If you see a therapist, how many sessions are you likely to need?

Is this one question or many?  If you see a therapist, how many treatment sessions are you likely to need?  Sometimes that’s a little like asking “If I go on a journey, how long should I travel for?”  Happily though, we do now have enough research evidence to be able to respond fairly helpfully to this “how many treatment sessions?” question.  To give useful answers though, it’s probably sensible to break the very general “how many sessions?” query into a number of more targeted sub-questions.

These sub-questions could include “On average, how quickly am I likely to feel appreciable benefit?”, “How many sessions will it take to achieve full recovery?”, “Are there some kinds of problem that are likely to need more treatment sessions than others?”, “Is there any point in getting ‘top-up’ sessions after the main therapy has finished?”, “How would I know if the therapy isn’t working?” and “If the therapy isn’t working, what’s the best thing to do next?”  Let’s look at these sub-questions in a bit more detail.

How quickly am I likely to feel appreciable benefit?  A good place to look for answers to this question is in the 2013 sixth edition of the excellent Handbook of psychotherapy and behavior change.  In his chapter “The efficacy and effectiveness of psychotherapy”, Michael Lambert reviews relevant publications and concludes (p.204) “Therapy is highly efficient for a large minority of clients, perhaps 30% of whom attain a lasting benefit after only three sessions.” and when monitoring for “reliable improvement … it appears 50% of patients respond by the 8th session and 75% are predicted to need at least 14 sessions to experience this degree of relief.”

“Reliable improvement” is a formal way of measuring “appreciable benefit”; it is not however “recovery”.  In the“Handbook of psychotherapy and behavior change” chapter Measuring change in psychotherapy (Ogles 2013) it’s highlighted that two of the “most prominent definitions of clinically significant change include: (1) treated clients make statistically reliable improvements as a result of treatment (improvement), (2) treated clients are empirically indistinguishable from ‘normal’ peers following treatment (recovery).”  The most widely used assessment measure for “improvement” is called the “reliable change index (RCI)”.  The RCI was developed over twenty years ago (Jacobson and Truax 1991) and it compares pre-treatment and post-treatment assessment scores while taking into account the precision of the assessment measure being used. “The change is considered reliable, or unlikely to be the product of measurement error, if the change index (RCI) is greater than 1.96.” (p.155).  If you’ve continued to read this far without developing a headache, it’s probably helpful to underline that “reliable improvement” is the most widely used measure of “appreciable benefit” and Michael Lambert’s comments about “reliable improvement” in the previous paragraph largely refer to the “reliable change index (RCI)”.  Now what about “recovery”?

How many sessions will it take to achieve full recovery?  By “full recovery”, we mean here “indistinguishable from ‘normal’ peers”.  Trying to attain “full recovery” rather than just “reliable improvement” is important for the obvious reasons that we feel better and function better after full recovery than we do after reliable improvement. It’s also important because the chance of relapsing is considerably less after full recovery than it is after reliable improvement – see, for example, Recovery and subsequent recurrence in patients with recurrent major depressive disorder.  Again Michael Lambert’s chapter is an excellent source of evidence-based information and he writes “For patients who begin therapy in the dysfunctional range, 50% can be expected to achieve … recovery after about 20 sessions of psychotherapy.  More than 50 sessions are needed for 75% of patients to meet this criterion.”  Now these are average findings.  Some therapists achieve better results than this and others worse.  Commenting on one of the relevant major studies, Lambert (p.197) writes “Outcome by therapist showed considerable variability, with the most effective therapist’s patients showing rapid and substantial treatment response, while the least effective therapist’s patients showed an average worsening in functioning.”  This variation in therapist helpfulness is such an important issue and I have written extensively about it – for example, in the recent blog postFascinatingly, therapists themselves vary considerably in their effectiveness”.

Unsurprisingly clients also make a big difference to the number of therapy sessions they need to make progress. As in most areas of our lives, commitment and hard work help hugely.  With cognitive & behavioural therapies, encouraging clients to actively work on relevant challenges between therapy sessions adds considerably to effectiveness – see, for example the paper Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. As the paper Homework compliance counts in cognitive-behavioral therapy” shows, committed clients who really tackle these between-session challenges make better progress. You see the same pattern in mindfulness training, with the recent paper The effects of amount of home meditation practice in mindfulness based cognitive therapy on hazard of relapse to depression showing that clients, who work to do the formal daily meditation practice, achieve better results than those who don’t.

Are there some kinds of problem that are likely to need more treatment sessions than others?  Yes!  In general clients who want help with more severe problems will probably need more treatment sessions to achieve recovery.  By more severe, I’m referring to variables like the extent & intensity of symptoms at presentation,  how long the problem has been going on for, and how resistant it has proved to previous attempts at therapy. Relevant too is the overall quality of the client’s life … so it’s not just the severity of the presenting problems that govern speed of response, but also the strengths & resources the client has more generally in other areas of their life.  “Is there any point in getting ‘top-up’ sessions after the main therapy has finished?”  Often this is the case, especially for problems that have gone on longer before therapy was started.  “How would I know if the therapy isn’t working?” and “If the therapy isn’t working, what’s the best thing to do next?”  These are very important questions.  Again I have written extensively about these issues – see the two recent blog posts Routine outcome monitoring can really help therapists clarify where they need to try harder and Practice-based evidence can complement evidence-based practice so very well.

So what are the overall messages?  “If you see a therapist, how many sessions are you likely to need?” is a really relevant question, not least because it’s likely to help having some idea of the size of the journey before embarking on it.  Reiterating Lambert’s review findings, quite a few clients (possibly about 30%), may only need three or so sessions to achieve very worthwhile benefits.  About 50% are likely to have achieved worthwhile benefit after eight sessions and approximately 75% after fourteen.  There is a problem here though.  Aiming for formal “full recovery” makes better sense if possible.  Here we may well need twenty sessions of therapy to help about 50% of clients to full recovery.  To help 75% reach this very desirable goal may well take at least fifty sessions, so for example Arntz & colleagues’ recent successful treatment of clients suffering with diverse personality disorders – Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders – involved forty sessions in the first year of treatment and ten in the second. As Richard Layard & David Clark have so cogently argued in their tremendous 2014 book Thrive: the power of evidence-based psychological therapies, there is a compelling case – in terms of both relief of suffering and economic saving – for more major investment in the treatment and prevention of psychological disorders.  Research strongly suggests that, in general, clients are more often under-treated than over-treated. This comment however crucially assumes that worthwhile progress is being made.  It is important to consider careful monitoring of treatment response using well-validated questionnaires to clarify that this is the case.  Lack of response over the first three to six sessions should be a red flag.  Is this therapy practised in this way by this therapist really right for this client?  I have looked here at the “how many sessions?” question and I hope this post will help those involved in therapy be more informed about what is likely to be an adequate dose.

This blog has been reposted from http://goodmedicine.org.uk/stressedtozest/2015/04/if-you-see-therapist-how-many-sessions-are-you-likely-need?utm_source=Main+List&utm_campaign=1291e0d3c2

Until next time, Steve.

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Steve Clifford                                                                                                                             Senior Accredited Integrative Psychotherapist.                                                                 Accredited Cognitive Behavioural Psychotherapist.

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Should I see a therapist?

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Well, that really depends on why you want to see a therapist. If you are going to see them with the hope that they will solve your problems, then perhaps not. If, however, you are going to them with the hope that they will help you to solve your problems, then that’s another matter. You see, the job of a therapist is not to “fix,” but instead to help you to mobilise your resources. A good therapist does not solve your problems, but helps you to develop the capacity to solve your own problems.

People often look to have therapy when they have a major life crisis, such as a death, the end of a relationship or the loss of a job. Sometimes people feel empty or inadequate inside, or they may feel that life is not going right and they may feel unfulfilled.

It can take courage to go and see a therapist, after all, firstly the person has to admit they have needs and then they have to face them. Fear of facing painful feelings can prevent people seeking help and many turn to work, alcohol or other coping strategies to push thoughts and feelings out of their consciousness. Therapy does require a commitment from you, but it is worthwhile and talking about difficult emotions in a safe space can be very liberating. Expressing your thoughts and feelings in such a way as to clarify your own situation, come to terms with painful emotions and see your difficulties with greater objectivity can really be helpful.

It is the therapist job to provide you with a space where you can talk without fear of judgement. In other words, a confidential place where you can feel held, secure and safe. For many, the therapy room is a refuge, a sanctuary. I like to think of it as your room, your space within my world. A place where you can return to at any time in your life should you need.

A good therapist will make you feel at ease, they may even feel more like a friend than a professional therapist, someone with whom you may feel you can tell anything. Whilst friendship and friendliness may be an important ingredient, along with warmth, genuineness and congruence they can never be a friend as such. You are seeking their help as a professional not as a chum, buddy, lover or any other relationship.  It is precisely because of the uniqueness of this relationship where warmth and friendship in the therapy space combined with professional integrity come together in the service of your difficulties. Next time you are telling a friend something notice how they will often come back and try to tell you a worse story, or perhaps they will tell you what to do or simply rubbish what you say. A good therapist won’t do this. Of course, there may be a value in the therapist sharing or disclosing something of themselves, they will only do so really if it is deemed to be helpful and supports the therapeutic endeavour. You can be sure of one thing though, unlike a friend or acquaintance, a good therapist won’t dump their garbage on your shoulders!

The term psychotherapist is one that I really like. Not because it is a lovely grandiose title… but because of the original Greek meaning of the word. Here the word therapist literally means “attendant” and the word psyche literally means “spirit” or “soul.” So a psychotherapist is literally a “Soul Attendant.”

One of the problems when deciding that you want to take up therapy is to find the right type of therapy for you. The problem is that there are just so many different types of therapy to choose from. Therapies vary from analytical laying on the couch type therapy, to body therapy, cognitive behavioural, transpersonal to neurolinguistic programming. The list is seemingly endless. I suggest you go to a good bookshop and look for books on therapy in the psychology section, alternatively contact a few therapists and ask them to tell you more about their particular approach.

Probably the best way to find a therapist is through personal recommendation. This may be from your doctor or a friend. The key thing is that the therapists approach has to feel right for you.

These days a lot is spoken about a type of therapy know as cognitive behavioural therapy or CBT, which is my own speciality. This is an action-oriented as well as word-oriented therapy. It helps people understand what is happening and what they can do to change the way they feel and react. CBT looks at the way thoughts (cognitions) and beliefs affect our emotions and the meaning we give to events. This affects our emotions and our reactions (behaviours). Unlike some other approaches, CBT is a relatively short term psychotherapeutic approach. The length of therapy tends to depend on the complexity of the presenting problem. A block of sessions ( usually six) may often be enough for a noticeable difference to emerge. Improvement to “quality of life” is often the best measure of success. The goal of CBT could be said, to enable the client to learn ways to address problems and difficulties in order to become their own therapist.

If somebody asked me what do you do? I would reply that I do many things, but one of the most important things is”tilting the mirror.” In other words. Reflecting back in such a way as enable the client to glimpse a slightly different perspective. Helping the client gain insight and understanding. This may be helping the client to see how unhelpful thinking traits, such as catastrophizing mind reading, black and white thinking distort their view of reality. We may look at the meaning they give to events creates a huge emotional upheaval and how stepping back and distancing can help. Then together we look at the problem area and the way it impacts on the person’s life. We consider how life would be different if the problem was resolved. We look at what may need to happen or change, then we look at the emotions arising out of the event or situation and talk about them. Together we identify what needs to happen to bring about resolution of the problem area. Then we identify strategies and goals (or aspirations) to aim for. Working within a specific time frame, using measures and behavioural experiments to help us. Through the course of therapy the client and therapist walk “shoulder to shoulder,” addressing the difficulties In a collaborative way.

Some people say, “I felt worse after my first session,” for others, getting it out in the open can be a great relief. Problems rarely resolve themselves without action, and if they do so, it may not be in the way we desire. Having the opportunity to explore them with another person may help a great deal.

Don’t expect miracles, but don’t dismiss the possibility that resolution of difficulties can feel like a miracle. Therapists are not “miracle workers” and if they present themselves that way, don’t go anywhere near them! The therapist is there to guide you to achieve your goals, not to do the work for you or “make” you feel better. Every session you attend is one step closer to feeling better.

Until next time, Steve Clifford, Cognitive Behavioural Psychotherapist.

visit us @ www.stevecliffordcbt.com
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Could Emotional distress and Spiritual development be linked?


A fundamental question at the heart of psychology that is often overlooked relates to the link between emotional distress and spiritual development. What is it that links psychological with spiritual?

Could it be that deeply painful and traumatic experiences shift our awareness. Dr Russell Razzaque, author of “Breaking down is waking up,” describes how we are all functioning at an “ego” level, one in which we are pretending to be a series of characters and forms engaged in a dance. He goes on to describe a world with different levels, where it’s possible to move from one level to the other, from our solid everyday tangible life to another more spiritual level. He describes it being a bit like a sea, where above, the planet looks like a series of unconnected islands and continents but, below exists a different reality, where we see that none of it is separate at all – it’s just part of one giant land mass that makes up the Earth’s surface. It’s all a matter of perspective.

In order to experience this deeper level requires an expansion of awareness, and thus can occur through practices such as meditation or can happen spontaneously, perhaps, he suggests as a consequence of psychological distress. The difference being that it is not a conscious choice but a spontaneous experience. As such it can sometimes be somewhat frightening when it does.

Because we move through the world with our ego constructed “self” a self we create in our minds to make sense of “our world,” changes to this perception can be hard to comprehend as our reality is shifted. People talk of “peak experiences” where just for a moment a different reality is experienced. Peak experiences are often described as a heightened sense of wonder, awe or ecstasy, moments that stand out from everyday experiences (Cherry). Other such mind altering experiences can be, so called, “out of body experiences,” the consequence can be that people see life very differently afterwards. Similarly, some drug takers may glimpse “another world,” quite often a surreal but sometimes spiritual world.

Finally, returning to psychiatrist Dr Russell Razzaque, he leaves us with this interesting statistic, and that is, that 74% of people who have suffered a major mental illness describe themselves as ” deeply spiritual” – a figure many times higher than that of the general population.

Until next time, Steve Clifford, Cognitive Behavioural Psychotherapist.

Visit us @  www.steveclifford.com

Ask us your mental health questions anytime @ www.facebook.com/yourmentalhealthmatters

Cherry. K. “What are peak experiences – psychology overview.” www. psychology .about.com [Accessed 7/7/14].

Razzaque. R. (2014). Why Breakdowns Can Also Be Breakthroughs, in Watkins Mind, Body, Spirit, Issue 38, Summer, pp 52-53.

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Create a Garden Sanctuary – Beat #Depression


Tip 2 – Extract from “50 Tips to Beat Depression” available on Amazon

When you are depressed and the whole world can seem too much, sometimes just getting out in the garden and away from it all can help.  Whether it is clearing a weedy corner or sitting in a tranquil place, inner calm can come from immersing oneself in nature.  Sitting quietly in the garden can enable you to slow down and escape the rush and hurry, which may have contributed to your present condition.  Studies have shown that gazing at greenery produces a rise in alpha wave activity, which indicates increased mental relaxation. Taking time to reflect is all part of the healing process.  Tidying and pruning an overgrown garden can symbolically help us to create a sense of order, as we thin out and rid ourselves of the unwanted “overgrowth” in our lives, in the same way that watering and tending new seedlings can help us develop the nurturing aspects of ourselves.  Even the smallest of spaces can be transformed into a healing oasis by just adding a few pots and some greenery.

With best wishes, Steve

Please feel free to email your blog posts for “Your Mental Health Matters” to stevecliffordcbt@gmail.com                                                                                         Steve Clifford, Cognitive Behavioural Psychotherapist

Visit us @  www.steveclifford.com                                                                                      Like us @ www.facebook.com/yourmentalhealthmatters                                                Tweet us @ cbt4you

Get yourself a few rays of Sunshine – Beat #Depression


Tip 29 – Extract from “50 Tips to Beat Depression” available on Amazon

It is not just Morecombe and Wise who extol the benefits of sunshine.  Boosting the supply of vitamin D in the body serves to maintain optimum levels of serotonin to assist the activity of cells throughout the body, regulating mood, sleep and our ability to process information.  In the summer months go out for a few minutes every day, soak up the sun and ensure supplies of vitamin D are topped up.  Meet friends for a picnic, take a stroll before nightfall and watch the sunset.  In the winter, consider hiring or purchasing a light box, (see tip 40), as serotonin levels change with the seasons and are at their lowest in the winter months.

Until next time.

With best wishes, Steve.

Please feel free to email your blog posts for “Your Mental Health Matters” to stevecliffordcbt@gmail.com

Steve Clifford, Cognitive Behavioural Psychotherapist

Visit us @  www.steveclifford.com                                                                                      Ask us your mental health questions anytime @ www.facebook.com/yourmentalhealthmatters                                                                  Tweet us @ cbt4you


Remember the Positives – Beat #Depression


Tip 6 – Extract from “50 Tips to Beat Depression” available on Amazon

It’s very easy when you are feeling down to lose sight of the positives.  One facet of depression is the way the depressed outlook shapes thinking.  The depressed person tends to ruminate on the negative things people say, and hears only critical comments. This is called “filtering out” and is a particular type of unhelpful thinking trait that often goes hand in hand with depression.  Instead of noticing things in a balanced way, we only notice things that “fit” our negative mind-set and we dismiss the positives. This in turn serves to reinforce low self-esteem and a negative outlook.

One way to turn this around is to create a positive book (see tip 25).  Buy a small exercise book, and if you are creative, cover it with a bright paper cover or positive images from magazines.  Use this book to jot down positive things that happen, positive things people say and positive things that you have achieved during the day.  Slowly you will begin to notice more and more positives as you learn to hear them and not dismiss them from your radar.

Consultant Psychologist Rick Norris, in his excellent book, “The Promised Land,” recommends compiling a list of 20 positive memories.  He acknowledges that this can be somewhat overwhelming, as depressed people get out of the habit of playing memories that make them happy, because their mental filter tends to screen these out of their conscious mind.  He suggests recalling three positive memories each day for a week. He tells us the benefit of doing this exercise last thing at night is because it can be a pleasant way to drop off to sleep and also that we tend to be more in tune with our sub-conscious mind during sleep, perhaps  leading to sweeter dreams!

With best wishes, Steve

Please feel free to email your blog posts for “Your Mental Health Matters” to stevecliffordcbt@gmail.com                                                                                               Steve Clifford, Cognitive Behavioural Psychotherapist

Visit us @  www.steveclifford.com                                                                                      Ask us your mental health questions anytime @ www.facebook.com/yourmentalhealthmatters                                                                  Tweet us @ cbt4you

Make a Comfort Box – Beat #Depression


Tip 3 – Extract from “50 Tips to Beat Depression” available on Amazon

It’s often hard to remember the good things in life when you are feeling low in mood.  At such times happiness and positive memories can seem far away.  Stimulating positive memories and associations can be invaluable in helping to keep us grounded in the real world and help lift the spirit.  Creating a “capsule” containing mementoes from the past can help to evoke feelings of comfort, warmth and personal security during difficult times.

A shoebox, biscuit tin or similar can be used to house objects to inspire hope.  I have a comfort box and mine includes a variety of objects: photographs and even “thank you cards” which I can use as “evidence” to support my being a worthwhile person.  I recommend any of the following:

CD, LP, MP3 of favourite music, chill-out, relaxation, etc.

DVD of favourite film with uplifting, or feel good theme, etc.

Photograph of a loved one or of something or somewhere of importance

Memento of a holiday, postcard, seashell, souvenir, foreign money, flight ticket stubs, booklet or programme from places visited

A note, card or letter from a loved one or write a letter to yourself when feeling well, offering encouragement and re-assurance that you will come through this difficult time

A favourite poem, statement, prayer or article that inspires hope

A favourite book, magazine or colourful picture

A favourite object, i.e. a small stone, crystal, lucky charm or something that is tactile

A sketchpad with crayons or watercolour paints

Aromatic oils for massage, scented candles, bath bombs or bath oils/salts

Herbal teas such as Chamomile, known for its calming properties

Favourite item of clothing, warm jumper or a blanket

A hot water bottle

Vouchers for a massage or beauty treatment

A list of telephone numbers, e-mail addresses of family or friends to whom you can turn for support (try to look for support from more than one person).

A list of national help lines e.g. Samaritans, Sane, MIND, etc. .

Any object associated with feeling happy and well.

With best wishes, Steve

Please feel free to email your blog posts for “Your Mental Health Matters” to stevecliffordcbt@gmail.com                                                                                                Steve Clifford, Cognitive Behavioural Psychotherapist

Visit us @  www.steveclifford.com                                                                                      Ask us your mental health questions anytime at: www.facebook.com/yourmentalhealthmatters                                                                  Tweet us @ cbt4you