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Why do we religiously adhere to the 50 minute-hour? I am looking for some discussion on this issue. In the new world of behavioral medicine (in which I work) does this concept help us/our patients or hinder us?
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From: http://drgaryseeman.com/resources/getmost.php
People often wonder why the typical "therapy hour" is 45 to 50 minutes. Group therapy sessions usually last longer and brief therapy interventions may take much less time. One answer that's funny and probably true is that psychotherapy pioneer Sigmund Freud couldn't last more than 50 minutes before visiting the bathroom! [3] There are other useful reasons for this session length:
1. Therapy can be emotionally intense and someone may learn many things in session. More time in session can be difficult to absorb mentally and emotionally.
2. Psychotherapists spend time outside of session thinking about the client(s), completing required notes and doing treatment planning. The minimum needed is 5-10 minutes, so the standard session time allows for scheduling of sessions on the hour. In some situations a therapist may offer longer sessions. For instance, a couple in therapy may find themselves just getting into a long-needed conversation. Added time may help them maintain the momentum.
3. A standard session time helps the therapist pace the session for the client, for instance giving them time to pull themselves together before going back to work. This predictable session length helps establish an expected emotional rhythm to even intense sessions. It instills a sense of emotional safety and teaches the client that he/she can choose to open up difficult feelings and then contain them.
4. Standard starting and stopping times and session length provide a way for client and therapist to notice if emotional reactions or issues are expressed in lateness or attempts to stay beyond the end of the session. Exploring such attempts to go "outside the therapy frame" often gives the client powerful and unexpected insights.
5. Often clients bring up significant issues at the very end of the session. This can occur for many reasons. Sometimes it's because the issue is uncomfortable to talk about, but as the end of the session approaches, the client realizes it's something she/he really wants to bring up. This happens so often, there's even a name for it "doorknob therapy"! [4]
People often wonder why the typical "therapy hour" is 45 to 50 minutes. Group therapy sessions usually last longer and brief therapy interventions may take much less time. One answer that's funny and probably true is that psychotherapy pioneer Sigmund Freud couldn't last more than 50 minutes before visiting the bathroom! [3] There are other useful reasons for this session length:
1. Therapy can be emotionally intense and someone may learn many things in session. More time in session can be difficult to absorb mentally and emotionally.
2. Psychotherapists spend time outside of session thinking about the client(s), completing required notes and doing treatment planning. The minimum needed is 5-10 minutes, so the standard session time allows for scheduling of sessions on the hour. In some situations a therapist may offer longer sessions. For instance, a couple in therapy may find themselves just getting into a long-needed conversation. Added time may help them maintain the momentum.
3. A standard session time helps the therapist pace the session for the client, for instance giving them time to pull themselves together before going back to work. This predictable session length helps establish an expected emotional rhythm to even intense sessions. It instills a sense of emotional safety and teaches the client that he/she can choose to open up difficult feelings and then contain them.
4. Standard starting and stopping times and session length provide a way for client and therapist to notice if emotional reactions or issues are expressed in lateness or attempts to stay beyond the end of the session. Exploring such attempts to go "outside the therapy frame" often gives the client powerful and unexpected insights.
5. Often clients bring up significant issues at the very end of the session. This can occur for many reasons. Sometimes it's because the issue is uncomfortable to talk about, but as the end of the session approaches, the client realizes it's something she/he really wants to bring up. This happens so often, there's even a name for it "doorknob therapy"! [4]
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Currently, I am seeing several members of one family all in a row - a mom and three kids for half an hour each. I don't take notes during sessions so that I can be "fully present". I sure miss the 50 min hour I had with individual adult clients
I think that billing is one of the reasons. In Ontario, OHIP reimburses for each 15 minutes of treatment....
I think that billing is one of the reasons. In Ontario, OHIP reimburses for each 15 minutes of treatment....
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Great points, and all true. I just got an offer from a big HMO to see patients in their rural FP clinics, for the psychiatrist rate per Pt. So do I stick to the 50/min per Pt billing or not? I have worked in medical (inpatient and out) for years, and I feel I could triage new Pt's in 20-30 min for the same rate and see more people per day (greater good for more people kind of bioethics ?). BUT, what do you think? Is this defensible? Everyone else does it so does that make it OK for us?
I have worked out my answer, but I think this is a good point to debate for students, as this is the reality of the field presently.
I have worked out my answer, but I think this is a good point to debate for students, as this is the reality of the field presently.
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psisci said:Great points, and all true. I just got an offer from a big HMO to see patients in their rural FP clinics, for the psychiatrist rate per Pt. So do I stick to the 50/min per Pt billing or not? I have worked in medical (inpatient and out) for years, and I feel I could triage new Pt's in 20-30 min for the same rate and see more people per day (greater good for more people kind of bioethics ?). BUT, what do you think? Is this defensible? Everyone else does it so does that make it OK for us?
I have worked out my answer, but I think this is a good point to debate for students, as this is the reality of the field presently.
Sounds like a great gig. Wouldn't the duration of your sessions depend on what the HMO recommends?
Clinical psychology is stuck. As a field, they have lagged behind psychiatry, in part due to their reluctance to give up antiquated modes of assessment (e.g., projective testing) and therapy (50-min hours, psychoanalytic/psychodynamic influences in some programs). As a result, this profession has been run over by clinical social work, which has kept pace with a changing healthcare system. Clinical psychology training models are markedly inconsistent with healthcare in 2005, which emphasizes cost- and time-efficient care.
Your experience as a psychologist in a medical setting is likely VERY different from your graduate school training in psychology. You've become a "mini-psychiatrist" of sorts. If I were you, I would definitely push for the 20-30 minute evaluations. It's about time psychology caught up with the rest of behavioral healthcare. In defending this position, you may want to mention that you can't last more than 20-30 minutes before needing to visit the bathroom.
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You must be a student. Which PsyD program do you attend? Trust me, everything you think it positive about a career in clinical psychology will slap you in the face once it comes time to get a job. Publish or perish. Your clinical skills will be worthless. Therapy? Hah!
Have fun competing with the thousands of PsyDs, MSWs, and BAs for a $45K/year job.
Have fun competing with the thousands of PsyDs, MSWs, and BAs for a $45K/year job.
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I agree with you PH about how clinical psych training programs do not prepare one for the reality of a psychologist working in a medical/healthcare setting. Luckily, I am more of an action oriented, brief intervention minded clinician so the fast-paced medical world fits me fine. However, be careful picking on Paendrag! This person is a very well trained PhD neuropsych type, and in no way represents the bad side of professional school psychology that we know you abhor.
My plan is to schedule each new pt for 20-30 min, and go from there depending on what they need. Another problem with psychologists in medical settings is the codes we have to use; most of them are for 50 min!! The only code for 20-30 is for straight psychoherapy. I use 90801 Dx interview, as this code is not time oriented. I will not have this problem with my new gig as I am not dependant on billing/coding for my income, but in my other offices I am. Anyone have any good coding secrets I have not stumbled upon yet?
My plan is to schedule each new pt for 20-30 min, and go from there depending on what they need. Another problem with psychologists in medical settings is the codes we have to use; most of them are for 50 min!! The only code for 20-30 is for straight psychoherapy. I use 90801 Dx interview, as this code is not time oriented. I will not have this problem with my new gig as I am not dependant on billing/coding for my income, but in my other offices I am. Anyone have any good coding secrets I have not stumbled upon yet?
