What is the role of time in therapy?

The length of time that is spent in therapy, and the way in which that time is divided up, have a bearing on all aspects of the process and the outcome of the therapy. Different forms of therapy practices use time in different ways. Attitudes to time may be linked to assumptions about change associated with particular approaches to therapy. Most counselling and psychotherapy forms are structured around one-hour meetings with a therapist held once a week. There are on the other hand many other types of time slots that can be used in therapy. Turner (1996) discovered that clients profit just as much from shorter sessions of therapy as from longer sessions. Some therapists use longer blocks of time to increase the emotional intensity of the work.

The frequency of meetings with a therapist can also vary. In traditional psychoanalysis sessions, the frequency of meetings was around four sessions each week. This early form of psychotherapy also typically involved long-term contracts between the therapist and client that could last for years. Recently the tendency has shifted towards therapy that only last for a maximum of twenty sessions. The factors that have influenced this shift include a high demand for therapy in society, pressure to reduce the waiting times and the development of very effective and efficient therapy methods. However, in practice Morrison and colleagues (2003) found that therapists tend to spend more sessions with their client than recommended by research-based protocols. 

Most counselling and therapy sessions take place within a fairly limited number of sessions. The average number of meetings between the client and his or her therapist lies around six to eight therapy sessions. Structuring counselling around time limits makes for a special demand on therapists: It is essential that they employ time-limited approaches to organise their working week. Time-limited counselling and psychotherapy are built around six central principles:

1. An initial assessment of clients in terms of readiness and appropriateness for short-term work.
2. Engaging the active involvement and cooperation of the client, using homework assignments or behavioural experiments, for example.
3. Finding a specific focus for the therapy, rather than seeking to address underlying personality issues.
4. Adopting an active approach, which provides the client with new perspectives and experiences.
5. Structuring the therapeutic process in terms of stages or phases, each of which is associated with a specific aim or focus
6. Making strategic use of the ending of therapy to consolidate gains and explore possible implications of that ending and loss of the therapist for the life of the client.

There is a risk to time-limited therapy: Hansen and colleagues (2002) found that for people with moderately severe problems, between 10 and 20 sessions are required to achieve clinically significant change. This study concluded on the basis of this research findings that some therapy providers may be risking harm to clients by creating the hope of effective help but then not providing enough sessions for that help to be delivered. Ethical considerations also lie behind the use of client assessment in many forms of brief therapy: It may actually be harmful to some clients with severe and chronic problems to be offered a restricted number of sessions.

Nicholas Cummings (2007) has suggested that it is realistic to take the view that a person with a problem will address aspects of that difficulty in a piece-meal fashion, at different times, depending on their life situation and opportunities for change at that particular moment. Cummings developed intermittent therapy, which adopts a highly active approach to therapeutic change. Intermittent therapy has two important advantages:

• The first advantage is that the client is positioned as a person who is empowered and able to make important decisions about their treatment.
• The second advantage is that the incompleteness of the therapy and the fact that a person knows that they can return to see their therapist at a future time seems to help clients to remember what it was that they learned in therapy, and make use of these methods in their daily life.

In single-session therapy the client is offered a choice in relation to the number of sessions. From the study by Rosenbaum (1994) it can be concluded that it appears that many clients do not feel like they need further sessions after the first one. The therapy session in a single-session therapy lasts up to two hours.

What is the role of the organisational context in therapy?

The physical place where therapy happens can have a profound impact on the therapy process and the outcome for the client. In recent years, the emerging discipline of emotional geography has generated a wealth of insight into the ways in which mental health, well-being and emotional healing are shaped by the locations in which people live and where they receive help. Organisational factors in counselling and psychotherapy services can exert a strong influence on both clients and staff. The difference in size between the large national voluntary agencies and the smaller local ones has implications in terms of organisational structure and functioning. 

• A significant amount of counselling and psychotherapy is provided by therapists employed by national statutory agencies. 
• Another type of organisational setting is where counselling is made available to employees of large organisations.

The field of organisational studies or organisational behaviour is a well-established area of research and practice that offers a range of perspectives relevant to the understanding of organisational factors in therapy. Aspects of organisational theory that are particularly relevant to counselling and psychotherapy services include the idea of the organisation as an open system, the analysis of organisational cultures and values, and the significance of gender issues.

Who can be a therapist?

The existence of a strong and secure therapeutic relationship, and the sense of an alliance between the client and therapist around the kind of work that needs to be done, are fundamental elements within all forms of therapy practice. Over recent years there has been debate around the need for therapists to undergo a full professional training, or whether paraprofessional therapists, who have limited training but adhere to professional standards, are able to do a competent job. Much of the therapy literature and training is based on an assumption that a therapist is someone who has undergone several years of training and is working in a paid, full-time position. The key characteristic of non-professional counsellors is that they do the same kind of work as professional counsellors or psychotherapists, but without the same training or scale of payment. A controversial aspect of non-professional counselling is that research evidence suggests that non-professionals tend to achieve the same client outcomes as highly trained professional therapists. A possible explaining factor is that paraprofessional counselling is characterised by the therapist and the client belonging to a similar social and cultural group. Barker and Pistrang (2002) have suggested that psychotherapeutic help can be viewed as existing on a continuum, with highly trained professional therapists at one end, supportive family and friends at the other, and paraprofessional helpers somewhere in the middle. 

• Self-help packages, in the form of books and manuals as well as on-line materials, and ‘stepped care’ models in which clients are initially offered the least intrusive form of intervention, have become part of the array of therapy formats used in healthcare systems. The distinctive features of low-intensity support are that it involves the delivery of a structured treatment protocol, and clients have the possibility to access more extended, intensive forms of therapy if they need it. 
• Embedded counselling is the use of counselling skills and therapeutic principles and concepts by nurses, teachers, health workers, social workers, clergy, and others, whose primary professional role is not explicitly a psychotherapeutic one. 
• A great deal of counselling that occurs within contemporary society takes place in self-help groups that consist of people with similar problems who meet together without the assistance of a professional leader. 
• The advantages of peer counselling are that it can be easy to access, there is an absence of power imbalance, and participants have the opportunity to acquire helping skills and experience.
• A therapeutic community is a residential setting in which individuals seeking psychotherapeutic help live for a period of time and receive intensive therapy.

What different types of clients do we distinguish?

Although counselling and psychotherapy are widely considered to focus on the needs and problems of individual persons, there are many effective therapy formats that involve working with couples, families, groups, and communities. 

• Most counselling and psychotherapy on offer, and most therapy theory and research, is focused on work with individual clients. 
• People seek therapy as a couple because they recognise that their problems are rooted in their relationship rather than being attributable to individual issues. The presence in the therapy room of both partners brings a number of therapeutic processes into play that are not readily activated in one-to-one work. The communication patterns and style within the relationship can be directly observed in couple therapy.  The aims of much couple therapy are to help the couple to achieve a shared understanding of what they want from each other and how they want to be together, and to clarify any boundaries between what information they share with each other and what they say to others outside their relationship.
• One of the oldest established traditions of therapy practice has involved work with families rather than with individual clients. 
• Group therapy is another type of therapy. Group-based approaches are used in counselling, psychotherapy, social work, and organisational development.
• Psychotherapeutic principles and methods can also be applied when working at a community level. Community therapy represents a combination of using the psychotherapeutic process to heal and come to terms with previous adversity, and to create support structures and resilience so that the community can move forward with greater confidence.

Caplan and Grunebaum (1967) identified three levels of prevention that can be applied in therapy on the community level: primary prevention, secondary prevention and tertiary prevention.

1. Primary prevention aims to reduce the future incidence of a problem.
2. Secondary prevention targets individuals at risk of developing a certain problem and those who have started to show the early signs of a problem.
3. Tertiary prevention is designed to minimise the negative impact of an already existing problem.

What is the role of technology in therapy?

Over recent years, different types of technology have been integrated into the process of therapy; such as the telephone, various internet applications, audio-or video-recording of sessions for supervision and training, brief client self-report measures to track progress in therapy, and medication.

• Telephone counselling services provide counselling to a greater amount of clients than any other type of counselling or psychotherapy agency. From the point of view of the caller, telephone counselling and psychotherapy has two major advantages over face-to-face therapy: access and control. It is easier to pick up a phone and speak directly to a counsellor than it is to make an appointment to visit a counselling agency some time next week. Many people are ambivalent about seeking help for psychological problems, but the telephone puts them in a position of power and control, able to make contact and then terminate when they want to.
• The fastest growing mode of delivery of counselling and psychotherapy within the past two decades has been via the internet. There are two main means of conducting individual therapy over the internet: asynchronous (time-delayed) communication between therapist and client, and various types of synchronous contact in real time. We distinguish email counselling and psychotherapy, communication by video link, computer-based and online assessment, online therapy websites, text messaging, psychotherapy apps, chat rooms, virtual reality and the use of avatars.

What are self-help materials?

Self-help reading, also referred to as bibliotherapy, can be undertaken in the absence of any kind of relationship with a professional therapist, or can be used to supplement the work that happens in therapy sessions. Psychotherapeutic concepts and methods have become widely packaged and marketed in the form of books, websites, and videos. There are three main categories of book that are used in bibliotherapy:

• The first category consists of explicit self-help manuals, which are designed to enable people to understand and resolve a particular difficulty in their lives.
• A further category of bibliotherapy texts comprises autobiographical and biographical works by people who have experienced specific mental health problems.
• The final category of bibliotherapy works consists of fictional texts, such as novels that depict life stories, behavioural patterns, choices, and coping strategies that may be relevant to those undergoing therapy.

Systematic reviews of the effectiveness of self-help reading have consistently found convincing evidence that self-help reading is moderately helpful for the majority of people, across a wide range of presenting difficulties

How can we combine different formats within therapy?

We can identify three strategies that can be applied when combining different formats in therapy: adjunctive interventions, programmes and communities and stepped care.

• Adjunctive interventions consist of assembling a package such as a treatment programme or therapeutic community.
• Some counselling and psychotherapy services are organised around planned packages that incorporate different therapy formats. Some of these approaches are described as programmes.
• Within stepped care, a therapeutic pathway is constructed that begins with the least intensive, intrusive, or costly format, and offers a structure that ratchets up to more demanding formats. 

The process of a stepped care therapy consists of three important principles:

1. Developing robust methods of assessment to ensure that each ‘step-up’ occurs at the right time for each client. 
2. Identifying client groups for whom stepped care is appropriate.
3. Assessing the acceptability of stepped care for both service users and health professionals.