Retiring, Rethinking, and Reconstructing the Norm of Once-Weekly Psychotherapy

Evidence-based psychotherapies hold clear potential to alleviate mental health problems (Cuijpers et al. 2020; Weisz et al. 2017), yet there is no scientifically-driven consensus for how long treatment should last (treatment duration, including total numbers of hours or weeks a treatment might last) or how often sessions should occur (treatment frequency). In practice, once-weekly therapy is the dominant outpatient service available to youths and adults alike, largely due to long-held beliefs and insurance companies’ limiting reimbursable treatment-time to 50-min, weekly sessions. But ubiquity cannot be mistaken for clinical or practical superiority. Indeed, weekly hour-long therapy sessions are among numerous treatment structures that can help patients achieve clinical gains, with recent trials supporting the utility of brief, intensive, and concentrated treatments for widely-varying problem types (Dobias et al. 2020). Further, existing psychological services—dominated by weekly, outpatient options—fall short of meeting population-level mental health needs. Most youths and adults with psychiatric disorders never access care due to financial and logistical constraints, and among those who do, premature drop-out is common (Abel et al. 2020; Burns et al. 1999; McKay and Bannon 2004). Among those who do access psychological support, receipt of evidence-based intervention remains rare, often taking the form of unstructured, brief interactions with physicians (e.g., in primary care settings) or healthcare workers with limited mental health training (Kazdin 2019). Despite repeated calls to diversify treatment options, and to ensure that these diverse options are backed by scientific evidence (Kazdin 2019; Schleider et al. 2020), the “weekly therapy hour”—in many cases, absent of any quality assessment ensuring reliance of evidence-based approaches—remains the practical default. Given limited accessibility of, and significant dropout from, weekly outpatient therapy (suggesting that many are unable to access treatment as it is routinely provided), and the established efficacy of alternative treatment formats (suggesting that treatment may be redesigned to improve accessibility without sacrificing clinical utility), we assert that it is our field’s ethical obligation to retire and rebuild the longstanding “default” to once-weekly outpatient services.Footnote1 To be clear, we do not endorse eliminating weekly psychotherapy as an option for patients; many once-weekly, evidence-based treatments, if delivered as intended, may benefit patients greatly. However, repositioning evidence-based weekly therapy as one of many treatment options, and improving the availability of additional, diverse evidence-based service types, may strengthen the accessibility, flexibility, and potentially the effectiveness of mental health treatment overall.