278: When Weekly Couples Therapy Isn't Enough with Shane Birkel

Welcome back to The Couples Therapist Couch! This podcast is about the practice of Couples Therapy. Each week, Shane Birkel interviews an expert in the field of Couples Therapy to explore all about the world of relationships and how to be an amazing therapist.

In this solo episode, Shane talks what to do when weekly couples therapy isn’t enough. Listen to the episode on Apple Podcasts, Spotify, and your other favorite podcast spots, and watch it on YouTube – follow and leave a 5-star review.

• Episode Summary & Player
• Show Notes
• The Couples Therapist Couch Summary
• Transcript

The Couples Therapist Couch 278: When Weekly Couples Therapiy Isn't Enough with Shane Birkel

This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more

Get the Couples Therapy 101 course: https://www.couplestherapistcouch.com/

Join the Couples Therapist Inner Circle: https://www.couplestherapistcouch.com/inner-circle-new 

In this solo episode, Shane talks what to do when weekly couples therapy isn’t enough. Hear the pros & cons of therapy intensives, why 50-minute sessions are still the standard in couples therapy, how to get to the heart of the matter with your clients, how much to ramp up & wind down the conversation with your clients, and how to find what session length is right for your clients. Here's a small sample of what you'll hear in this episode:

• The hidden cost of ramp-up and wind-down time in weekly sessions
• Psychoeducation vs. deep emotional learning
• Couples often arrive in crisis and 50 minutes isn't enough
• Why couples therapy requires different skills than individual therapy
• Healing attachment wounds through felt experience, not just insight

Show Notes

• 278: When Weekly Couples Therapy Isn't Enough with Shane Birkel
• This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more
• [1:29] Why couples therapy requires different skills than individual therapy
• [2:55] The problem with the 50-minute weekly session structure
• [3:53] How the insurance/medical model shapes therapy format
• [5:21] What would most benefit couples if we designed it from scratch
• [6:45] Couples often arrive in crisis and 50 minutes isn't enough
• [8:12] How a longer container changes the nervous system from the start
• [9:07] Psychoeducation vs. deep emotional learning
• [10:34] Healing attachment wounds through felt experience, not just insight
• [12:02] Making the most of 50-minute sessions when that's what you have
• [13:59] The hidden cost of ramp-up and wind-down time in weekly sessions
• [16:19] The value of extended first sessions and intake work
• [17:44] This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more
• [18:41] Intensives aren't "faster therapy", they're a different container
• [20:10] Communicating the value of intensives to prospective clients
• [21:08] How depth compounds hour by hour in an intensive
• [22:36] What a typical six-hour intensive looks like in practice
• [23:36] What happens after the intensive 
• [24:33] Using follow-up sessions to build on intensive gains
• [25:33] The case for efficiency in couples healing
• [26:02] Why you should explore intensive work
• This episode is brought to you by Alma. Visit https://helloalma.com/dg/?utm_source=podcast&utm_medium=paid&utm_campaign=privatepractice to learn more

What is The Couples Therapist Couch?

This podcast is about the practice of Couples Therapy. Many of the episodes are interviews with leaders in the field of Relationships. The show is meant to help Therapists and Coaches learn how to help people to deepen their connection, but in the process it explores what is most needed for each of us to love, heal, and grow. Each week, Shane Birkel interviews an expert in the field of Couples Therapy to explore all about the world of relationships and how to be an amazing therapist.

Learn more about the Couples Therapy 101 course: https://www.couplestherapistcouch.com/

Find out more about the Couples Therapist Inner Circle: https://www.couplestherapistcouch.com/inner-circle-new

Transcript

Please note: this transcript is not 100% accurate.

00:00
And so you're building on the gains in that intensive in a way that I don't think is usually possible when you're doing weekly therapy.

00:14
the Couples Therapist Couch, the podcast for couples therapists, marriage counselors, and relationship coaches to explore the practice of couples therapy. And now your host, Shane Birkel.

00:30
Hey everybody. Welcome back to The Couples Therapist Couch. This is Shane Birkel, and this is the podcast that's all about the practice of couples therapy. Thank you so much for tuning in. I'm a licensed marriage and family therapist, and the goal of this podcast is to help you learn how to more effectively work with couples and possibly even learn how to have a better relationship. The episode this week is brought to you by Alma. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates.

00:59
Alma handles all of the paperwork and guarantees payment within two weeks. Visit HelloAlma.com or click on the link in the show notes to learn more. All right. Hey everybody. Welcome back to The Couples Therapist Couch. This is Shane Birkel. I'm a licensed marriage and family therapist and this is the podcast. It's all about the practice of couples therapy. You know, I try to couples transform their relationships. I try to help therapists learn how to work with couples in a way that is going to be most effective.

01:29
And today I wanted to talk about, guess you could call the topic therapy intensives, but I think it goes a lot deeper than that. I mean, I think that a lot of times there are therapists who are really good at couples therapy. And one of the things I always talk about is that couples therapy is very different than individual therapy. The skills required by the therapist to work with couples are very different than the skills.

01:59
that you need to work with individuals. There's a lot of crossover. I think there are probably a lot of good, really good individual therapists that would make really good couples therapists as well. even in the process of doing couples therapy, I find myself often focusing on one person at a time, doing some individual work, insight. But when you have a couple in the room, it completely changes the dynamic.

02:27
and the possibilities for what you can do. And I think it's a huge advantage oftentimes in a lot of ways, where just by doing couples therapy, I mean, even if it's uh the normal setup, right? 50 minutes a week for every week. You know, I think there's so much more that is possible in a lot of situations with couples therapy. Now, there are situations where individual therapy is the right.

02:55
approach. Obviously not everyone's in a relationship to begin with. But um that being said, I wanted to talk a little bit about why it's set up as 50 minute sessions. And I feel like I want to take a step back because sometimes there's nothing wrong with the therapy. Like the therapist is doing really good couples work, but it's more about the structure and what's possible within the structure.

03:24
And I think that one of the reasons we do 50 minute sessions weekly is because that's what the insurance companies have decided. That's what the politicians have decided. I think they like to fit it into a nice package. And part of that comes from the medical model, you know, where if you break your leg, there's sort of a clear treatment plan where you probably maybe have surgery and then you have

03:53
uh some sort of treatment plan going forward from there to heal. And I think for people in politics, people in insurance companies, they like to imagine that the world fits into those nicely wrapped packages where somebody has depression, here's the pill you give them, or somebody has anxiety, you need 12.

04:23
weeks of 50-minute sessions every week, and then you'll be healed. And unfortunately, whether you're a therapist or just a human being who's not a therapist, you know that these relationship issues, these emotional issues, these psychological issues, they don't fit into a nicely wrapped package like that. We have to take a step back and think... If we were to take a step back and think about...

04:51
What is going to be the most impactful way to help people heal from what they're going through? I don't think when we're talking about couples therapy, I don't think it would be 50 minute weekly sessions. Now I do work with people, I do work with couples in 50 minute weekly sessions and I think it can be incredibly helpful. I think there's a lot you can do and I don't want to make anyone feel like what they're doing isn't good. We have to work with

05:21
the system in which we live. But that being said, I think if I were strictly to talk about what is the most beneficial, to me, it's when we can have a lot of time to really get deep into the emotional learning. mean, a lot of times, maybe even in the first 50 minutes,

05:47
As a therapist, you're coming up with ideas of what's wrong, what would be most helpful, what needs to happen for these people to heal and grow. But when we're talking about attachment wounds, when we're talking about emotional learning, when we're talking about deep insights, these are things that don't just require our psychological knowledge. A lot of times it requires the ability to slow down.

06:17
and for people to have time to sit with the things that are coming up for them. That's the process of emotional learning. And there's only so much you can do in 50 minutes. another thing about that is that people are often, by the time they come to couples therapy, unfortunately, they're often in a state of crisis and they're often feeling like

06:45
they're making big decisions like, I going to stay in this relationship or not? Or if things don't change, I don't know what I'm going to do. Or we've been struggling with this forever and this is our chance to see what's possible. If you imagine someone trying to explain what's going on for them, mean, usually we're talking about they have 10, 20 year relationship history.

07:14
that they're trying to explain. ah I'm often asking questions about their family of origin, their childhood experiences, and how that informs what's going on in the relationship in the present. And there's only so much you can get into. And so a lot of times, I think what happens when we only have 50-minute sessions is that the people are rushing. They're rushing because they want to make the most of it, and the therapist wants to make the most of it. And sometimes that might be the right choice.

07:44
But it's sort of like, how do we create safety when we only have this much time? And I think that's a different question. I have six hours where I'm doing an intensive in one day with the couple, there's just something that happens even right from the beginning where their nervous system is just a little bit more calm. There's not the feeling that we have to rush through this.

08:12
There's the feeling that they can each have a turn to explain what's going on for them, what they really want, what they're struggling with, what's keeping them stuck. And it just right from the beginning has a different feel that creates more safety and creates more ability for people to regulate their nervous systems. You know, I truly believe that

08:38
When we're talking about these attachment injuries, a lot of times people have been living with these attachment wounds for 30, 40, 50 years, their whole life. And it just takes time. And you can only heal that through experience. There's something to be said for the psycho education, like, for example, understanding what healthy communication looks like. Right? that's that...

09:07
one level of reality. That's sort of, I would say, a superficial level of reality. know, somebody could read a book or even like a one-page document explanation of here's how you communicate in a respectful, healthy way. And you know, that can be incredibly helpful, you know, if people can try to apply that to what's going on in their relationship. But a lot of times what happens is the emotions

09:36
come in and get in the way of being able to use that sort of healthy communication structure. And those are the things that are incredibly beneficial about therapy. The opportunities we have when people come to therapy is that we're not just working with teaching or insight that is coming from the brain or the head. When we have sufficient amount of time in couples therapy,

10:06
We are helping people drop into their body, into their felt sense of reality. And that's where real meaningful change can happen. Again, we're talking about attachment wounds that people developed probably from the time they were born. If you imagine a little two-year-old, three, four, five-year-old, they're living in this environment day in and day out. And their brain is learning what it means to be

10:34
in reality, in a relationship, in a family, what it means to be loved, what it means to be worthy. And I think when we, you know, the more that I've done these longer intensive sessions, the more I've come to realize that so many of our relationship issues stem from this deeper sense of, you know, almost like a primal, really deep sense of, it could be worthiness.

11:04
feeling that I'm not enough, feeling that I'm not deserving of love, meaning about what it means to ask for what I want. I don't want to be a burden on other people. Some people are people pleasers or I don't want to be controlled. There's all these themes that come up that when we really slow that down, we can help people make sense of it. We can help people see why it makes sense that you are feeling stuck.

11:33
in certain ways in your life and certain ways in your relationship because anybody who would have gone through the things that that person went through during their childhood would be experiencing these stuck places. When we have that long period of time, now let's say that you're working with someone for 50 minute sessions every week, like sort of a typical therapy setup.

12:02
You know, a lot of times you can, and by the way, I do that as well. And one of the things that helps with that is I try to get right to the point so that we can make the most of those 50 minutes. So, you know, even if that's the framework that you're working under as a therapist, you know, just making sure, I think a lot of times it's sort of an art form. I think there's a balance of how do we

12:31
create safety and make people feel comfortable, but also not waste too much time, right? So we could start off in the first few minutes talking about, you know, the game that happened yesterday or, you know, people are often talking about a recent vacation and the, you know, just sort of like that normal human kind of like we're connecting with each other. We know we really haven't gotten to the heart of the conversation yet.

13:01
They could be filling you in about what happened in the last week, but I'm thinking to myself, I'm trying to really quickly get, if it's someone I've worked with before, I'm trying to really quickly get back to the heart of the matter to pick up on where we left off. But when you imagine uh working with someone in this way, every time they come in for a session, there's going to be that buffer period. And it depends on the person.

13:31
or the couple that you're working with. It depends on your personality. There's a lot of different factors and there's no right or wrong. But sometimes that time where you're just sort of easing into things, and they may have been just coming from work and they have to go back to work afterward. And there's a level of, there might be something in the back of the client's mind, which is like, well, I can't take it too deep because I do have to go back to work after this.

13:59
Again, very understandable, but it's just a very different experience than when you have the intensive. So let's say you're meeting for 12 weeks. That's like, let's just say 12 hours of therapy over 12 weeks. I'm not going to do the math of 50 minutes times 12 weeks. So it's not even 11, not even 10 hours, but how much of that time is being spent at the beginning of each of those sessions?

14:29
to sort of ramp up and at the end to sort of wind down, because that's important. Because I think that's an important part of being a therapist is being able, first of all, at the beginning to make people feel safe and to have a little bit of that back and forth of human interaction. But also at the end to really honor the fact that these are people who have to go back out into the world.

14:55
And if we've stirred up a lot of stuff, I want to make sure they're feeling safe and their nervous system is at least somewhat regulated as they're leaving the office. If I can, it doesn't always happen. It's hard. so that how much time does that leave in the middle for really deep processing work? mean, sometimes less than half of those 50 minutes is really

15:23
getting back into where you were. And I don't even know, in some cases, maybe it's not even possible with that amount of time to get back to what you could achieve when you have these longer five or six hour sessions. mean, could even be, I would say it doesn't even have to be five or six hours. The more time you can have, the better. I mean, I think once you do more than five or six hours in a day with one couple,

15:51
it might start to feel a little bit exhausting, both for the therapist and for the couple. But I think if you could even do double sessions, that just increases the amount of healing that's going to happen in each of those sessions. Or if you can do like a three hour block or four hour block, to me it doesn't matter exactly what the timeframe is.

16:19
You know, I think about, you know, when I work with couples, when it's the first session, like it's really, really helpful to have a little bit more time to get into things, even if you can make that a double session, you know, that just allows you to really figure out um what's going on more clearly and help them have more of a plan. And to me, you know, if I have a five or six hour intensive in one day,

16:49
I think a lot of times those people are leaving with more benefit than somebody who comes to therapy every week for 50 minutes for 12 weeks. I want to be responsible about the way I say that. mean, it's probably not true in every case. I do think there's something to be said for the space that happens in between therapy sessions.

17:16
A lot of times when we do those five or six hour intensives, you know, we don't schedule something again for two or three weeks because it just takes some time for all of that learning to sort of sink in that emotional learning. And for people to try to see what happens when they go back out into the world and, you know, back into their day-to-day dynamics and their relationship. Building a private practice can be challenging.

17:44
filing all of the right paperwork is time consuming and tedious. And even after you're done, it can take months to get credentialed and start seeing clients. That's why Alma makes it easy and financially rewarding to accept insurance. When you join Alma, you can get credentialed within 45 days and access enhanced reimbursement rates with major payers. They also handle all of the paperwork from eligibility checks to claim submissions and guarantee payment within two weeks of each appointment.

18:13
Plus when you join Alma, you'll get access to time-saving tools for intakes, scheduling, treatment plans, progress notes, and more in their included platform. Alma helps you spend less time on administrative work and more time offering great care to your clients. Visit helloalma.com or click the link in the show notes to learn more. So I want to emphasize that the intensive isn't, it's not like faster therapy. It's not like

18:41
I can accomplish in six hours what most people can accomplish in 12. No, it's a different type of container that allow, maybe I would go back to the surgery example. If someone breaks their leg and they need to have surgery, it's sort of like, what would happen if you in the middle of the surgery, if you said, well, we're going to take a week and then come back to it, right? I mean, maybe that's a bad analogy, but I feel like it's somewhat valid that

19:12
There's something that needs to be completed in that surgery in order for the most optimal amount of healing to happen going forward from there. When we're thinking about, again, I know there are a lot of restrictions out there. mean, doing intensive is going to be more expensive for people, at least upfront. It's going to be hard to get it covered by insurance perhaps. I mean, that's a whole different conversation.

19:41
It may be hard to, you know, for the people to take off time to do it in that way. Although I think it's more helpful for some people because they can just take off one full day instead of a little bit out of their work day every week. Um, but there, there are a lot of limitations and part of it is just the mindset in our society that therapy is something that happens every week for an hour. And so when people approach you and try to schedule

20:10
couples therapy, their expectation might be, oh, we're just going to schedule a 50 minute session. So it requires us as therapists to sort of communicate why it's so beneficial. And I think it's really helpful for people to have some explanation on their website of how helpful this is. Because when couples are coming in, I was kind of saying this before, but they really want to feel the benefit.

20:40
If you tell them that you can do therapy with them for half price, but it's going to take three times as much time and they're only going to get like half as healed as they otherwise would. mean, people would be more than happy to pay the double if they're going to get the results that they're seeking. And if it's going to take less time as far as on the calendar, mean,

21:08
What's happening in therapy isn't less time, if that makes sense, but you don't have those intermittent breaks every week. So when you're in the intensive, you're just getting deeper. Hour one, you're, you know, may look very similar, but hour two, all of a sudden you're getting deeper and deeper. Hour three, then you're getting deeper and deeper. Hour four, you know, and so you're building on the gains in that intensive in a way that I don't think is usually possible when you're doing

21:38
weekly therapy. I know it may not be possible for everybody to do these types of sessions, but if we're purely having a conversation about what is the most helpful way of working with couples, I absolutely believe in my experience that doing these types of intensives is the best way to help people. And again, it does matter what you're doing.

22:08
makes a big difference if you have some sort of approach that you're using, or at least experience with couples that you feel like there's a level of competence that you know how to create safety in the room, that you know how to slow down at the right times and help people. But that being said, I think that having the time that intensives have, to me, that's the best way

22:36
of approaching couples therapy. And the other thing is like every couple's different. mean, different people might need different things and different timeframes, but I usually try to get people to start with a, I call it a six hour intensive, but we usually take a lunch break in the middle. So it usually goes from like, let's say nine in the morning until three in the afternoon. And we take a lunch break in the middle. Any couple who wants to work with me, I try to encourage them to start with that. And then when we have that amount of time,

23:06
It really helps us to make a plan for what's going to happen going forward. mean, sometimes people go through that intensive and they feel so much relief and they feel so much more clarity about what's going on. I might not see him again for two months because they leave there and they feel like we have so much clarity. We have a really good plan in place. We both know what we're working on. That might be right for some people.

23:36
For other people, we kind of start wrapping it up and they're like, it'd be really helpful if we could meet again next week. And maybe that could be a 50 minute session. But then you have like a foundational knowledge at that point of what's going on. And then those 50 minute sessions I think can make a lot more sense. And for a lot of people, I still try to get them to do a double session, which is, I call 100 minutes or almost two hours.

24:04
Then those follow-up sessions, you've already gained so much traction in the intensive and they've sort of like, hopefully have a lot of consciousness around what are the problems, what are the patterns, what are the things we're working on? And then those can just help you move the needle forward like that much more quickly when you have the follow-up sessions at that point. I'm really thinking about the future of clinical work. I'm really thinking about

24:33
the way we're moving. And like I said before, like what's most helpful for people. Let's say you want to work out, start working out and getting good shape and build your muscles and getting good physical shape. You probably want to get as much benefit and as much of the gains as you can. Not with the least amount of effort. That's not how I would say it, but like the most efficiently. Right? Like if you told me, here's a workout plan.

25:03
you're going to accomplish your goals, but it's going to take twice as much time and effort. people are going to choose what is going to do it most efficiently. And maybe it depends what your goals are. uh somebody who plays tennis might have a very different workout plan than somebody who plays football or something like that. But it's really getting clear on what's going to get, what's going to help me achieve the goals that I'm trying to achieve. And so in this case in relationships,

25:33
as quickly as possible or as effectively as possible. So, you know, I'm just a big advocate for this. I'm happy to answer questions anybody have about the specifics of this. I mean, this kind of stuff makes me really excited thinking about the future of our clinical work, thinking about the future of couples therapy. And, you know, I really encourage people to start considering doing intensives or at least doing longer sessions. Maybe I'll do some more

26:02
podcast episodes, talking about that, because I'd really like to help people if they feel like they need assistance or don't know where to start when it comes to offering more intensive sessions. So I hope all of you found this helpful. If you have any questions, always feel free to reach out. The episode this week is brought to you by Alma. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates. Alma handles all of the paperwork and guarantees payment within two weeks. Visit HelloAlma.com

26:32
or click on the link in the show notes to learn more. And thank you again, everybody. This is Shane Birkel, and this is The Couples Therapist Couch podcast. It's all about the practice of couples therapy. I hope you have a great week and we'll see you next time. Bye, everybody!