How many minutes are there in an hour? 60, right? Well, in the psychological parallel universe, there is an actual expression “the 50 minute hour”. What this means in practice is that a session usually starts on the hour (say, 10am) and finishes more or less 51-55 minutes later (say, 10.53am)… hence the “50 minute hour”! For the therapist, the remaining few minutes before the next client walks in on the next hour, are used to write quick notes, make hurried phone calls, take toilet breaks, and make cups of tea. For the clients, the remaining few minutes of the hour are usually used to pay, check when their next appointment is and get themselves to their car or to public transport.
I always say in jest that if you want a volunteer to give a fairly accurate guestimate of when an hour has passed, you’ll be in luck if you have a psychologist in the party! After countless 50 minute hours I think my entire internal clock now ticks solely according to this rhythm. You can imagine how perplexed I have been twice last year when the clock in my office stopped working mid-session (weirdly, I was the only therapist at the clinic this happened to last year – twice!!). It is incredibly disconcerting to know intuitively that it should be, say 11.40am, but the clock still shows it is 11.25am… Luckily, by the second time I glanced at the clock, and it still showed the same time, I realised something was wrong, and I quickly wrapped up the session, truly in the nick of time at 11.59am! (I felt a bit like Cinderella there!)
Psychotherapy sessions tend to vary with regards to how they go in terms of time allocation to different parts of the session. However, I think for most therapists, there is a sense of their own idiosyncratic management of what is called the “flow” of a session, and this is usually quite similar in most of their sessions. For me, most of the time there is a little bit of saying hello and “checking in” time in the beginning – maybe having a bit of small talk about the weather, the traffic or COVID-19 numbers. Usually I welcome a bit of small talk. It is a social phenomenon that has often been unnecessarily scorned as being superficial, silly, repetitive and meaningless; however, I believe it has huge value in connecting people, finding commonalities, and smoothing over potentially awkward pauses. This goes for the therapy set-up as well as in the world out there. Further “checking in” might be finding out how a test at school has gone, what medicine the doctor has prescribed, or whether the client did secure the rental property he or she talked about last time.
My next step will usually be to quickly recap the work we had done in the previous session. This serves a dual purpose in my mind: (1) it communicates to the client that I value our work enough to make proper notes after a session, read the notes before the next session and really make an effort to remember the details of our last session’s work, and (2) it serves as a link between sessions, thus creating a sense of continuity. This linking up of sessions helps me and the client to stay focused on the task at hand, and not be too distracted by things that have happened in the client’s life since I last saw him or her. Of course, filling the therapist in on important happenings is crucial, but when we find ourselves working therapy hour after therapy hour only on debriefing events, we tend to lose the over-arching umbrella of consistently deepening and broadening our work. Naturally, the flipside of the argument is also true: if I try and plunge the client straight back in to where we finished the last time, and they have a different burning issue they want to discuss, we will also not get the focus of the session just right. I often wriggle my way out of this conundrum by saying something like this:
“Last time you were here, we focused on the impact of your friend Jessie’s untimely death on you when you were just a teenager. We looked at how it shook your childlike faith in the goodness of the world, and how it subsequently impacted the way you related to other friends, even up until now. Would you like to dig a bit deeper into that today? Or is there anything else that came up in the last 2 weeks since I last saw you that you feel needs to take priority to talk through today?”
By doing this, I give my client the responsibility to lead us to where we will be doing relevant and good work that day. My gut feeling is that the responses about which avenue the client wants to take (continuing on from the last session, or opening up newer content) are about 50-50, which really drives the point home that it is indeed helpful to ask our clients where it is that THEY would like to work that day.
Another technique that often serves me well, especially when I feel that we have been jumping around between topics, or that there is a sense of superficial or frothy energy to a session, is to say the following:
“I know that therapy is a big investment for most people – you need to schedule the time in your day to come here (on time!), work hard in your session and then pay for it! I would love for you to leave here today at the end of our session feeling that you got value for your time, money and emotional courage. Where to you think do we need to work for our remaining half an hour so that you will be able to leave with that feeling?”
This often changes the direction of the conversation beautifully and gently towards pure therapeutic gold. It also communicates clearly to the client that they are active participants, rather than passive recipients, in the therapeutic process. Moreover it helps to prevent the phenomenon of the belated “doorknob revelation” where the client is already on their way out after the session, and as they are leaving, they come up with something really important!
Back to the flow of a therapy session: we have touched on saying hello, the value of a bit of small talk, linking up the current session with previous work and helping the client to steer the session into relevant and fertile pastures. Often the “deepest” point of a session is around the 35 to 45 minute mark. This still allows plenty of time to then make a quick summary, look at practical plans and goals for the week (if applicable), draw the strings of the session together, look for recurring themes, and reflect on any big emotions, memories or fears in a kind and compassionate way that makes the client feel safe and emotionally contained before ending the session. Sometimes people leave my office still feeling quite fragile after they have cried in the session, but my hope is always that I have done enough in the last few minutes of the session to contain, or therapeutically “hold” their emotions, so that it at least feels like a good, fresh and healing bandage had been wrapped around what was painful and raw. Additionally, I often attempt to use the last minutes to reflect on anything positive I have picked up during the session. Maybe they showed courage to talk about something they feel ashamed about, maybe they trusted me enough to cry in my presence. Maybe they made themselves vulnerable by showing me photos of their childhood, maybe they simply arrived for their session because part of them is hopeful that things can go better at some point. These are the things that I constantly am on the lookout for, and that I gladly reflect back to my clients.
Often at the end of the 50 minute hour, clients reflect on how fast the time has gone by. Some people joke that maybe they should do a “double booking” for the next appointment, and some are curious as to why there even is some form of agreement that sessions should last about 50 minutes. To this I usually respond in a way that agrees both with the lament of an hour gone by too fast, and with the fact that our minds and hearts probably digest psychotherapeutic input better when delivered in not-too-big chunks. Yes, a 3 hour session would be marvellous in some ways. But how much will we be able to absorb and remember a day or a week later? It is probably wiser to work our way through the hard yakka of therapy in a piecemeal manner. Why it was decided that 50 minutes is a reasonable chunk of time (who decided this?!) is beyond me – maybe the decision was made by a very pragmatic influential therapist who needed to remember that all his or her sessions started exactly on the hour!
When I think of the expression “the 50 minute hour” there is something deeply heart-warming to me. Yes, it does mainly refer to the fact that clients will spend roughly an hour from arriving at the clinic, sitting in the waiting room, having their session, wrapping up and paying afterwards. And of course, that the therapist does an hour of work, including note writing, but only spending 50 of the 60 minutes in the actual session with the client. But to me there is another ring to it too. If therapy goes well, if there is a sense of connection between therapist and client and if the therapeutic focus and interventions are clear and relevant, that is when you get 60 minutes out of just 50. In other words – you put in 50 minutes of effort, but you reap the benefit as if it had been more.
I also love the idea that the 50 minute hour implies that the therapy hour has an aspect to it that is not contained within the walls of therapy room and the confines of the actual session. The therapy hour stretches itself out to include “life out there”. Therefore I often tell my clients when they step out of my office after their session that this is the moment that therapy really starts.
It is late in the night now. My clock on the wall tells me so, and my internal clock is nodding in agreement! Who knows what the 50 minute hours that are waiting for me tomorrow will hold for me and for my clients..?
PS: Real life is often stranger than fiction. The day after I finished writing this blog, the clock in my office stopped mid-session…again! We really should invest in super long life batteries!
Felix & Sage Psychology