Why do therapists almost universally use a 50-minute hour to see patients?
Because Freud said so, that’s why.
It may seem strange now that, since Freud has often come under critical scrutiny over the last several decades, most therapists hold rather strictly and without serious question, to some or most of his technical recommendations. At this stage, it seems unlikely that most therapists even know where their technique comes from. It has simply been the culture within which most therapists were educated and began their practice. The 50-minute hour has been one of those unquestioned recommendations since literally the 1890’s. It seems to work for most patients and most therapists, and that was all the justification anyone seemed to need. It simply has not been seriously questioned. And, to be clear, I do not intend with this writing to call that bit of technique into question myself. I do, however, wish to add a new perspective that might be useful to many patients and therapists.
To begin with, psychoanalysis has been traditionally done with 5-6 sessions per week (Freud worked Saturdays) with each session being 50 minutes long. The patient in a formal analysis would be lying on the couch with the analyst sitting behind him or her just out of sight. As time went on, that tradition has been modified in some cases to reduce the number of sessions to 3 or 4 per week. The duration remains 50 minutes per session.
As psychotherapy began to replace psychoanalysis as the method of choice since the 1960’s the technique moved away from the couch to simply sitting up face to face across the therapist’s office at whatever distance the therapist was comfortable with. The sessions were reduced to once a week with some therapists seeing patients more than once a week but the session length has remained 50 minutes to this day.
The Story of My Innovation.
Almost 15 years ago, a female patient came to me after divorcing her husband of 30 years. We began with the standard 50-minute session scheduled for once a week face to face. It became clear to both of us rather quickly that she needed more support than 50 minutes a week was going to provide her so she asked if more hours were available on my calendar. I did have more hours then but she lamented her commute from her home rather far north of my office was very difficult for her and could she perhaps see me for two hours back to back rather than on separate days?
I will never forget that moment. I was actually initially confused by the question. I had never heard of such a request before, certainly not in my own practice, but more importantly, I took some pride in a vast library of books on technique and psychoanalytic theory and there was no reference to such a thing that I was aware of. I literally sat there for a moment scanning the books on my shelves and was at a loss as to how to respond.
When I suggested to her that nothing of the sort had been done before she seemed mildly disappointed and simply said, “Well, can we try it?” I remember feeling a bit like I was contemplating some mischief that might get me in trouble, but, after a brief hesitation, I said, “Sure, let’s try.” And so began my trial of a technical innovation that was to transform my entire practice.
What happened almost immediately was that the work went deeper than I had experienced before with just the 50 minute hour to work with. The sustained attention seemed to afford a stronger, safer holding environment. This facilitated the bringing to conscious awareness of insights that would not have been accessible with less sustained effort on both our parts. Resistances could be more readily addressed, projective processes more thoroughly explored, and the evolution of the link between us could more patiently be nurtured with the extra time.
I seems like a patient might be able to hide from me for 50 minutes, but no one has been able to hide from me for 100 minutes, at least so far. I believe that changing the time of the clinical hour has gone a very long way in countering resistance. It was in the working through of resistances that Freud saw any therapist’s greatest challenge. Perhaps that challenge is not as great as it once was.
Most importantly, dream interpretation, which has always remained central to my day to day work, was significantly more productive given the extra time to explore the patient’s associations to each element of the dream.
To paraphrase Hamlet, it seemed like an undiscovered country we were exploring.
Over the course of the first 2 years of this work she improved considerably by every measure: insight concerning the developmental precursors to her issues, anxiety management, lifting depression, effective working through of the grieving process, and on and on. We were both pleased. This continued for approximately 5 years at which time we terminated due to her relocation plans.
During all this time I had not been comfortable talking about my “discovery” to other clinicians. What mischief might I be accused of? What heresy even?
In spite of such concerns I decided to suggest it to other patients who seemed able and willing to make the transition to what I hoped would be consistently deeper and more effective work. That was ten years ago and now the vast majority of my patients see me in blocks of 100 minutes once or even twice a week. The results have been unequivocally positive for all of the ones with whom I have tried the longer sessions. I have yet to experience any downside and no patient has raised concerns. I will continue to offer this technical option to all new patients if my schedule allows it.
In large part because of the quality of the work this allows the patients to experience, my practice is now nearly at capacity. My third analyst suggested to me in response to a question I posited to her about marketing, that the best marketing was doing good work. This innovation is now a central part of the best work I do.
It seemed like a good time to do a bit of research and see if there actually was any support in the literature for my little bit of mischief. All I could find was some anecdotal musings from my second analyst concerning “condensed analysis” that was conducted in Los Angeles years ago when famous analysts would be flown into town to do extended sessions on a Saturday as part of formal analytic training in a local institute. This seemed rather different that what I was doing and was, in any case, hardly the results of careful research.
I continued my search. I could only find 2 references to modifying the length of the clinical hour and, perhaps somewhat ironically, they were both from Freud himself.
The first was a rather vague reference from “Further Recommendations on Technique, 1913, (I) On the Beginning the Treatment” pages 127-128. He states,
…When the hours of work are less frequent, there is a risk of not being able to keep pace with the patient’s real life and of the treatment loosing contact with the present and being forced into by-paths. Occasionally, too, one comes across patients to whom one must give more than the average time of one hour a day, because the best part of an hour is gone before they begin to open up and to become communicative.
The second reference I happened upon accidentally while researching a lecture on Freud that I had been asked to give to a local organization. In The Correspondence of Sigmund Freud and Sandor Ferenczi, Volume 3, 1914-1919, p 129-130, Ferenczi requests, “I would like…to spend this time in treatment with you and request that you reserve two hours a day….” Freud responds, “…Since you want it that way…, I will reserve for you two hours a day from the middle of June on….”
Somewhat after the fact, I seem to be in good company and on relatively solid theoretical ground. I hope this little excursion will be useful to clinicians and patients alike.