Dismantling the stigma of being a revolving-door therapy client

If you have been in and out of your therapist's room for a couple of years, struggling emotionally, and feel you cannot do without your monthly session with your psychologist or counsellor, then this reflection might be for you.

It is particularly for you if you feel you should be able to do without these sessions and feel shame about asking for a mental health care plan again from your doctor over subsequent years.

I want to be clear: I do not want to convey the idea here that your struggles should be dismissed. Nor do I want to suggest that many people do not benefit from therapy offered as 10 sessions dispersed over a year. You might be seeing a very warm, dedicated and empathetic therapist who keeps you going.

Therapy rationing and hunger

Having said that, my purpose here is to bring some openness to exactly what the arrangement is and the politics that influence it. In particular, I want to counter the feelings of shame that may arise from what I might call therapy rationing and the fact that you might feel hungry for something more or different and may blame yourself for not being able to change and move on.

Changing thoughts, feelings and ways of reacting takes time.

We need to have frank conversations about why some people may feel it is out of reach, someday stepping out of the therapist's office with more agency and more zest for facing life’s difficulties as opposed to feeling overrun and helpless.

The 'out of reach for me' feeling may even play a role for those who could afford to pay for an adequate amount of mental health care outside of Medicare.

It can be logical to deduce that the rationing must be there for a reason and not just the limits of the state’s coffers. You might be thinking like this because 10 sessions are the norm as prescribed by political will and the Department of Health.

Can we stop skirting around the fact that the 10-session-a-year norm is a difficult space for therapist and client alike?

This next part is for my colleagues who provide therapy and GPs who sit with a lot of patients seeking mental health treatment.

My point here is that I am not sure the conversation even enters the therapy room between therapist and client or between GP and patient. Hence, I invite you to have that discussion, and I wonder what difference this might make to the authenticity of the relationship as well as the stigma a client may feel if the effect of the 10-session norm were discussed more.

Perhaps we are all a little like the frog that doesn't notice the water gradually heating.

For most mental health professionals, such as psychologists and mental health social workers, it has become the norm to offer 10 sessions, and many private practices are built around this. To my knowledge, it is the minority who offer weekly therapy. I thought this was the norm until personal and clinical experience, plus research I came across, indicated otherwise.

For therapists working in this fashion, it might not be satisfying work either. I distinctly remember the protests from psychologists when the 20 Medicare sessions were scrapped after Covid-19 had less of an impact and restrictions on movement eased in Australia. I don’t think the protest was simply related to money but reflected concern about clients' opportunities for improvement in therapy.

Of course, for a counsellor like me, it does not really matter, as people who see me for therapy are not reimbursed by Medicare, but I still care about the impact of the normative narrative on people in the form of stigma. I dare say a fair few counsellors feel the influence of the politics of the 10 sessions too knowingly or unknowingly.

Again, I invite us all to think about what this really means for our work and for our clients.

Psychologist and psychoanalyst Jonathan Shedler puts it like this in a recent Substack post:

"When patients don’t get the help they need, they don’t come away thinking, I didn’t get good treatment. They come away thinking, I am too broken to be helped."

Shedler also emphasises in the same post that there is a lack of conversation with people seeking help about the limitations of short-term treatments, especially when offered in what he calls institutional settings, as the politics of the institution inevitably influence.

Think about this:

Six months of weekly therapy takes you to a total of 24 sessions. Compare this with three years of 10 sessions a year—that is 30 sessions infrequently dispersed. Does anyone really believe this is going to substantially create deep and lasting psychological change? Do you get to learn new ways of doing things without repeating something multiple times with frequent intervals?

Psychotherapy research has repeatedly found that meaningful psychological change often unfolds over months and years rather than weeks. You, of course, need to receive quality therapy (and that is another discussion), but there is a dose-response relationship as discussed by Puder and Shedler in the Psychiatry & Psychology Podcast reviewing a large study by Lambert et al.

‘A study of over 10,000 therapy clients, assessed session-to-session with a validated outcome instrument, found that it took 21 sessions or about six months of weekly therapy to see clinically significant changes in 50% of patients. Only after 40 sessions, or almost a year of weekly therapy, did researchers see significant changes in 75% of patients (Lambert, 2001).’

It is also my experience that trust is often something that develops over time between client and therapist. Also even though therapist and client may like each other from the first session, it takes time to get to know each other and liking is not the same as understanding as I have written about in this post ‘How do I find a therapist who understands me?’. Meeting once a month for 10 sessions over a year does not provide the frame for getting to know each other deeply, let alone offer much opportunity for discussions about what may feel jarring sometimes in therapy.

So where does this leave me?

I know it is not fixing anything, as not everyone can afford a higher frequency of therapy but I hope that you might discuss this with your therapist and have a frank and de-stigmatising conversation. Should you want to read a bit more about why weekly therapy is something I recommend, I wrote a blog post about it.