We tend to think of therapy in hours — the old 50-minute notion, sometimes 30 minutes. The hour is real. But the hour is not the therapy, and we should stop talking as if it were.
On the latest Got Therapy?, Dr. Dan Rose and I spent an episode asking a question that sounds simple: when does therapy start? A session can be warm, attentive, and full of good conversation and still leave the honest clinician asking whether anything therapeutic happened in it. Dan's answer is a concept from the interpersonal school: the moment of meeting — "a moment of emotional clarity that is co-constructed by two individuals." It is not the whole hour. It may be a few minutes. It is the part that counts.
This matters for three reasons.
First, it changes what we supervise
If therapy is the hour, then a supervisor's job is to check that the hour went smoothly. If therapy is the moment, the job is to help clinicians recognize it, make room for it, and notice when they are standing in its way. Dan has a name for that last problem — counter-resistance, which he defines as "when the therapist is resistant." It is what happens when a client offers something important and the therapist, because it doesn't fit the plan, moves on.
Second, it makes our models accountable
Dan is right that every model has its own therapeutic moment: an emotional opening in psychodynamic work, a moment of competency in a cognitive-behavioral skill, a measurable behavioral change. His reminder to "mind your ABCs" — affect, behavior, cognition — is a useful test for any approach. If a clinician cannot say what their own model treats as a therapeutic moment, they will have a hard time recognizing one.
Third, it raises the bar for the first session
Dan tells newer clinicians they must give the client "some bang for their buck in the initial session or they won't come back," and he aims for a therapeutic moment in session one. I think that is the right standard.
The standard also cuts the other way. So far, most of the conversation is about what the therapist must bring — the training, the checklists, the process. Far less is said about what the client brings. Clients have a job to do. Showing up, as Dan said, is no small thing. But we owe clients a clearer account of the work they are being welcomed into — and we owe them hope, in something more than a sign on the office wall.
The hour will stay on the schedule. It should. But the profession would be better served if we taught, supervised, and evaluated therapy by the question underneath the hour: did anything therapeutic happen here, and would we know it if it did?
Michael Baltimore Ph.D. co-hosts Got Therapy? with Dan Rose Psy.D. This editorial draws on Episode 85.