weekly sessions for depression. The greater problems you have or the more ambitious you are for the kind of personal change you seek, the longer therapy is usually necessary. If you are learning a new instrument or a new language, you will likely spend several years becoming truly proficient, and for those seeking therapy to work on deep-seated issues in themselves, I think it is natural to think in a similar way.