Time is money: considering the cost of the hourlong session

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In a world of adaptation, improvement and streamlining to meet present and future demand, it seems therapy duration is stuck in the twentieth century. A conversation is needed to effect change.

What happened to the days where Freud would sit for hours with a client until their level of distress diminished? The psychotherapy industry is working with a model that has little evidence to support the one-hour session. When I say "one hour" that actually means anything from 45 to 60 minutes, depending on the service.

To cut a long story short, insurance got involved in dictating payments based upon 30-to-60-minute sessions. This largely arbitrary dictation is the ongoing issue, and maybe it's one that insurers should investigate to determine whether extending sessions is in their best interest. Therapists are not going to work for free, after all.

For ten years I have been reading the same thing from real people who have endured severe trauma. They start getting into profound trauma discussion by the end of the session, only to be told the session is over. Thereafter lie the consequences--the crux of this issue.

That sufferer leaves therapy utterly symptomatic. It takes all their physical and mental strength to reframe from killing themselves, killing someone else, drinking, turning to drugs, keeping a relationship together, insert extensive list of created problems.

Then, they begin the next week's session focused on that week's struggles.

Nearing the end of the new session at hand session--or completely wasting the session due to issues created by the lack of therapy duration--they may start to get into something new. The cycle repeats. Little to nothing gets solved in an adequate timeframe, as much of the next session becomes focused on the struggles endured, and often caused by, the previous session's discussion.

From my online research, part of the issue falls upon the insurers failing to pay therapists for anything longer than single, one-hour sessions. The other part falls onto the therapeutic industry, as they're the responsible party who provide industry guidelines to the insurers.

Maybe, just maybe, the top echelon of the therapeutic industry (psychiatric associations) should be having conversations with insurers to amend payment guidelines and trial a flexible time capacity, especially for severely symptomatic sufferers.

I watch person after person come to MyPTSD, spend hours, days, initially, then posting how they finally begin to understand an important aspect of their trauma from discussing the issue. That is what longevity discussion achieves. Imagine what a trained therapist could do in a 2-to-4-hour session? Even an extension to 90 minutes would be beneficial.

Maybe insurers should do some investigation of their own. I will take a gamble, stating that the insurer would find it cheaper in the long-term to allow longer sessions for those assessed as severe cases, which would enable faster and more sustained healing with less therapeutic time wasted. In turn, trauma therapists obtain more available time to reduce waiting lists. It's a win win for everyone. If the MyPTSD community were a study, I could tell you now that approximately 70% of severe trauma sufferers within therapy follow this chaotic therapy pattern.

Let's be honest. The financial impact the ill have on the economy is well documented. If we use America as our example, approximately 10% of the country endures PTSD at any given time. Approximately 5% of that sample are lifetime PTSD patients, with around 30% in the severe spectrum.

Simple math on the subject is revealing. 32 million (10% of the population) American citizens live with PTSD at any given time. Approximately 9.6 million (30% of those diagnosed) are suffering at the severe level and costing the economy billions per annum.

I think it's time that the industry and insurers shake things up a little and see what pops out the other end, what benefits all concerned. Clients stop chasing their tails with wasted session time, insurers save money with less sessions as people are getting faster results, and therapists get paid regardless.

Everyone wins with a little exploration and flexibility--unless the insurance industry wants people to remain ill for longer!

What path did your trauma therapy experience follow?

Would you like more time when discussing severe trauma concerns?


Very much agreed.

The 2 best trauma guys I’ve ever encountered were both paid salary and set their schedules up as they pleased. 1 was a colleague in an NGO I worked for in a different capacity, the other I was briefly dating. They each had the 2 scheduled clients a day, most days, paradigm. Morning & afternoon. They hardly lacked for work. Did the morning client take up the whole morning? Not usually, no. Work with them until done…then go work on other things. Ditto Afternoon. (Groups, new patient interviews, continuing education, touching base with other clients, case management, etc. Busy guys, both of them.))

When I was first diagnosed I had the opportunity to use this paradigm, and I outright refused. I’m mad as hell over that, 15 some odd years later. In part because they generally had a client from broken to functional in about 6mo, and doing well in about a year. ((That seemed insanely long to me at the time. Head meet brick wall. That is so wicked *fast*. Some took longer, some took less. But 6-12mo??? Envy. Pure unadulterated envy. Even if that timeline wouldn’t apply, that it could -or could have- equals a lot of regret.)) And in part because I had no idea back when how incredibly *rare* that paradigm is, so these past few years trying to get myself in hand with even 120 min sessions? Much less hourly -which is just about enough to completely lose my grip- had been an exercise in frustration at best and in making things far worse, as normal. Came to the conclusion a little while ago, that if I can’t find someone who can work with me as I need to be, then I’d rather not work with anyone at all.

I can understand the logistics in why its rare. Exactly. Time is money. But the logistics can be gotten around. And IMO very much should be.


I agree, I think an hour long session can be incredibly unhelpful in working through trauma.

I’ve been lucky enough to find a therapist who, despite contracting with me – and charging for – a weekly hour long session, has been very flexible. I don’t think we’ve ever met for less than 90 minutes and when in the midst of processing traumatic material I’ve been there close to 2 hours without additional charge. While most of my time has been in weekly sessions, I’ve been able to book an additional session often at very short notice. I don’t tend to contact between sessions unless for scheduling but again, on the occasion where I’ve sent something (maybe 2/3 times in 2 years, she’s responded quickly and concisely usually offering an additional session to talk through whatever it was.

I consider myself very fortunate, I do pay her privately but she’s done way more work with me than she’s ever been paid for and I appreciate her enormously. I know my recovery has been much quicker and the therapeutic process much less stressful because of the care and flexibility of my therapist.


In the beginning I couldn’t forgive the therapists for abandoning me in a state of crisis created during their session.

Then with several therapists I tried going back once or twice to see if I could address the problem with them, without success. It seemed like they were owned by the insurance companies. They literally seemed irritated that I would “go there.”

The best experience I’ve had was with a therapist who acknowledged this issue and did what he could to mitigate the stress of what was an inherently bad “schedule” of therapy for me. I don’t believe his efforts made much of a difference because I needed more time to have productive conversations about trauma. Still, I was able to deal with him because I didn’t feel blamed for the outcome of the session.

This great therapist did not participate in any insurance network, but I could still get reimbursed for a part of the cost. Still, it fell apart – too expensive.

I would really like to know how others have dealt with this situation.



I completely agree. My trauma therapist fought with my insurance company to give me bi-weekly 90 min. sessions when we were doing EMDR. It would take me the first 15 or so minutes to talk out what was currently going on in my life. Then another 15-20 of grounding and preparing for EMDR. The EMDR would take between 30-45 minutes depending up how many times we had to slow down and backtrack so I could avoid dissociation.

The last part of the session was grounding and stabilization. Unlike with my CBT T., I never left sessions completely dissociated then destabilized for days to weeks. One hour is just not enough for trauma therapy.

Now that I don’t need EMDR most of the time, I’m back to an hour, which at times is very rushed to get through material. I’m just grateful that my T. helped educate my insurance company that they were culpable should the lack of adequate time result in my destabilization.



My therapist takes as long as is needed for each session. I get therapy on the NHS so I don’t get and he does not assign me a time limit. I see him when I need to for as long as I need to and then I feel better.

I have had twice or three times a week sessions and now I am down to a session every 3 months – if I need it. Flexibility is the key as far as I am concerned. I really do not understand why people see a therapist every week for years with no improvement. Surely you should be looking for a target and judging whether you have got there. and if not how close etc.


Thank you for this. The reason I’m not in therapy is partly financial, and partly because the ‘5 minute warning’, 45 minutes after sitting down, no matter what state i was in, simply felt inhuman. As a child I was left on the sidewalk in front of an orphanage repeatedly. Being ‘ejected’ from sessions – from the room to the sidewalk – when I was in a state, brought back the same emotions.

And I think the two reference points – Freud and insurance – frame the issue perfectly. I will never stop bitching about Freud’s ghost that has to be exorcised before psychotherapy will really grow up. And having business considerations dictate trauma processing is just insane – and inhuman.
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