PERSONAL VIEW

Two or Three Sessions?A Discussion of Some Ideas about the Frequency of Sessions in

Psychotherapy

Ruth Barnett

SUMMARY. In this paper I explore some issues involved in attempting to assess whetherthere are definable differences, beneficial or otherwise, between psychotherapy at twotimes and three times a week. I question the common assumption that more is better and Iexplore whether there is good reason to formulate such an hypothesis and how far it mightbe tested and evaluated. Firstly, I consider the number of sessions we have ourselvesexperienced in our training therapies. Secondly, I look at some assumptions we makeabout the work we do with our patients with regard to number of sessions per week and Iillustrate this with material from some of my own patients. Thirdly, I attempt to draw thisdiscussion together around the question of the optimum number of sessions per week. Iconclude that there are some discernable differences between the work in two or threesessions a week. Assessment of their benefits and/or disadvantages is more difficult andopen to the influence of ideological assumptions and prejudices. My material shows thatthe frequency of sessions may have rather different meanings for different patients. Norwill therapists necessarily agree on how the different use made of two or three sessions isto be regarded.

Introduction

Some time ago two of my patients changed from two to three sessions a week atroughly the same time. I became quite preoccupied with what might be the individualmeaning for each of them of this change. I felt at that time that one was using the increaseconstructively and the other in a way that was not furthering the therapy. What seemed likea quite straightforward issue at first gradually took on increasing complexity. Fairly soontwo more patients moved from two or three sessions a week and I wondered whether I wasagreeing in the best interests of the patients, or might there be some ulterior motive inmyself? I realised that I was looking at my patients' material in a different way although Icould not exactly define what the difference was. Was my newly stimulated interest in thisissue affecting my work as it was affecting my thinking? It seemed so but I could not besure whether this was beneficial. It concerned me that I noticed colleagues who seemed tocollect in their practices a preponderance of patients of one particular type or with a certainsimilar kind of problem which particularly interested the therapist at the time. I ponderedwhether there might be an optimum number of sessions per week which was best for theparticular patient or whether it was more a matter of what the therapist had been broughtup to think best and feel most comfortable with herself.

Training Issues

The problem of how many sessions a week were really in the best interests of mypatients echoed thoughts I had had for a long time about whether there was an

Ruth Barnett is a full-time practising psychotherapist and member of the LCP and LINK. Address forcorrespondence: 73 Fortune Green Road, London NW6 1DR.

British Journal of Psychotherapy, Vol 8(4), 1992© The author

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optimum number of sessions per week. I began to think about why some therapists work atone or two sessions a week while others work at four or five. Many years ago when I wastraining I thought it was very clear that psychoanalysts were trained to work at fivesessions a week and I was training to work at two sessions a week. A very naive idea, Igradually realised. Many of my trainers were psychoanalysts and they taught uspsychoanalytic theory and practice. But the question of what was the difference betweenpsychoanalysis and psychotherapy was evaded. The number of sessions a week seemed tohave something to do with it but precisely what this was eluded me. I learned how theoriginal analysts had worked with patients six and even seven times a week and that a fewstill did. But on the other hand in some parts of the world psychoanalysts are trained towork three times a week while some psychotherapy courses, already at the time I wastraining, trained at three times a week. Strangely, it never occurred to me to ask my owntraining therapist why he had agreed to see me twice a week when he was an analysttrained to work at five times a week. At that time I subscribed to an assumption, that Ibelieve is fairly widespread, that training at more sessions per week also equips a therapistto work at fewer sessions. I now question is this really the case? If so it would suggest thatthere really is no definable difference; the soup is all the same however many ladlesful youhave per week. So was it the cook's recipe rather than the quantity of ladlesful? Why thenare many therapists trained with the same 'recipe' as analysts? It seems to me that sometherapists are more easily able to adapt their skills in varied ways and situations thanothers whether they are psychotherapists or psychoanalysts.

Another assumption I found myself confronting was whether more meant better in thetraining situation. Was five times a week analytic training 'the best' and anything involvingfewer sessions second-rate in comparison? I never found this actually stated but it wasoften insinuated. Few could afford the cost of analytic training yet large numbers of peopleneeded and wanted psychotherapy, many of whom in any case would be unable to affordto pay for full analysis. Psychotherapy training courses were created to meet this need.These issues give rise to a number of questions. Does this make psychotherapy a second-rate because cheaper form of treatment? Or could it be that treatment at one, two or threetimes a week might in some cases be more appropriate to a person's current needs?Furthermore, might some people actually use fewer sessions more productively?

The importance of financial considerations, in my opinion, cannot be lightly dismissedeither regarding training or in assessing prospective patients. I am aware that there aresome bursaries and grants available to trainee analysts. I do not believe they are plentifulenough to enable all those to train who might be assessed to be suitable for analytictraining. I think we can take it that many people who might have been found suitable to betrained as analysts have taken psychotherapy training instead. But it must surely be truealso that many who have trained as psychotherapists would not have been assessed assuitable for training as analysts. Undoubtedly it would be very difficult and open to attackand abuse to define the criteria for selection. This leaves us with what seems to me to bemounting confusion about the optimum frequency of sessions.

For some time it seemed to make sense to me that many people might be choosingpsychotherapy training courses not so much for a less costly training for themselves thanbecause they wanted to work with people who would not be able to afford analysis. Iwondered whether what had developed was a two-layered system: the best

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for those who could pay and something cheaper for those who could not afford it. Ipondered whether psychotherapy training aimed to equip therapists to meet the needs ofpeople for whom fewer sessions were appropriate quite apart from their ability to pay.There seemed to be sound sense in the latter view. Why then was I finding more and moreof my psychotherapist colleagues increasing their sessions and working at three, four andfive sessions a week? I considered further why my own work was developing in a similarway. Previously I had felt `safe' with the assumption that I was trained for working withpeople at one or two sessions a week and that was what I would do and continue to do.How could I take my patients where I had not been myself? My personal therapy in mytraining did not seem enough. My own training organisation, the LCP, had increasedpersonal therapy in training to a required minimum of three times a week. I pondered onwhat this move from two to three sessions might mean. I discovered many of my owntraining cohort had decided to 'top up' (as several expressed it) by having a further personaltherapy. I too felt this need and embarked on an analysis. This went some way to meetingmy specific problem of not feeling able to work at more sessions per week than I hadexperienced myself. How to assess the appropriate number of sessions per week both forthe training of therapists and for patients continued to occupy my thoughts.

I have observed that this issue seems to possess a power to generate passionateemotions in most therapists and often leads to heated controversy. The British Journal ofPsychotherapy published an account of one such debate arising in the Conference onPsychoanalysis and Psychotherapy - Similarities and Differences. The issue of theoptimum number of sessions could not be properly addressed at this conference becausefeelings, fantasies and misunderstandings about status differences interfered with opendebate.

The question of professional status being linked with frequency of sessions wouldappear to be fundamental in the growing confusion in the field of psychotherapy. What ishappening in the field of counselling is adding to this confusion. Just as psychoanalystsform a large proportion of the trainers in psychotherapy training courses so counsellingcourses are also 'buying in' psychotherapists and analysts as trainers. A similar blurring ofthe boundaries between counselling and psychotherapy is developing parallel to theblurring of boundaries between psychotherapy and psychoanalysis. Financial limitations,both for the training of counsellors and the fees clientele can afford, status and number ofsessions per week are again key issues in most of the discussions of counselling andpsychotherapy that I have observed. The question of how many sessions per week are mostappropriate interests me most. Counselling used to be mainly once a week or lessfrequently. Twice-weekly counselling is rapidly becoming quite usual. Moreover, theviews of counsellors on the optimum frequency of sessions for a particular patient tends tobe rather different to that of many psychotherapists. An example of this was manifest in aworkshop I led at the BAC conference in 1989 on the theme of 'Counselling andPsychotherapy - Similarities and Differences'. The consensus view of this group ofcounsellors was that they worked mainly at once or twice a week with people who hadmoderate problems relating more to their current life situations. They referred on forpsychotherapy those people they assessed as having more serious psychiatric problemsderived from their earlier childhood family experiences. The group was astonished to beinformed that many psychotherapists refer patients on for counselling when they feel thatthey are too severely disturbed to be able to use psychotherapy. The

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counsellors thought that the more severely disturbed people would need more sessions perweek. Psychotherapists often assess a person as not likely to be able to cope with morethan once-weekly counselling or what is sometimes euphemistically called `supportivepsychotherapy'. The only conclusion that I have been able to come to is that there is anincreasingly urgent need for some hard thinking and research into why and when differentnumbers of sessions per week are indicated.

Work with Patients

Larry, a man of 42, had been a managing director of a small but very successful firmuntil it was taken over by a larger foreign company. Feeling insulted by the plans the newowners had for him he left feeling further cheated by a poor redundancy settlement. Hishealth deteriorated and his GP took him on for private counselling approximately once aweek. This lasted for six months during which he left both his wife (second marriage) andhis extramarital relationship and rented a flat on his own so that he could read (mainlybooks about therapy) and write about his travels abroad on business. The counsellingended when his redundancy money ran out, and it was a few months later, when hisdivorce had come through and the marital home was sold, that he came to me forpsychotherapy. Counselling had helped him, he told me, but had never felt enough. Hereally wanted three sessions a week but felt he could only afford two because he wanted togive himself a year to see if he could write before he thought of getting another job.

It became clear when we started work together that twice a week was as much as hecould manage. He came eagerly, usually early and smartly dressed, and very hungry for myattention. But he was convinced that I would ill-treat him and reject him. He experiencedme as another doctor like the ones who had assaulted him with terrifying treatment in hisfour hospitalisations in early childhood (two were lung operations). He could not toleratehis feelings of rage against me and, despite his urgent hunger, he kept himself deprived ofwhat he wanted so much from me: he came to his early morning sessions having notbreakfasted and then he left them hungry and stopped at a cafe between my house and thetube station to `ravenously stuff on food he did not much care for. He could keep neitheranything from the session nor even an image of me in his mind between sessions: hestarted most sessions with comments about being surprised to see me, that I looked like astranger and he wondered why I was not wearing a white coat. Although I told him it wasan account when I gave him the first one he was convinced it was a letter of dismissal andtold me in the following session how he had not dared to open it till he got home.

Towards the end of the third month of our work it had become clear to us that thesessions were for him a repeat of his mother's daily visits when he was in hospital. Theroutine 15 minutes had been always too little leaving him hungry and angry each time. Hecame to a Thursday session hardly able to speak he felt so angry. He hated me for hurtinghim so much every time he came. He described his anger like a fire that he felt could burnup me and my house and himself. I told him I though he wanted to burn me up like eatingme up he was so hungry and angry. He continued to tell me about his anger and thenaccused me of wanting to take his anger away, `and then I will have nothing, just nothingbecause I am nothing but anger, convulsions of anger'. This led to a detailed memory abouta girl in a wheelchair at the special school he had attended. She had had an attack ofconvulsions in the playground and died. He had been fond of

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her and was very shocked. I told him I thought he feared that his dangerous anger mightkill me off too like the girl in the wheel chair but also I thought he feared that his angryconvulsions would kill himself. It was too dangerous for us to be together too much like hehad felt with this little girl. The realisation of this freed him somewhat to talk more aboutthe girl, the loss he felt, but also that she did not have to struggle any more like he did. Atthe end of the session he urgently wanted to come again the next day.

It became clear in the following Monday session that he had really wanted me to seehim the next day Friday, but that his leaving it to the end of the session made it impossible.We talked about his hunger for more, the third session, and fear of what might happen toboth of us with more sessions and we negotiated three sessions on Mondays, Wednesdaysand Fridays. This meant that he did get a Friday session in that week. He felt very fearfulin this first `third session', very undeserving and with little to say at first. And then he had amemory of falling off the back of a chair he had been told not to climb on. Finding himselfin hospital with a broken collar bone had felt like punishment; all his hospital experienceswere severe punishment to him. He believed I must need to punish him for his greed formore sessions. His need to appease and please me was expressed in bringing frequentdreams and nearly always he brought dreams from then on in threes.

Fiona came to me, aged 23, looking and dressing as a childlike pixyish waif with awistful half-smile as she came in and left sessions. During sessions she could hardly talk tome as she sat in the chair with her face buried in her hands crying. She complained ofbouts of depression and unmanageable feelings of self-blame. Her voice was incongruouslyharsh and guttural with the rage she could barely suppress. She worked in a city financecompany and shared a flat with her boyfriend and his sister. There was nothing but rowsand discontent in which she always felt herself to be the victim at work and at home. Itwas a repeat of how she had experienced her family as youngest of three daughters. Shehad felt bullied at school where father was head master and bullied at home where motherwas in charge. Finally she had expressed her rage by taking an overdose at seventeen. Shefollowed this by running away to London and getting man after man to victimise her untilshe met one who took her seriously. Roy, a social worker and in a weekly therapy grouphimself, persuaded her to seek therapy while agreeing to move out of the flatshare to givethem both space.

At our initial meeting Fiona wanted one session a week like Roy but during ourdiscussion she agreed she wanted and needed more and we settled for two sessions,Mondays and Thursdays. The first months of working together were typified by longsilences and bitter crying. When she talked it was endless complaining about how she wasvictimised in ways that were always her own fault. She got all her objects to punish her forher vicious, usually envious anger towards them. She wanted to be my victim too. Myinterventions she turned into persecutions. She was frightened of me but also excited. Hermind often went blank before she could finish what she was trying to tell me about.

Towards the end of the first year we reached a stage where she began to feel confidentenough that I was not going to be damaged or driven away by the proximity of her rage.She began to allow us to look at her wishes and manipulations to get me to bully her sothat she could retaliate. She needed to feel angry for protection. She could not tolerate notfeeling angry because that meant to her being weak and vulnerable. After a twoweekbreak for Christmas she started her first session with a request for a third session.

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She rejected my suggestion that this might be to do with feeling neglected and not givenenough by me in the break. No, she had had a much more enjoyable time than she hadexpected. Spending a lot of time with Roy visiting both their parents had kept her busy.She said she wanted an extra session to get on with her therapy and she was quiteinsistent. But when we found an acceptable Wednesday time for a third session she toldme that in the current week she would not be able to come at this new time. I pointed outher fear of getting closer to me and that perhaps she was wanting to make me her victim.

In the Monday session of the first week of three sessions Fiona thought she might visither parents and that would mean missing the Wednesday session. I told her I felt she wasunsure whether she could allow three sessions now she had them and wanted to punish mefor giving her the extra session. She was angry with this and admitted she wanted me tobecome angry. She left me not knowing if she was coming on Wednesday but she didcome. In the meantime she had vented her anger on both Roy and me by going out with aman at work and sleeping with him. She used the Wednesday session to tell me howenjoyable this had been and then immersed herself in torments of guilt and self-blameabout hurting Roy. I told her I thought she wanted to hurt me by telling me that this mancould give her something much better than I could give her even with a third session. 'Iknew you would disapprove' she responded. I told her it was not for me to either approveor disapprove but I thought she had wanted me to disapprove so that she could be angrywith me. The next two weeks she found ways of missing a session in each, one aWednesday and one a Monday. But in the fourth week of three times a week, though onlythe second week she actually came three times, she decided to use the couch for the firsttime.

After this she came regularly to her sessions and a pattern emerged. Against abackground of material about how hard her life was with endless persecutions andvictimisations she was too angry on Mondays to begin talking for some time and wasoften late, but by the end of the session had worked through this. Wednesday sessions feltcloser; we were able to start to build something together which in Thursday sessions sheattacked so that she left in a fury to create some sort of disturbance over the weekend withRoy or her parents so that she could come back and punish me with it the next Monday. Inher material she described her ambivalence towards Roy 'if I commit myself it would belike a death sentence'. She both wanted his attention and despised it as weakness; as soonas she began enjoying something with him she had to provoke a row. She did the samewith me. My not becoming angry as she wished me to infuriated her. She experienced theholiday breaks as sadistic attacks and retaliated. During each of the spring and summerbreaks in her second year she changed her work within her firm so that she could notcome at one and two of her times respectively. She anticipated, expected and was angry atmy not responding with instant total dismissal of her. In her third year she became evenmore destructive attacking the therapy with missed and cancelled sessions and planningtwo holidays not to coincide with mine.

Roger, an unmarried accountant living in his own flat, was 39 when we startedworking together. He presented himself as having no feelings and saw himself as a failureat work and in personal relationships. His father had died suddenly a few monthspreviously from a massive heart attack and his mother had insisted that he and his olderbrother (also unmarried) both have a full medical to see if they had any heart impairment.Roger used this medical, at which he was pronounced very fit, to reveal his stress and gethimself referred for psychotherapy. When we first met he was

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preoccupied with his age approaching 40 and his sense of failure at his lack ofachievement. He was in an uncommitted relationship with Elaine, also an accountant butin a different firm. Elaine, who had had some therapy herself, wanted him to have threesessions urgently because he was incapable of sexual arousal with her. I established that hewas asking for three sessions for himself not for Elaine. We found two suitable times butwere unable to find a third although I had several alternatives to offer. I told him I thoughthe was showing me that he needed to not fit in with me and what Elaine wanted. He couldnot understand this but we began work at two sessions a week, Tuesdays and Fridays.

At first Roger idealised me persistently. All the confusion in the sessions was onlybecause he could not see the plan he was convinced I had. He need do nothing but comeand talk to me and I would make him change in some miraculous way within six months.He took me straight into his fantasy life, along with the perfect girls with whom he hadblissful relationships and perfect children. This was his gratifying substitute fordisappointing reality. He structured his life to avoid anxiety with obsessional routines:suits he wore in strict rotation of the days of the week, daily exercise at a leisure centre etc.He was unable to come to sessions without at least thinking about if not carefullypreparing what he was going to tell me. He could not entertain the thought of perhapshaving nothing to say. And he found it difficult to believe that I was listening or thinkingrather than dismissing him as inadequate when I was silent for too long for his liking.

Six months into the therapy we were learning how he kept me at a safe distance withhis various ways of keeping control. His material was mainly about how he triumphedover his senior partners by doing almost no real work and foiled all their attempts to gethim to become a full partner and take on more responsibility. He became my junior partnersitting beside me looking at himself on the couch and expecting me to do all the work. Hedid the same with Elaine. He spent a great deal of time with her but never involvinghimself. Nor did he mentione Elaine's existence to his mother whom he visited everySunday and telephoned daily.

One Monday session he told me in great detail about his senior partner's complaintsabout his aloofness and his own puzzlement at the long hours this man devoted to the firm.He then told me in his typically expressionless voice: `while I was in the waiting room mymind touched upon Elaine asking me when I was going to have three sessions'. As Iremained silent he went on, 'I have been wondering about it. It's like when I buy somethingand then afterwards I'm not really sure if I want it, but once I've bought it I can't go backon it'. I then remembered what I had forgotten up to that point, that I had told him I wouldlet him know when any new times for sessions came up. So I told him that I thought hewas feeling forgotten and neglected by me as I had not found any new time for him. Heresponded, 'Well I wouldn't think that because I know you have everything worked out andit may not be the right time yet, it was only because Elaine asked me and I promised herthat I would ask you about it'. I suggested that he did not like to give up his idealisedversion of me in his mind and he was avoiding this by making it Elaine's idea. Heresponded that he needed to think about that. The next session he started with telling mehe had thought about it and he definitely wanted a third session himself not for Elaine andhe wondered why he hadn't been able to just say that last time. He agreed immediately tothe extra session time I then offered. Interestingly the next session expressed theambivalence he had been denying. He came in looking pleased and told me with what wasmore than his usual

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animation how my cat had come up to him in the waiting room and all about how he likedcats and my cat was friendly in a way that I wasn't. He went on to complain about variousthings that were not quite right that showed my neglect: the picture in the waiting room,the flaws in the carpet where the cat scratched at the door etc. I told him I thought he wastelling me about the disadvantages he felt as well as advantages of having an extra sessionand we were able to explore this further.

Lynette, a pharmacist born in France and married to an Englishman, was 27 andpregnant with her first child when she came to me. She had been married a year anddescribed her illness beginning the day after her marriage. She knew she loved herhusband but had strange feelings of not loving him, feeling herself to be `not there' and `full of black rubbish'. She had been seeing a male therapist once a week but had left him,she told me, because he kept falling asleep and didn't even notice when she walked out.Well into her first year we came back to this and discovered that she had seen andresponded to this therapist as her father who was a very quiet retiring man who infuriatedher because he seldom had anything to say. She experienced her father as cut off and notinterested in her. She wanted two sessions and I felt this would be right for her.

The work began and we went through months of her pouring out her fears and distressat having so many `rubbish feelings' which were mainly about her mother. I never feltsleepy but I felt disabled and confused. Her need to talk was urgent and she allowed me nospace. We were merged like she was with her mother. She described this as coming to mewith her two big black bags (two sessions) to fill with the rubbish inside her and then shetook the bags away with her. She left nothing with me and I felt that I hardly existed forher. She was often not sure of her own self existing. Her material, like her childhood wasdominated by her mother. She was the only child and her mother had been underpsychiatric treatment for depression since Lynette's birth, possibly before also. Lynettefeared going mad but trusted her GP who supported her in avoiding drugs. He gave herdrugs only when she went to him in panic during my breaks and discouraged her fromusing them if she could manage without.

Baby John was born in February, three months after we began and we lost only twosessions. The work proceeded steadily with two sessions until the last month of her secondyear with me. A friend confided in her that she could not tell her mother about an abortionshe was planning. This upset Lynette greatly. She brought material about her anorexicperiod in response to her mother being convinced she was pregnant and how she had laterfelt compelled to get pregnant by the boy her mother suspected. She had then panicked andhad an abortion without her mother knowing. It was not new ground but a new depth andintensity. Lynette asked to come again that week and I found her a time. The nature of ourwork was changing. The following week she had a strange experience just after leaving hersession. She described it in the next session: 'I was in the post office - I went there straightafter my session to fill in a form but I couldn't read it. I kept looking at it and looking at itbut I couldn't read it. I wasn't there, I felt as though I was still in your room'. I suggestedshe had felt merged with me in the session and had left herself behind. She said it was 'justlike that' and went on to remember several other experiences when she had felt somethingsimilar. It had frightened her with Florence, the friend who confided in her about theabortion. `I saw me so much in her - I mean the me when I was younger - and when wesaid goodbye I had to pull hard to pull me back'. I felt she was becoming aware of herselfand me as separate and this was distressing for her. I offered her a third session which shefelt was

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right, `the pulling me back won't have to be so far each time' she said. There was aqualitative change in our work from this point. She was able to look with me at how shecontrolled me by leaving me no space. I had to interrupt her to show her this, something Ihad tried unsuccessfully to do before. She was able to observe herself relating to me andshe linked it herself to her relationship with her mother.

Discussion

It is not easy to compare the move from two to three sessions in the therapies of thesefour patients. Each seemed to choose the time to make the move at their own pace. Larryand Fiona made the change within two months of each other which had set me thinkingabout the use they were each making of it and the whole issue of frequency of sessions.Roger and Lynette made the similar increase also within two months of each other andsome nine months after Larry and Fiona had done so. I then had four sets of material inwhich to look for a qualitative difference between working with two as compared to threesessions a week. Larry increased after only three months and Roger after six. Both hadstated a wish for three sessions at our first meeting but had needed to start with two. Fionaand Lynette expressed no wish for three sessions initially. Fiona fought her neediness foralmost a year before she could allow herself a third session. Lynette needed two years toreach readiness to begin separating from me, at which point she needed and made use ofthe extra session.

The difference was most marked in Lynette's case; we were able to work with ratherthan be in the transference. Up till then any transference interpretation I made was usuallyignored or not heard by her. She would sometimes continue talking as if I had not spoken,at other times respond with, `Why do you say that?' or 'I didn't hear what you said'.Sometimes I could feel her unexpressed puzzlement or anxiety at my interventions. Withthree sessions she began to allow a dialogue between us and expressed surprise at mybeing there and having a body and face with features. She told me I had been `just a voicebehind the couch'. Now she was experiencing a relationship with me. But this change wasnot the result of moving from two to three sessions. It had already taken place as part ofthe process of our work, and the increase in sessions followed on rather than was causal inthe process.

I have no doubt both that the work Lynette and I did in three sessions a week wasqualitatively different and that it was to her benefit. I would conclude that the move fromtwo to three sessions was constructive but I find it hard to assess this in terms of anoptimum frequency. I do not think it would have been helpful to insist on three sessionsfrom the beginning even if I could have foreseen how the work would progress. Twosessions was what she wanted and settled into using in the way she needed and could beregarded as optimum in the early stages. Nor would it have been productive to insist onthree sessions in the later stages of her therapy when she needed to drop to once a week.With the other three there was nothing as clear as this. The pattern of how each of themrelated to me in the transference showed no actual change, although in each case it becameclearer. But this happened over the subsequent months rather than at the point ofincreasing sessions.

It may be useful to regard the number of sessions per week both as a vehicle for thetherapy and as an object within it. Regarding the increase as a vehicle for the therapy wecan look at where the pressure comes from to increase. Larry and Fiona were both veryhungry for what they wanted from me but needed equally strongly to keep

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themselves deprived. In Larry's case I think perhaps the approach of our first break, whichhe knew was coming and feared, provided the pressure for him to increase his sessions amonth before Christmas. For Fiona it was the break itself, though not the first one, thatprovided the necessary pressure. Roger had an expectation that something very profoundand magical would happen within six months. The reality of experiencing this to have beenan illusion spurred him into asking for the third session which his ambivalence hadprevented him having at the beginning. I think I can best describe the pressure for Lynetteas the urge to begin the labour of being born, of emerging or rather 'demerging' from me.

Having made the increase each of the four used it, as an object, in different ways.Lynette used it as a `birth canal'. She became pregnant with her second child soon after theincrease and through experiencing her foetus becoming a separate entity inside her sheseparated from me and from her mother who had only had one child. Fiona attacked thisobject like she did all her objects, triumphantly finding ways to reduce it in many weeks totwo or even one session. Roger absorbed his third session into a routine of three sessionslike his five suits for the days of the week. And for Larry the frustration intensified as hisanger prevented him keeping anything of our work in his mind between the sessions. Thechanged object was as unsatisfying as before.

That more material is generated in three sessions than two sessions a week is aconcrete difference that cannot be dismissed. But this is not necessarily beneficial. Lynette's material clearly increased in richness and vitality and we could begin to understand it in adifferent way. In Larry's sessions this was harder to define. There was an intensification ofthe frustration and anger. He was less able to cover this with a polite front and other waysof escape and protection began to emerge, notably his scrambling of words and inventingword mixtures. Roger fitted his three sessions in to the structure of his week as just anotherroutine. It had worried him that he was getting less than the three he thought he wassupposed to have. He produced more material but there was no more that we could do withit. And Fiona used the increase in sessions to intensify her sadomasochistic relating to me.There was more material and it emphasised the pattern more clearly.

I have found that patients have preconceived ideas about the number of sessions. Theyoften know other people who are in therapy and are influenced by how many sessions thesepeople have and how they perceive them to be affected by their therapy. It was importantto Larry that he had more than his ex-wife. In this issue she represented for him his oldersister whom he felt in childhood his mother favoured and gave much more to than to him.It was important to him too that his sessions were my first ones in the morning so that Iwas fresh and he got the best before anyone else. So for Larry more sessions meant `morefood' but, like the hungry baby who has been kept waiting too long, he was unable to feed.Fiona too wanted more than her boyfriend but was worried about more sessions meaningmore ill and more needy. She wished to disown having any needs. Neediness, for her, wasequated with the vulnerability and powerlessness she had suffered as a victim of bullyingat school and had built into her fantasy life. But she also used more sessions to mean morepower to attack and bully me. Lynette, who was perhaps the most disturbed of the four, feltvery keenly at first that two sessions was self-indulgence and my time might be needed forpeople more ill than her. As she became less `ill' she was able to feel herself to be ill andaware of her justified need for more. Roger felt three sessions must be `correct' as this waswhat had first been agreed. He experienced two sessions as `not working' because he hadnot

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cooperated with the master-plan he was convinced I had. So he expected things to speedup with three sessions. This seemed to be a re-idealisation of me, that I would at last makethings happen. Issues of `greed and need' about taking more and being given more werethere in all four of the therapies in relation to the change from two to three sessions.

I wondered whether the spread of the sessions over the week made any difference.Larry wanted his sessions spread evenly as Monday, Wednesday and Friday. Roger andLynette took what I could offer which was Tuesday, Wednesday, Friday and Monday,Wednesday, Thursday respectively. Fiona attacked the therapy ferociously at breaksmaking changes of time necessary and we moved from Monday, Wednesday, Thursday toMonday, Wednesday, Friday. I could pinpoint nothing that seemed significant about whichdays there were sessions.

Conclusion

Inevitably, I think, both therapists and patients make assumptions about what havingmore or fewer sessions per week means. Patients may think about their sessions in quitedifferent ways as far apart as `more sessions means more ill' and `more sessions meansmore care'. Perhaps as therapists we tend to think of more sessions as enabling better andmore intense work in the therapy. If this assumption is justified we should be able to showa difference in the work before and after an increase in the number of sessions. How toassess such a difference poses problems. The four patients whose material I havepresented are so different in the complexity of their inner lives and ways of functioningand relating as to make comparison both with each other and with themselves before andafter the increase in sessions extremely difficult.

Lynette's therapy was the only one of the four in which I could perceive a clear change.This change, however, was complex. And it can be argued that the increase from two tothree sessions was more a result, or at least part of the process of the change, rather thanthe cause of it. There was no exploration of what might be the meaning of changing thenumber of sessions; once labour has begun you simply get on with the delivery. Tocontinue the imagery perhaps increasing the sessions just at this time was like opening thecervix wider to facilitate the birth process. It is worth noting that Lynette and I worked,that is laboured, almost exactly nine months in three sessions a week until the baby wasborn and then, from the baby's birth with one session a week. There were, of course, therealities of managing two children instead of one. But, whereas with the birth of the firstone we continued our two sessions a week after missing only two, after the second wasborn Lynette was able to find only one time each week to come for a session. This was atdifferent times and I felt I was `demand feeding' her until we established a regular weeklytime which continued for another year up to the end of her therapy. Following ourassumption we might expect a drop in the quality and intensity of the work. I do not thinkthis was the case. After the birth of her second child Lynette experienced herself asdifferent from her mother who had only one child. She discovered that she could argueand be angry with her mother and with me in the sessions without causing damage. She nolonger needed her symptoms to avoid her anger.

To assess what change there may have been due to the move from two to threesessions in the other three therapies is also difficult. There was a gradual increase inclarity and intensity of how they were using the therapy. I cannot be sure that this was

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any different to what it might have been if they had continued with two sessions. I thinkthere is a danger in looking too narrowly at the number of sessions per week. There areother visible and definable factors like whether the couch or chair is used and many subtleand indefinable influences of the ambiance of the consulting room and boundaries of thetreatment relationship. How comfortable the therapist feels to be working at differentnumbers of sessions a week needs to be taken into account as well as what the experienceis for the patient. This is likely to vary for a therapist with the different patients she sees.Even if it might be possible we are, I think, a long way from having any sort of tool to usefor assessing what would be the optimum number of sessions for a particular therapist-patient couple to work with. Perhaps the tool can only be our own intuitive skill gainedthrough experience. For this reason alone I believe it to be worth the endeavour toscrutinise and compare the work of patients before and after a change in the number oftheir sessions a week. An accumulation of material on this subject might then lead to moreideas and also throw further light on the issue of how many sessions per week should beexpected in the personal therapy required for training as a psychotherapist.