Does session frequency matter? The case of PTSD

How often do you see your clients? Depending on the setting you work in, you may have – or feel you have – little control over how often you see your clients. An already too-full caseload, working part-time, the pressure of mounting wait lists, the sense that a little bit of contact is better than nothing, the fear that if you offer clients all their allocated sessions up front and they don’t recover, they have no safety blanket for the rest of the year…all seem to limit how often we can schedule sessions. And the clients themselves may not be willing to commit to the frequency of attendance you might recommend. How much does this matter though? Is psychotherapy equally effective, no matter how often it is scheduled?  This week’s (editor: hah! – as if I’ve been producing these weekly) study looks at this question systematically, which was particularly interesting to me as colleagues I respect have suspected for some time that there might be something especially powerful about seeing clients with trauma more often than weekly.


Hoppen, Kip and Morina (2023) performed a meta-analysis of 160 randomised controlled trials involving 10,566 adult clients whose primary problem was PTSD. It excluded small trials (N < 20) and trials targeting comorbid PTSD and substance use disorders or traumatic brain injury. It also excluded trials where PTSD diagnosis was established by self-report (questionnaires) rather than by semi-structured interview schedules. The search was current on November 29th, 2022. Treatment frequency was examined both dichotomously as “standard” (less frequent than 1.5 sessions/week) and “intense” (1.5 sessions/week or more frequently) and continuously, although the pattern of results was the same regardless of how frequency was measured. Dropout was measured as the number of participants randomised minus the number completing post-treatment assessment.

The average number of sessions across all studies was 10.8. Only 27.5% of studies delivered PTSD treatment intensively, most of which offered sessions twice per week (k=23). Psychotherapy delivered both intensively and at standard frequency produced large effect sizes compared to passive controls (g= 1.04, 1.09 respectively) and medium to large effect sizes compared to active controls (g= 0.48, 0.59 respectively) at posttreatment. There was no difference in efficacy between frequencies. It should be noted that only four studies involved a direct comparison of treatments of different intensity/frequency, although these also found no significant difference in efficacy. On the other hand, there was a significant difference in drop-out rates. Intensively delivered therapy had an average dropout rate of 11.3% (k= 35 treatment arms) vs standard frequency 17.8% (k= 137 treatment arms).

So, this may be a good news/bad news situation for many therapists. The good news is that evidence doesn’t currently suggest the need to schedule sessions more frequently than weekly for people with trauma. The bad news is that many therapists may struggle to schedule even weekly sessions. It is worth nothing that of the studies that adequately reported frequency and did not provide treatment more than weekly, only three studies spread sessions less regularly than weekly and none of these studies exceeded fortnightly spacing. The evidence base for psychotherapy with PTSD is established primarily on studies providing weekly treatment. If your client with PTSD is not progressing, this would arguably be one of the first things to check: are they coming weekly?

I am so interested in this topic that one of my Honours students is currently doing a study on how frequently psychotherapists in Australia schedule their sessions. If you’ve enjoyed this article, it would help Imogen and myself out enormously if you could complete the 5-minute survey and spread the word to colleagues.  Click HERE

Clinical Implications

  • To be confident that you can achieve comparable results to the literature with your adult PTSD clients, they should receive sessions at least weekly.

 

  • To reduce the risk of drop-out with adult PTSD clients, offer sessions more frequently than weekly (e.g., twice per week).

 

  • I’m not telling you how to run your business…but here’s how you could run your business: Offer a single session to assess and overview treatment, then contract with the client to delay starting treatment until they – and you – can offer a block of sessions, weekly or more often, depending on what’s possible.

 

  • If you or your client are unable to achieve weekly - or at the very worst, fortnightly – sessions, consider referring them to a service who can

 

For the original article, go to: https://www.sciencedirect.com/science/article/pii/S0887618523000221?via%3Dihub

REFERENCE
Hoppen, T. H., Kip, A., & Morina, N. (2023). Are psychological interventions for adult PTSD more efficacious and acceptable when treatment is delivered in higher frequency? A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 95, 102684–102684. https://doi.org/10.1016/j.janxdis.2023.102684

Matthew Smout