Time-Limited Psychotherapy: Hidden Effects
By R. Hidalgo
(Copyright (c) R. Hidalgo 2000; Aug. 2000)
In this article the effects, primarily unconscious, of a twelve-session-per-academic-year limit on university students receiving psychotherapy from a student health clinic are reviewed. Langs's method of decoding the derivative communication of patients was implemented, using the forced termination as a primary context requiring students' adaptation. A ubiquitous presence of negative effects is listed and elaborated in the paper. These effects generally complicated the benefits and symptom relief derived by students, rather than totally negated any benefit to them. The expectation that only a minority of patients in "indefinite term" psychotherapy stays longer than twelve sessions when allowed free choice was verified by local data. This led to the final proposition and eventual decision to eliminate the forced termination.
One day I was struck by the fact that, in trying to understand the unconscious meanings of my patients' communications, I was ignoring the obvious detail that everything the patients were telling me was in the context of an imposed twelve-sessions-per-academic-year limit. For the next two years I listened to more than 100 patients over several hundred hours with that fact in mind. Thus, the patients' material became a surprisingly meaningful unconscious commentary on the implications and effects of the forced ending.
The method I used to understand the unconscious meanings of the patients' communications was Langs's (1990) decoding of derivatives. The principle is relatively straightforward. When two people are communicating, certain thoughts, memories, fantasies, or perceptions are too threatening to acknowledge directly or sometimes, consciously. At this point they are left with two strategies: to lie and obliterate meaning (consciously or unconsciously), or to find a way (consciously or unconsciously) to encode the messages into a communication about another situation that consciously may "fascinate and disturb...[but] unconsciously, in it, [they] find a strong communicative vehicle with which to work over the [dangerous] stimulus" (Langs, 1983). Langs (1983) adds, "Surface messages tend to vary in the extent to which they convey and express underlying threatening and dangerous raw messages."
The themes that commonly emerged in the patients' material suggested that the time limit was causing harm in one way or another. Some of the themes appearing in the context of the twelve-session limit were: being in an environment that is contaminated, making effective results impossible or unlikely; being in a place that is unreliable and undependable; facing an event that threatens to ruin the good that had been achieved; introducing a bad element prematurely; being in a setting designed for the benefit and needs of the therapist; being with someone who is arbitrary and demanding; being with someone who is ill; being with someone incompetent; having an affair; having old wounds reopened; experiencing a relapse; being cut short; and not having enough time. The negative, harmful implications of these messages are obvious. That they apply to the time-limited setting will become apparent by the elaboration of a few cases.
Evidence from the Unconscious
(Patient's material omitted from submitted article).
In the example above, taking the lab as an unconscious symbol for the clinic, the material becomes a rich communication about the patient's experiences at the clinic within the twelve-session limit. Two obvious "contaminants" at the clinic were the lack of total confidentiality (the patient would wait in a large waiting room with other students) and the twelve-session limit. From this perspective the patient was unconsciously communicating that, like in the lab, she did not feel she would get the results she was looking for; that she felt pressed for time, having to share her time and space with other students (the rationale for the twelve-session limit was to make room for more students); that she experienced the therapist as careless; and that she wanted to look for another psychotherapy, but lacking energy and time, she decided to continue in this setting even though she was feeling hopeless about obtaining results.
(Patient's material omitted from submitted article).
While consciously, the patient in this example spoke of making small gains that were cut short, unconsciously, she seemed to be implying that any gains were lost. Themes of efforts at healing that went badly, abstinence from drugs that resulted in relapse, being unappreciated, and being in a state of limbo, suggested that this patient unconsciously did not feel she had made any gains at all. Rather, she felt caught in a state of limbo where she was unappreciated.
(Patient's material omitted from submitted article).
In this example, I suggested that the patient's inability to end his affair at the end of three months as originally agreed, might be an unconscious allusion to an analogous experience in therapy, which was also supposed to have ended at the end of twelve session but had unwittingly continued to a 13th session. The patient looked momentarily befuddled, and after a few moments of reflection admitted he could not stop on his own in therapy either, particularly in light of his mixed feelings about stopping. He agreed that I needed to put a stop to the therapy and he left without staying the full hour.
What was occurring in the patient's affair corresponded so well with his unconscious experience in therapy that he readily accepted the interpretation. The patient's immediate restoration of calm and his decision to leave before the end of the hour may have indicated his relief and momentary gain in self-control resulting from the accuracy of the interpretation.
Viewed as a derivative communication, the patient beginning an affair with a married woman just after beginning therapy in the time-limited setting suggested that he experienced this arrangement as a time-limited, sexual affair. His material implied that he experienced this therapy arrangement as immediately gratifying but dangerous and immoral. Like this married woman, I was unavailable ("married to the clinic") except as a temporary source of immediate gratification and immediate escape from the pain due to his wife's rejection. He appears to have agreed to enter this dangerous, yet gratifying "affair" only because he counted on me to end it as agreed. His allusions to his lover wavering and ultimately going back on her original agreement paralleled my own private wavering and ultimate betrayal when I unwittingly continued past the twelve-session limit. Indeed, I did on occasion entertain conscious yet unspoken wishes to continue. I had grown fond of this patient and I imagined being able to accomplish satisfying results in the long run. I wished to spare myself the frustration of not getting to experience this gratification.
The times that I went a bit over the fifty minutes of sessions and my scheduling a thirteenth session could have been experienced as messages of my own discomfort with the imposed time limit and my counter-transferential wish to continue. My own needs, unconsciously enacted, seem to have greatly burdened this patient and caused him much distress. In particular, I exposed him to his near-total dependence indicated by his inability to take care of himself when his needs conflicted with his lover's or mine.
Uncannily, this was a patient of little impulse control who had a history in his adolescence of sexually abusing his little sister who was several years younger. Still dependent on external controls and supervision, he was left alone with his own lack of impulse control to enter a dangerous, immoral and abusive relationship with his sister. His experience in therapy and his affair appear to have constituted unconscious re-enactments of his earlier traumatic situation with his sister. He may have experienced my agreement to work with him in this time-limited arrangement as a symptom of my own poor impulse control, intended for my own immediate gratification. My not stopping at the twelfth session could have been experienced as yet further evidence of my lack of impulse control, abandoning him to his own lack of impulse control and depriving him of the needed supervision and external controls. His wife's clear and unwavering stance, representative of good impulse control, could be seen as his unconscious model of rectification of a harmful situation - his attempt to direct me to provide the necessary solid stance and self-control, which I finally did with my last interpretation.
Introducing Unnecessary Complications at the Outset
Upon first meeting with patients I devoted the first half of the session to allowing them to freely tell me what was on their mind. Assuming they had read the disclosure statement handed to them during check-in, I would listen for their unconscious reactions to the twelve-session limit. On occasion, I could offer an interpretation linking their material to the forced termination even during the first interview. The clearest example was a never-married woman in her mid-forties who presented the complaint that she had never been able to establish a long-term relationship. Once I made the link, she could readily see that she was selecting yet another short-term relationship by agreeing to this time-limited structure. However, there were important reasons she was not aware of this on her own, and exposing this to her during the first session caused her increased painful conflict.
I saw patients, already taxed by their emotional problems, become disorganized, confused, and immobilized during the intake interview when confronted with the reality and the implications of the time limit. I saw patients decide not to return, requesting a referral to an "indefinite-term" structure. I saw patients ration their sessions to once a month, to three sessions per quarter, to alternate weeks, or to an initial four or five sessions, saving the rest for another time of critical need. I witnessed a patient weep and beg on her knees to just have one more session past the twelfth. Some patients went to their last session without mentioning the end and became startled upon realizing they were at their twelfth session. I saw patients and therapists, including myself, "forget" the twelve-session limit.
These behaviors appear to be attempts to cope with, and defend against, the difficulties of the forced termination. Needing help and having taken the difficult step of coming to a first interview, most patients agreed to return in spite of the additional problems presented by the time limit. Consciously, they believed they could be helped, not seeing the time limit as a problem or a concern. Some even appeared to experience the time limit as a relief. Relief, from having to risk transferring unmet dependencies onto the therapist while hoping to gain some immediate symptom relief. Those patients who requested a referral to an "indefinite term" structure may have been the healthiest, preferring not to enter yet another harmful relationship.
With all the inherent conflicts and complexity involved in arriving for the first time at a therapist's consultation room, particularly at a clinic in the context of managed care, I think that therapists should do all they can to keep things as simple as possible. Patients' phone calls to insurance companies, to the referring primary care provider, to the mental health clinic, screening processes, selecting or being assigned to a therapist, forms to read, fill out and sign, waiting periods, occasional scheduling errors and re-scheduling, comprise a host of complications and barriers to initiating psychotherapy. Internal resistances also need to be overcome. These factors impinge upon the patients' decision to enter psychotherapy and probably exacerbate their initial ambivalence.
Another inherent complication commonly found at the outset of psychotherapy is the patients' conscious or unconscious questioning of the therapist's ability and/or willingness to help. This coincides with the therapist's own inevitable initial ambivalence about helping - ambivalence activated by the reality that no therapist knows, at the outset, if they will be able to help a particular patient. To offer help for a limited amount of time has many implications about the therapist's willingness and ability to help, including the implication that the therapist is unable and unwilling to help beyond a certain point. For many patients, the offer of help for only a limited time may have recreated an original environmental failure. The time limit seemed, not only to exacerbate initial, inevitable ambivalence, but also to expose patients (prematurely) to their own and their therapists' ambivalence.
By keeping things as straightforward and simple as possible therapists can spare patients additional, avoidable difficulties, at least for a time. Eliminating an imposed time limit leaves the question of ending unasked and unanswered during the first interview and spares patients from being forced to deal with separation and loss until the patients indicate they are ready or needing to address the end. Also, by not introducing the end at the beginning, the therapist can more readily be found to be someone who is simply willing and able to help, compensating for the idea of one that is not. Of course, if the patient introduces the question of the end at the outset, the therapist has an opportunity to follow the patient and investigate the motives and meanings related to raising the question at the outset. In this case we are not leading.
Re-enactment of Premature Separations
In a number of cases the forced termination appeared to re-enact earlier traumas suffered by the patient, like the premature death of a parent, traumatic weaning, premature birth and incubation, and divorce. Themes of untimely death, premature endings, divorce, abortion, lack of time, and efforts that were cut short, which appeared during the first interview may well have been allusions to the patients' unconscious experience of the time limit. These served as clues that a referral to an indefinite term setting was indicated.
(Patient's material omitted from submitted article).
In this case, the patient was confronted with a dilemma which caused her much confusion and distress. Should she pursue this course of time-limited therapy, so similar to the very pattern she wanted to break, or seek open-ended therapy? Clearly a referral to an indefinite term setting was indicated, yet for this patient it also constituted an immediate rejection unless she was free to stay with the present therapist. Yet, to stay confronted her with a future rejection, albeit deferred for twelve weeks, unless she was ready to leave just at the time her ration of sessions ran out. For this patient the forced termination clearly repeated the experience of earlier premature separations that were also beyond her control. Further, having to discuss this dilemma at the very beginning of therapy may have been experienced by this patient as premature separateness from the therapist at a time when she needed to experience "joining". Having to deal with the forced termination during the first interview appeared to have impinged on the ability of the therapist to establish rapport and begin to build a therapeutic alliance with this patient. Yet, to not disclose this fact at the outset would have been unethical and incompetent. Clearly, an open-ended structure with no pre-defined time limit would have spared this patient and the therapist much painful conflict.
The Benefits Contaminated
In spite of the preceding observations, it appeared not to be the case that no good could come of therapy in the time-limited structure. In fact, about 5 out of 6 patients did resolve their presenting symptoms within this twelve-session limit. These could be placed in two groups. One group with good ego development could use the limited time to free up a developmental block in an otherwise healthy personality structure. Another group had poor ego development, much underlying illness and well-developed compensatory defenses that had temporarily broken down. The improvements in the latter group were probably due to symptom relief and to re-bolstering the broken down defenses, rather than to the cure of the underlying illness. These patients commonly described feeling better between the fourth and seventh session without knowing what caused the improvement. They directly or indirectly expressed anxiety about a future relapse. While feeling better, they were left with nothing to rely on to promote health or treat illness. The lack of insight about what caused their illness and restored their health indicated that the whole process occurred unconsciously, leaving these patients vulnerable to the unconscious elements [perceptions, memories, and fantasies], which were involved in the cause of their emotional illness and the restoration of their sense of well-being.
When these patients did get better, the negative effects of the time limit tainted their symptom relief without obliterating all possibility of improvement. For example,
(Patient's material omitted from submitted article).
In this example, the patient's description of getting behind in work, having to leave a job she loved due to funding running out, and trying to extend it by finding more funds, had obvious parallels to her experience in the time-limited therapy. However, the parallels between her allusions to a boss taking advantage of her tenuous position by asking her to do things beyond the scope of her work and her situation in time-limited therapy were less obvious. Yet, a couple of possibilities seemed plausible. First, her efforts to remain by obtaining more funding were clearly beyond the scope of her work and suggested that she was the one in therapy making the efforts to correct the time-limited situation when that was the therapist's responsibility. Second, that agreeing to continue to see her when she was feeling well yet unable to pursue her deeper issues was to take advantage of her tenuous position by asking her to do more than she was able to accomplish within the time limit. To continue therapy under these circumstances would be for the therapist's sake and an exploitation of her tenuous position and her inability to stop (refuse). Clearly, this patient was able to benefit from therapy. On the other hand, it is equally obvious that the forced termination caused her painful conflict.
While few patients worked over this conflict so explicitly, their conflict could be inferred from a noticeable pattern exhibited by a number of patients. Many patients, feeling better somewhere between the fourth and the seventh session, found themselves going blank, not knowing what to talk about, in conflict about pursuing a deep or a surface issue, or not knowing if they should continue. It was probably no accident that the average number of sessions patients attended in the time-limited setting was five. The average patient, having found relief around the fifth session, may have chosen, like the patient above, to save the remaining sessions for when they were "really needed". Thus, avoiding getting into deep issues that could not be resolved in the time left, and not wasting the remaining sessions on surface issues.
In the twelve-session-per-academic-year structure at the clinic only about four percent (4%) of patients stayed for the full twelve sessions in contrast to twenty percent (20%) of patients staying for at least twelve sessions in other local organizations that offered open-ended psychotherapy (between 1991 and 1995 Presbyterian Counseling Services reported 21.6% and Family Services of King County reported 20.1% of patients stayed in therapy twelve sessions or more). This low percentage of patients staying for their twelve sessions, in conjunction with the low number of average sessions (5 at our clinic in contrast to an average of 9 to 12 at Family Services and Presbyterian Counseling) suggested that the time limit was contributing to, if not causing, patients to leave therapy sooner. (Family Services of King County reported a yearly mean of 8.9 sessions between 1991 and 1995, ranging from 8.4 to 9.5 and Presbyterian Counseling Services reported a yearly mean of 11.4 sessions between 1991 and 1995, ranging from just under 11 to just under 12.) In the light of the above, the patients' decision to leave at around the fifth session suggested an adaptive, healthy response to an impossible conflict set up by the forced termination, irrespective of the extent of their underlying pathology.
When No Benefit Was Obtained
Some, in my estimation around one in six patients, could either make no use of the therapy within this structure, or, any benefit they did derive was ruined by the negative "side-effects" of the forced termination. Those who failed to return after the initial appointment or those who accepted a referral to an indefinite term setting may have fallen into this group. Some patients directly expressed their sense that they were deriving no benefit, or that the benefit they derived was not worth it. Some, with much frustration and anger, decided not to return after a few sessions because they were deriving no benefit.
Others expressed their sense of lack of benefit indirectly, derivatively. One patient during her tenth session alluded to being at an unfulfilling job. Another woman during her eighth session complained that she could only do menial labor at her internship. A student alluded to being stuck in a contaminated lab where results could not be obtained. A man withdrew from the University and therapy at his eleventh session when he found he was unable to accomplish what he had hoped for. A patient during her eleventh session related that her friend relapsed and she was tempted to start using drugs again herself. A man during his eleventh session alluded to feeling worse "on" his anti-depressants than "off" them. A patient reported during his eleventh session a dream in which terrorists broke into his house and killed his children.
These themes of lack of fulfillment, lack of results, lack of meaningful work, lack of accomplishment, of relapse, of feeling worse, of a terrorist killing children, could well serve as unconscious, encoded, derivative messages communicating the lack of benefit, frustration, and even destruction that these patients experienced because of the time-limited setting. Only a few patients seemed able to consciously tolerate and express their disappointment. The majority expressed conscious gratitude for benefit derived while derivatively communicating their sense of lack of benefit.
The Framework of Psychotherapy
One of Langs's essential contributions to psychotherapy was to meticulously describe the importance of the psychotherapist's task of setting and managing the framework of psychotherapy (Langs, 1990). The therapist's office, the furnishings and d�cor, the therapist's personal manner and dress, the setting and collection of fees, the frequency of sessions, and the scheduling of appointments are all elements of the framework. The degree of confidentiality and privacy and of the therapist's anonymity, neutrality, and reliability also form part of the framework of psychotherapy. At the student clinic, the twelve-session-per-academic-year limit was one such element of the framework.
Langs (1990) points out that the manner in which the therapist sets up and manages the framework of psychotherapy has many conscious and unconscious implications about the safety of the environment. It is well accepted that for an environment and relationship to be therapeutic it must evoke a sense of safety. The assurance of privacy and confidentiality with a reliable-enough person who will not be too opinionated, critical or moralistic is a cornerstone of building safety. How the therapist handles the changes, such as canceling an appointment, failing to appear for an appointment, starting late, ending late, changing the fees or the collection of fees, taking vacations, etc., whether instigated by the therapist or the patient, has implications regarding the safety of the environment. In particular, there are implications about the capability of the therapist to manage the situation reliably, dependably, and safely. Langs (1990) points out that while on the surface a therapist may look kind, flexible, compassionate, and adaptable, covertly they appear weak, undependable, selfish, incompetent, and ill.
Far from rare, these changes are ubiquitous and they are generally disregarded and dismissed by therapists without thought or discussion. It is uncommon to find therapists ponder, discuss and analyze the implications and meanings of their own and their patients' changes in the framework of psychotherapy, or to wonder how these changes influence them, their patients, and the therapy.
Heightened Impact of Frame Breaks
In the context of the time-limited setting it appeared that therapists' vacations, cancellations, and late arrivals took on more ominous meanings than when these occurred in a setting of indefinite term therapy. Possibly, these changes acted as reminders of the upcoming end that was out of the patients' control. Having to end prematurely would be experienced as a rejection or abandonment, instead of a completion. The tardiness, cancellations, and vacations of the therapists may have reminded patients of the fact that they were not in control of the ending of the therapy, making them feel vulnerable and exposed. Moreover, these changes could have amplified a sense that the therapist lacked commitment, reliability, and altruism, already implied by the twelve-session limit.
Paradoxically, these alterations could also have suggested that the limit on the number of sessions itself might be changed. If the beginning or ending of sessions could be changed, if appointments could be cancelled and made up, possibly the limit on the number of sessions could also be changed. This was, in fact, the case five to ten percent (5%-10%) of the time when, with the program director's approval, the twelve sessions could be extended to fifteen. This well-intended extension seemed to actually further complicate the situation. It appeared to cause more confusion and ambivalence, a mixture of hope and trepidation. Hope of being able to avoid a rejection, abandonment, as well as lack of control. Trepidation of being in the hands of someone who, while appearing caring and flexible, could also be weak, inconsistent, unreliable, out of control, and ill.
Some Derivatives Related to Extending the Frame
Patients' derivative communications indicated that when the therapist extended the number of sessions beyond the original twelve, the therapist was unconsciously perceived as unreliable, undependable, and unable to stick to his word. Recall the sense of betrayal and emotional crisis in the patient whose mistress wanted to continue their affair past the originally agreed-upon time. It appeared that there was further harm done by extending the time limit, no matter what benefit derived from the extension.
(Patient's material omitted from submitted article).
I suggested to this patient, that her material could relate to her request to extend the therapy beyond the original twelve sessions. I said that for me to agree to this would appear to change me from the "therapist" into "the rapist", and that continuing beyond the agreed number of sessions may be one of those types of changes requiring permission. She readily agreed with this and felt that as hard as it would be to stop, it would be better than to continue. Here we can see that agreeing to extend the time frame would have implied that the therapist had poor boundaries and was acting in seductive and sexually abusive ways.
(Patient's material omitted from submitted article).
The material from this other patient is a beautiful and powerful derivative communication about the lack of containment implied in the extension of the therapy beyond the original agreed-upon twelve sessions. She appears to have experienced it as dangerous and irresponsible, placing the burden of responsibility on her. Not holding to the time limit was akin to not fencing in the dogs, and left her, like the dogs, to run wild, at risk of lethal harm. Ultimately, it destroyed (killed) something, presumably a sense of safety and containment. Agreeing to extend the time limit seemed also to have been experienced as an abdication of the therapist's responsibility, placing it and the blame for the destruction, on her.
Unveiling a Myth
The belief that psychotherapy traps patients in a never-ending dependency causing caseloads to become glutted by long-term patients appears to be a myth. Local data gathered between 1990 and 1995 by two large community-based agencies in Seattle offering sliding fees and open-ended psychotherapy indicated that a mere four to nine percent (4%-9%) of patients stayed in therapy one year or more (Presbyterian Counseling Services reported 4% staying fifty two sessions or more; Family Services of King County reported 8.8% staying one year or more). Around twenty per cent (20%) of patients stayed in therapy between three months and one year (Presbyterian Counseling Services reported 21.6%; Family Services of King County reported 20.1%). A full 71%-74% left treatment in twelve sessions or less (Presbyterian Counseling Services reported 74.4/%; Family Services of King County reported 71.1%). These figures, collected over five years, represent a significant 5,000 to 10,000 patients.
Even the figures of Howard, K. et al (1989), while far larger than the figures from the local data, still show that a relatively small percentage of patients stay in treatment for a long time. In their study only 17% of patients stayed in treatment over a year and 33% stayed between six months and one year. Their data also indicated that a minority of patients used the majority of sessions such that the one sixth who stayed a year or more used slightly over one half of the sessions and the one third who stayed in treatment between six months and one year used slightly over three quarters of the sessions. This data appears to lend support to the notion that a minority of patients could "glut caseloads". However, their data may have been skewed by the fact that they were not studying patients in an indefinite-term setting, but patients in a setting with a clearly defined long-term orientation. Besides, the potential for a minority of patients to glut caseloads could be handled in a variety of ways that need not impinge negatively on the clinical milieu, such as adding new staff. At the student clinic, caseloads were indeed glutted but not by a minority of patients staying long term. That was not an option. The majority of patients who stayed an average of only 5 sessions glutted them. The free or very low cost services most likely accounted for the long waiting list.
The twelve-session-per-academic year limit appears to have been based on well intended but unsubstantiated and incorrect notions that "indefinite-term" therapy was no different from "long-term" therapy, and that unless barred, large numbers of patients would opt to stay for a long time and glut caseloads. No compelling evidence was found to support the belief that without a limit on the number of sessions, long-term patients would glut caseloads. In fact the evidence showed that patients tend to stay in therapy for only a brief term and only a small minority stay for a long time. The problem of accruing long waiting lists did not appear to be caused by patients staying in treatment for long periods of time, and need not have been handled by an arbitrary time limit forced onto patients, particularly when it had so many negative implications and detrimental effects.
Forced termination, at its best, appeared to exacerbate ambivalence about entering therapy, and at its worst, appeared to be highly damaging. It conveyed a number of unintended negative messages and caused unnecessary confusion and conflict in the patients. Eliminating the time limit and introducing open-ended therapy eliminated an apparent source of iatrogenic illness. It may have also stopped the loss of patients that were falling out of treatment prematurely or who were being referred elsewhere due to the complications elucidated above.
It should be emphasized that to not impose a time limit is not the same as endorsing long-term treatment. What is being endorsed is "indefinite-term" treatment. Offering an open-ended structure implies that the provider is giving the patients all the time they need and constitutes an essential element of the "holding environment" that is therapeutic, safe, and facilitates development. The question of ending should remain in the hands of the patients to be raised when they choose. Ideally, the question of when to end should never be asked, and should be addressed only as it emerges in the patients' material to be reflect upon, interpreted, and analyzed when it arises. This leaves patients free to end in their own time and in their own way. As the decision (the power) to enter psychotherapy rests exclusively in the hands of the patient, so should the decision to exit.
Howard K., Davidson C., Omahoney M., Orlinsky D., et al., (1989): Patterns of Psychotherapy Utilization, American Journal of Psychiatry, Vol. 146(6)
Langs, R., (1983): Unconscious Communication in Everyday Life, New Jersey: Jason Aronson Inc.
Langs, R., (1990): Psychotherapy: A basic Text, New Jersey: Jason Aronson Inc.
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