Frequency of Psychotherapy

[deleted760483]

Hello All -

I am concerned about the frequency with which some of my colleagues currently see patients for individual psychotherapy appointments. Many of my colleagues see patients once a month, and I have a general sense of literature indicating this is likely to be ineffective, but I am having difficulty actually locating literature that clearly states that. I am hoping to discuss this concern with administration to lead to policy change, but want to make sure it is not simply perceived as "my opinion." Does anyone have any particular articles that might be helpful in making my point? Thanks!

---

Members don't see this ad.

 

[cara susanna]

Do you work at the VA?

 

[deleted760483]

No.

 

[WisNeuro]

Here is a decent place to start

https://psycnet.apa.org/fulltext/2015-45474-001.pdf

 

[PsyDr]

Ken Howard is the name for that.

 

[Peacemaker36]

I see this happening at community hospitals and ACO's. I've spoken with many patients forced into this situation, and they are almost always poor and have no other options. Some of them have severe and persistent mental illness. I was just working with a patient who had a once/month therapist at a community health center, and the patient had to cancel once and the therapist cancelled once, and suddenly it was 3 months in-between sessions.

I don't think research is needed to show that 1x/month therapy is less effective. I'm sure it has led to suicides. I'm not sure it has led to lawsuits or enough complaints to affect policy.

 

[Ollie123]

Certainly research showing a therapy dose-response rate, but that is a somewhat different question than whether therapy is ineffective when below a certain frequency. Does one just take longer to get to the same end point if sessions are spaced widely or is any progress unlikely? Presumably it depends on the specifics, but I haven't seen any good research on the topic.

Sadly, monthly is not uncommon - especially in underfunded settings (e.g. CMHCs). At the same time I "get" why it happens, even if I feel terribly for the patients in those situations. The money has to come from somewhere and these facilities often do not have it. Reimbursement rates are low (or fixed). No-show rates are often moderately to extremely high. If you simply don't have money for additional staff...is it better to provide monthly therapy to 100 people or biweekly therapy to 50 people while another 50 are waitlisted? From a public health standpoint, I don't know the answer and its probably an incredibly complex question that varies by disorder, therapy type, etc.

Wish I had an answer for you, but you do have my sympathies...

 

[clausewitz2]

At least in my neck of the woods many CMHCs have access mandates that require them to see people living within a certain cachement area be given an appointment within a certain time frame from making contact.

With limited budgets this means some people get monthly, basically.

 

[Sanman]

I think some context is needed here. Why are they seeing these patients monthly? Are these stable patients coming in for a booster session after treatment was completed? Is this an issue of access to resources and an overburdened system? Are you the only clinic available to these patients and the other option is no treatment? There a number of possible reasons for this reality.

 

[erg923]

Hello All -

I am concerned about the frequency with which some of my colleagues currently see patients for individual psychotherapy appointments. Many of my colleagues see patients once a month, and I have a general sense of literature indicating this is likely to be ineffective, but I am having difficulty actually locating literature that clearly states that. I am hoping to discuss this concern with administration to lead to policy change, but want to make sure it is not simply perceived as "my opinion." Does anyone have any particular articles that might be helpful in making my point? Thanks!

Do you know if this is not patient preference? Perhaps scheduling or financial issues? Perhaps that's just what they want? For a motivated patient, I'm sure monthly can work for many mild and moderate stuff. It deviates from some suggested guidelines (and certainly wouldn't work for thing like PE), but I don't think this is something to get into a tizzy about.

 

[cara susanna]

This is also an issue at the VA clinic (community outpatient clinic pretty far from the main hospital) where I work. Caseloads are so large that we often can only see patients monthly, except for our slots in which we provide weekly evidence-based therapies. It also often does seem to be the patient's preference. I don't like it, but I'm not quite sure what I can do about it. I don't do my own scheduling so unless I place a ton of appointments right off of the bat it just seems to end up this way. Right now the VA is focused on access, and that seems to be the priority even at the expense of good clinical care. Plus, as I'm sure a lot of you know, we can't just refuse therapy to patients even if they aren't 100% engaged.

 

[Peacemaker36]

Sure, some patients prefer monthly appointments, for a variety of reasons. So what? Needy patients are people too!

Are monthly sessions okay? For me, it boils down to whether or not you believe therapy is something all patients with health insurance are entitled to. I don't have a strong opinion on this. Clearly the decision makers do not feel that therapy is an entitlement.

 

[futureapppsy2]

Certainly research showing a therapy dose-response rate, but that is a somewhat different question than whether therapy is ineffective when below a certain frequency. Does one just take longer to get to the same end point if sessions are spaced widely or is any progress unlikely? Presumably it depends on the specifics, but I haven't seen any good research on the topic.

Sadly, monthly is not uncommon - especially in underfunded settings (e.g. CMHCs). At the same time I "get" why it happens, even if I feel terribly for the patients in those situations. The money has to come from somewhere and these facilities often do not have it. Reimbursement rates are low (or fixed). No-show rates are often moderately to extremely high. If you simply don't have money for additional staff...is it better to provide monthly therapy to 100 people or biweekly therapy to 50 people while another 50 are waitlisted? From a public health standpoint, I don't know the answer and its probably an incredibly complex question that varies by disorder, therapy type, etc.

Wish I had an answer for you, but you do have my sympathies...

ABA’s done some really great work on dose-response that sorts some of those issues out nicely, but because most of ABA is delivered by techs, it’s a somewhat easier game to play in terms of resources.

 

[ClinicalABA]

ABA’s done some really great work on dose-response that sorts some of those issues out nicely, but because most of ABA is delivered by techs, it’s a somewhat easier game to play in terms of resources.

ABA has also done some incredible work with getting insurance mandate legislation passed in pretty much every state in the nation (in a relatively short period of time- last 10 years or so), and should serve as a model for psychology. In my state, insurance- with few exceptions- must cover any autism related medically necessary services (including diagnosis by a psychologist, by the way). There can be no annual or lifetime caps on number of hours. Insurance will authorize typically 10-20+ hours of therapy per week. This is provided mainly by non-licensed/certified staff (and reimbursed at a corresponding rate), but services are generally supervised by a licensed /certified clinician (LABA/BCBA) at a ratio 2 hours supervision per 10 hours direct service, In many cases, the supervision rate is comparable to psychotherapy rates. This allows for a "pyramidal" clinical and business model, with lower margins at the supervisor level, but higher at the direct support level. End result is: a) a proliferation of new, privately owned businesses providing ABA services; b) an abundance of jobs (need far outweighs demand) for masters level licensed/credentialed LABAs/BCBAs; and c) starting salaries for LABAs/BCBAs similar to or higher than mid-career medians for licensed psychologist.

In my opinion/observation, this is the result of (as futureappsy2 says) a strong research base in effectiveness and dose-response issues that is, due to the parsimonious and more understandable nature of the de rigeur inductive single-case research model, much more easily accessible for both stakeholders and decision makers. Add in a generally adorable modal client, a disorder that impacts higher SES families equally, and some well-heeled families with the resources to advocate effectively for insurance mandates, and you the current situation where we (in ABA) are having discussion about not being able to see a kiddo for more than 15 hours per week, while psychologist discuss things like the effectiveness of monthly sessions.

In more specific regards to OP- I think a lot of times psychologist provide services on a very lean schedule based on the premise that "some is better than none" vs. "a lot is shown to be the most effective." I'm not sure that there is a lot of evidence for the "some is better than none" argument, even in the case of "check-in" and review symptom stability model. If you have a caseload/population of mainly "once a monthers" you need to be very careful about turning down similar new clients on the basis of "it won't be enough so I'm not going to take the case." Can you imagine telling you physician that you only want to take 1/4 of the dose of your blood pressure meds every other day because it would save you money?

 

[LadyHalcyon]

There have been many studies that have examined dosage, frequency, and even interaction effects between therapist characteristics and dosage (e.g. "better" therapists can accomplish the same outcomes in fewer sessions etc.)

Attached is just one of many articles examining frequency/dosage effects for the treatment of depression. Ultimately, this meta-analysis found a small association between number of therapy sessions and effect size. "This association was no longer significant when the analysis adjusted for other characteristics of the studies." However, there was a strong association between number of sessions per week and effect size.

IMO once per month sessions do not constitute therapy, and should really only happen in the context of booster sessions. I suppose this also depends on the severity of the population one treats in addition to one's theoretical orientation/conceptualization of mechanism of change; but how much change can really be attributed to a one hour (likely even 45 min) session per month? View attachment How_much_psychotherapy_is_needed_to_trea.pdf

 

[member978]

There are obviously a lot of factors at play here, but you might also consider the primary care mental health integration/integrated behavioral health care model that may involve brief, less than weekly sessions and there is a solid literature base suggesting that can be helpful.

 

[aly cat]

I read some papers for a lit review about "minimally adequate treatment." I recall that there were guidelines of at least 8 sessions lasting at least 30 minutes, but cannot remember whether a frequency was specified. Any way, thought that specific phrase might be helpful in your search of the literature.

 

[foreverbull]

When therapy gets down to once a month or less with my private practice clients, it's generally a "maintenance/checkin" because a lot changes in peoples' lives in 4 weeks, so much of the session is devoted to life updates. For folks with extreme anxiety, moderate depression, etc. this doesn't seem very effective if it's early in treatment and there hasn't been much movement/change yet.

But certainly a factor like cost will play into frequency. Some clients would probably benefit more quickly from weekly sessions, but simply can't afford the cost and thus see me 2x/month or thereabouts. Cost of services is a HUGE limiting factor for folks whether in private practice or elsewhere. At Kaisers in CA, they won't hire enough clinicians to meet demand, so folks get seen infrequently (once every 3 weeks to a month, is what I hear clients who tried to get services there say). Kaiser has been slapped with fines for taking way too long to get clients services, and they hired a few more clinicians, but nothing has really changed in the system, as far as I've heard from clients. Those who aren't super high acuity get shuffled into groups as much as possible to avoid clogging up clinicians' hours with individual therapy. I can't imagine it'd be that different in community mental health in my area, in which funding is limited. It's unfortunate and frustrating to see, though. A little off topic, but again, funding is a huge limiting factor for frequency, and regardless of what the literature might say, companies are all about the bottom line, so there is a lot of resistance to providing more services and losing money as a result.

 

[ClinicalABA]

... to avoid clogging up clinicians' hours with individual therapy.

This says a lot about the state of mental health care in this country, particularly for lower SES and similarly vulnerable populations.

 

[foreverbull]

This says a lot about the state of mental health care in this country, particularly for lower SES and similarly vulnerable populations.

Indeed. Business models are ill-fitted to mental health needs and can perpetuate cycles of unequal access to care.

 

[deleted760483]

I'm sorry for unintentionally abandoning this thread. Here is more contextual information.

I work for a hospital. I would not say we are under funded, although I am aware that this last fiscal year was not great for us financially. We are one of two hospitals in the area, there are also several private practices (maybe 5) with around 3 - 8 counselors or so each, so we are certainly not the only option for patients in our area. The county I live in is roughly 250,000 people. We have a lot concentration of behavioral health professionals for our size, but definitely not as low as a lot of more rural areas.

The majority of the providers I am referring to are master's level providers not psychologists, so it isn't a matter of managing therapy to testing ratios or anything like that. These are providers who only provider individual psychotherapy. Many of them have ridiculously inefficient schedules though. Our clinic show rate is about 85%. We have some providers who, in an 8 hour day, schedule 2 hours of paperwork and an hour of lunch. Our master's level providers can only bill a 90834 so they are doing 45 minute sessions. So most of them are seeing 4 to 5 patients a day for 45 minutes each. So 3 to 4 hours of clinical work per day, plus documentation (for psychotherapy notes, which should takes about 3 minutes per note). These are considered full time employees. It is an absolute joke.

Most of these clients wish to be seen more regularly. I often seem them for testing any many express frustration about the frequency of their sessions. Some may be doing monthly therapy voluntarily for various reasons, but my anecdotal data tells me that most are not.

 

[Sanman]

I'm sorry for unintentionally abandoning this thread. Here is more contextual information.

I work for a hospital. I would not say we are under funded, although I am aware that this last fiscal year was not great for us financially. We are one of two hospitals in the area, there are also several private practices (maybe 5) with around 3 - 8 counselors or so each, so we are certainly not the only option for patients in our area. The county I live in is roughly 250,000 people. We have a lot concentration of behavioral health professionals for our size, but definitely not as low as a lot of more rural areas.

The majority of the providers I am referring to are master's level providers not psychologists, so it isn't a matter of managing therapy to testing ratios or anything like that. These are providers who only provider individual psychotherapy. Many of them have ridiculously inefficient schedules though. Our clinic show rate is about 85%. We have some providers who, in an 8 hour day, schedule 2 hours of paperwork and an hour of lunch. Our master's level providers can only bill a 90834 so they are doing 45 minute sessions. So most of them are seeing 4 to 5 patients a day for 45 minutes each. So 3 to 4 hours of clinical work per day, plus documentation (for psychotherapy notes, which should takes about 3 minutes per note). These are considered full time employees. It is an absolute joke.

Most of these clients wish to be seen more regularly. I often seem them for testing any many express frustration about the frequency of their sessions. Some may be doing monthly therapy voluntarily for various reasons, but my anecdotal data tells me that most are not.

Are they on salary? Sounds like a cushy gig.

You can make your point about effectiveness and increasing workload, but it sounds like you will be making a good number of enemies at work if you do.

 

[LadyHalcyon]

I don't know. Burnout is real and you have to keep that in mind. Seeing more than 5 people per day seems unreasonable to me. But I'm looking at it from an treatment efficacy perspective

 

[BuckeyeLove]

Seeing more than 5 people per day seems unreasonable to me

This would kill me. But I don't do therapy (outside of short term solution focused stuff for people admitted to my acute unit, where they are booted out after 6 days).

 

[LadyHalcyon]

Of course it is dependent on the context and the population. I sometimes see 7 people in a day and I feel so drained afterward.

This would kill me. But I don't do therapy (outside of short term solution focused stuff for people admitted to my acute unit, where they are booted out after 6 days).

 

[Ollie123]

Guess it depends on context. 5 per day with other administrative, supervisory, etc. duties is one thing. Its one thing to work in a setting with a high no-show rate where 5 may be the best you get out of a reasonably full schedule. Or if seeibff extremely high acuity cases. I also think fewer per day is a bit more necessaey as a generalist since it, frankly, should neccessitate a bit more time for reading up and prepping.

5 low-moderate acuity patients in a setting you know very well...that feels extremely light to me.

 

[LadyHalcyon]

I also can't only do therapy. Not only is in emotionally draining, but it also doesn't pay as much as testing. Plus, I like supervision and get bored doing the same thing day after day. For me personally, I want my caseload to be 15 pts spread over 3 days. I also work with underserved populations and specialize in complex trauma and personality disorders, which is likely why I feel best with a caseload of 15 . Right now I have one day per week dedicated to testing and one day per week dedicated to assessment writing and other paperwork/research/intervention planning. I should also mention I am only beginning to figure out how I should organize my schedule to achieve optimal work/life balance, while also being an effective clinician.