Psychotherapy

The 50-Minute Hour: Psychotherapy and Time

One of the questions clients occasionally ask about therapy centers on the 50-minute therapy hour.  Why 50 minutes?  Why not an hour?  Why not 90 minutes?  Why not less?

Every therapist approaches time differently.  For some, 50 minutes is the ideal amount of time in which a reasonable amount of work can be accomplished.  A client’s (and therapist’s) ability to focus and concentrate attention begins to fade at 45-50 minutes into the session; the ability to be productive diminishes after 50 minutes.  Time-limited sessions hold both the therapist and client accountable for addressing priorities.  The 50-minute session also allows 10 minutes following the session for the therapist to write notes, attend to administrative tasks, breathe, reset, and freshen in order to be ready for the next client.   

However, I think there is another equally important purpose to the time-limited sessions:  they create a structure that in turn creates safety, especially for clients new to the therapeutic process. Knowing that the session has an end creates a sense of safety, which in turn helps both therapist and client focus on the issues at hand; a time-limited session encourages the you to be vulnerable.  Indeed, it’s important that you know that there will be an ending; the vulnerability that is exposed and addressed during the session will not endure forever.  You are likely to become willing to allow yourself to feel vulnerable when you know that you will have to tolerate those feelings only for the period of time that constitutes the session.

The therapeutic relationship is a uniquely intimate one where you are likely to experience a wide array of feelings.  Difficult feelings—anger, sadness and grief, anxiety, shame—can and will arise in therapy.  These feelings can be challenging to tolerate in relationship. 

Despite the reality that all feelings are welcome in therapy, many clients have spent their lives fleeing them:  they deny or minimize their feelings, leave relationships that trigger vulnerable feelings, or escape into a variety of addictive behaviors.  Tolerating strong feelings in the context of a relationship can be very difficult, and the impulse to flee can indeed be powerful.  The intimacy that constitutes a good therapeutic relationship will, over time, support and even enhance your ability to tolerate the discomfort that attends vulnerability.  Trust in the therapeutic relationship builds over time—in small increments of time.  It takes time for you to integrate the experience of having strong feelings in relationship and knowing that you will survive your feelings, your vulnerability.  Discomfort and vulnerability do not last forever; there will be an end—just as there is always an end to everything else in life.  In the therapeutic relationship, it becomes safe to explore the discomfort of vulnerability here, now—precisely because there will be an ending.  

Indeed, psychotherapy’s effectiveness is predicated on the ability to have and express all one’s feelings in relationship—a relationship that is structured and facilitated by the 50-minute hour.


Coping with Emotional Tailspins

Mark came into my office agitated and on the verge of tears.  He reported that he’d had another argument with his boyfriend the night before.  Mark was afraid that a break-up was imminent.  He told me that he’d been unable to concentrate at work since the fight, and spent the day beating himself up because the cause of their disagreement was “trivial” (although he acknowledged that it didn’t seem so at the time).  The argument raised older fears about being alone, and beliefs about being unlovable resurfaced.  The argument, the guilt and self-recrimination, the anxiety, and all the thoughts and feelings he was experiencing sent him into an “emotional tailspin.”  He was desperate to regain some sense of balance and calm, but felt hopeless about doing so.

Many of us have experienced emotional tailspins, moments when we feel flooded with anxiety, guilt, shame, or grief.  These feelings are so acutely averse that our most immediate desire centers on finding some rapid means for stopping the feelings and/or escaping from them.  And while gaining some distance on the feelings is a reasonable first step, impulsive flight does little to resolve whatever issue triggered them, much less the dynamics that sustain the tailspin.  Impulsive flight derails us from the necessary work of understanding and healing the circumstances that created the tailspins in the first place.

Every emotional tailspin has antecedents.  Some event triggers the cascade of powerful emotions that over-ride (flood) our ability to cope, think, reason, or problem-solve.  The event also taps into dysfunctional beliefs we may have about ourselves.  Further, it’s been my experience that triggering events also stimulate memories of past experiences when we actually were helpless.  Those traumatic memories magnify the aversion we feel.  Our feelings quickly become the primary focus of our attention.  Consequently, we try to flee or otherwise change the feelings as quickly as we can in order to eliminate our acute distress.  While fleeing the feelings may diminish the emotional discomfort, flight does little to resolve the issues that created the emotional tailspin.  When our primary focus centers on ameliorating our discomfort, we fail to focus on our relationship to the problem itself.  The problem remains and will trigger yet another episode of aversion.  As a result, the downward spiral accelerates and worsens.  We feel increasingly out-of-control and incompetent, and more aversive feelings ensue.  We might even come to believe that we ARE incompetent and unlovable which further amplifies the aversion we feel.  We are in a full emotional tailspin, feeling both helpless and hopeless. 

There are a number of actions you can take to respond to, manage and prevent emotional tailspins. 

1.     Slow down.  When we feel panic or other strongly aversive feelings, there is often an immediate sense that we must act quickly, now.  Indeed, the impulse to flee aversive feelings is powerfully immediate.  But you do not need to take immediate action to rid yourself of the feeling—a form of emotional reactivity. 

There is a difference between being reactive and responsive:  reactivity is impulsive, free of conscious thought, and driven by discomfort.  Reactivity tends to be narrowly focused on the goal of ridding yourself of discomfort.  On the other hand, responsiveness is thoughtful, attempts to broaden focus and has the goal of deeper healing.  Slowing down allows you to develop enough emotional distance so that you see the whole picture, discern the choices for responding that are available, and choosing a plan of action that can resolve the problem. Slowing down helps you respond more appropriately.  Take one or two deep breaths to physiologically slow and diminish the sensations of panic and despair. 

2.     Stay in the present moment.  Be aware that you may be telling yourself a story about the situation.  A negative story about the situation will fuel the tailspin.  Similarly, try not to get ahead of yourself.  When we start thinking “what if,” we are likely to create more anxiety for ourselves and perpetuate the tailspin.

Focus on what is happening right now.  Grounding exercises and self-talk about what you are seeing, hearing, and sensing can be help you gain footing in the present moment.

3.     Feel feelings without judging them as good or bad, pleasant or unpleasant.  One strategy that helps you manage aversion centers on attending to your body’s sensations—without labeling or judging them.  Direct your attention to the parts of your body where you experience a sensation.  Feel the contours of tension or constriction, and then soften around the sensation.  (Again, deep breathing can be effective for softening around tension.)  Try not to tell yourself a story about the feeling (i.e., “this feeling is awful; I can’t stand feeling this way”) because doing so will likely create more tension.  You are not trying to get rid of the feeling; you are acknowledging the feeling and letting it be.  Feelings arise and fall on their own.  Indeed, the feeling you’re experiencing will diminish by itself on its own time.  If you try to rid yourself of the feeling, the sensation will tighten.  Have faith that the feeling will diminish on its own.

4.     Engage a reality check.  There is an old psychotherapy adage that comes from cognitive theory:  feelings are not facts; feelings are feelings.  Your experience of aversive feelings may be creating a filter through which you are misperceiving what is actually happening.

When you are experiencing an emotional tailspin, you may not perceive the whole picture.  Anxiety tends to narrow attention, and we tend to selectively focus on those aspects of the situation that are most upsetting.  There may be aspects of the situation you are not seeing and that might help you regain our footing. 

A reality check is an attempt to broaden the scope of attention.  It requires you to separate feelings from facts. 

Ask yourself:  what is actually happening right now?  Am I adding anything to what is actually happening?  What is the story I am telling myself about the situation?  How am I understanding this situation? 

5.     Seek an objective perspective; reach out for help.  When you are caught up in an emotional crisis and are acutely anxious, you are likely to be perceiving the situation through the lens of your anxiety. Seeking help from someone who can see the situation from a different perspective can help you reorient yourself and help you begin to regain balance. 

 

You’ll notice that these steps precede direct problem-solving.  Indeed, it’s my experience that it is often counter-productive to attempt to address and solve the immediate problem when one is caught up in an emotional tailspin.  This is not to say that problem-solving cannot occur.  It can, and should occur—but premature problem-solving robs you of the opportunity for the deeper, more essential, work of understanding and transformation.  Such work is vital if one is to avert recurrences of tailspins. 

However, I would suggest that one is engaging in problem-solving by using these strategies. Slowing down, being present to what is happening, feeling feelings, reality checking, and reaching for perspective: taken together, they are the first steps toward meaningful healing.

You are not helpless, and hope is always available.  These actions are empowering and can be first steps to personal transformation.