Shirah Vollmer MD

The Musings of Dr. Vollmer

Commitment In Psychotherapy

Posted by Dr. Vollmer on November 11, 2013


“Thursday at 2 pm is your next appointment,” I say, understanding that time set aside is a sign of respect and concern for the patient’s sense of well-being. Coordinating calendars is an activity which says “you are important to me,” As such, I have deep concern over the time-limited therapies which communicate that after a specified dose of psychotherapy, I will no longer be interested, or am no longer able to help you. Yes, these time-limited therapies then offer future referral sources, but the idea that my commitment to you, is from the outset, short-term, communicates that the patient is of limited value. There is something very important about the message that I will be here as long as it takes for things to improve; as long as we can agree to struggle together. Whether this translates into three weeks or three years is not critical, but what is critical, is the willingness to try, as long as need be. This, once again, brings us back to Winnicott’s “holding environment” where a critical therapeutic action, is the ability to be present, to hear what is said, and to show up again, and again, and again. When a licensed professional says “let’s make an appointment,” the meta-communication, is you are important, and we need to devote time to your issues. Likewise, when the licensed professional says “we are done with our ten sessions,” then the meta-communication, is I am no longer able to help you, sometimes leaving the patient to feel that they are hopeless. The therapist can say “you can get better, but I have to stop treating you,” and that could help the patient’s self-esteem, but my concern remains that the feeling of abandonment, triggered by the forced shut-down of limited sessions, can, for some people, result in a lowering of self-esteem, and a trigger for past experiences of isolation and betrayal. Yes, the therapist is being honest with the patient, but the patient could still feel that “if you really cared, you would not stop treating me.” I would say that this is “betrayal” with little “b,” meaning that it is a mixed message to try to help someone and then tell them that you are done helping, even if they are not done hurting. Limiting psychotherapy sessions is the future of mental health care for millions of Americans who will now have health insurance. On the one hand, it is exciting to see that the mental health needs for so many  can be addressed, unlike before, but on the other hand, it could feel like one big tease.

8 Responses to “Commitment In Psychotherapy”

  1. Jon said

    Yes, it is important for the psychotherapist to be committed to addressing their patient’s issues, but there can be other issues as well. There may be limited resources of time and money. In such a case both patient and therapist must make the best with such limited resources. This leads to the slippery problem. What are the exit criteria for psychotherapy? In one sense, the answer seems simple – when the patient is well enough to be on his/her own. However, how does one define that transition?

    • Yes, there are limited resources of time and money, but my concern is that creating a session limit puts into question the issue of the therapist’s commitment to the patient. There are no exit or entrance criteria for psychotherapy. There are checklists with varying degrees of reliability. This field is very grey, and as such, there are no clear criteria in either direction. In a similar way, substance abuse treatment also lacks scientific rigor, and yet, there are many dollars being allocated to substance abuse treatment. So, the money spent is not correlated with the data available. Given our limited data and our limited resources, we need to speculate intelligently about the operative components of therapeutic action. At this point, that is all we can do, and all we can do is wait until studies give us more information. Thanks.

  2. Ashana M said

    I’m not sure your reading of the meanings related to time commitment are universal. An appointment, to me, doesn’t inherently express any particular value of the client by the therapist. It’s merely a convenience, and makes it easier to ensure we will show up at the same time and place. What you are doing is a job, and what we are doing together in part is an economic transaction. So, a therapist’s ability to keep to a schedule has more to do with his or her general ability to plan and think about time than the value they place on me. If they are late or need to cancel frequently, it probably has nothing to do with me or my importance to them, and everything to do with their ability to manage their time well and think ahead.

    Similarly, time-limited therapy to me doesn’t indicate any particular value placed by the therapist on the client, but expresses instead a degree of certainty about how likely it is that the therapy will be helpful in a timely fashion. Unlimited therapy suggest to me that the therapist really isn’t certain that therapy will be helpful at all, but simply that they will keep trying until something eventually does happen to work. The sense is a little like sitting at a roulette table and waiting around for numbers to come up that may or may not do so. Unlimited therapy is actually fairly uninspiring and tends to suggest that it’s all a bit hopeless. But then I generally prefer to have specific, measurable, time-based goals for myself. However, I think many other people also find that type of goal-orientation motivating. In my classroom, if students don’t have a specific objective to reach and a specific time limit, they will waste most of their time. The more specific the time limit (you have 37 minutes to complete this), the better they manage their time. I think adults are also like that.

  3. Shelly said

    I realize that as much as the patient finds value in the patient-therapist relationship, the therapist also finds value in it, however, realistically the therapist must understand that insurance (or private pay) cannot cover the costs forever. However, if at the end of the day, the patient doesn’t feel hope or doesn’t feel better, therapy will end. As you say, with the new system, if your patients receive only a very few covered sessions, they may not even feel that the effort of starting therapy will be worthwhile since it is, as you say, simply a tease.

    • Yes, Shelly, I agree. One issue which I would like to expand on is the inconsistency of payment structures. As I responded to Jon, addiction treatment is in the same arena as depression and anxiety, and yet much more money is poured into addiction, on a belief system that it will help with sobriety, but the data are sorely lacking. I understand limited funding, and as such, we have to figure out a way to use the money wisely, and not in a way which makes sense to a few. Thanks.

  4. To me personally, time, especially regarding psychodynamic or psychoanalytic treatment has a multitude meanings…the practical of course, but also the more emotional…some conscious, other aspects, subconscious, even unconscious. Had the psychoanalysts my disabled daughter and I used many years ago, mentioned time limited treatment at the onset, I would have turned and walked out the door…Therapy, put simply, was about exploration and caring and compassion and putting some sort of limit on it before one even starts would be a red flag to me. A quick example….my daughter, typical teen like, about age 15 or so, once absolutely refused to get out of the car to go up to her analysts office for her appointment. We quietly sat in the car for the full 50 minutes of her allotted appointment, below the window of the office so the physician could see that his time was worth her presence whether she was in the office or outside. My daughter could do likewise. After this she never refused a therapy appointment (and there were many at 2-3 times weekly) again. Both therapist and patient and in this example, parents, must be committed to the treatment and the time it requires both from a scheduling viewpoint but also from a human connection perspective.

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