Myndgard

Blog · · 5 min read

What happens between sessions

Why the days between counselling appointments matter, what research on between-session tasks and self-monitoring shows, and how to keep it light.

By Myndgard Limited

Banner reading: What happens between sessions

A student who sees a counsellor once a week spends roughly one hour in the room and well over a hundred outside it. Most of what changes, or doesn't, happens in that second stretch of time: in lectures, late nights, conversations with flatmates, the run-up to a deadline.

Counsellors know this. The question is how much to ask of a student between sessions, and in what form, without turning support into another list of things to do.

What the research on between-session tasks shows

The most studied form of between-session work is "homework" in cognitive and behavioural therapies: practising a skill, trying something new, or keeping a simple record.

A 2010 meta-analysis by Kazantzis, Whittington and Dattilio in Clinical Psychology: Science and Practice pooled 46 studies (1,072 participants). Where studies compared the same therapy with and without homework, the pooled effect favoured homework (d = 0.48). The authors found no evidence of publication bias and concluded that homework assignments enhance therapy outcomes.

A later 2016 meta-analysis led by Kazantzis in Behavior Therapy looked at 17 studies (2,312 clients) and asked a more useful question: does it matter how much someone does, or how well? Both the amount of between-session work completed and its quality were linked with better outcomes. Only three studies measured quality, so that finding is tentative, but it points in a sensible direction. A small task done with some thought may matter as much as a long one done to tick a box.

These studies are mostly in cognitive behavioural therapy, so they do not settle what works across every counselling approach. They do show that what happens between sessions is part of therapy, not separate from it.

Why short, in-the-moment check-ins help

A second strand of research is about memory. Asking someone in a session "how has your week been?" relies on recall, and recall is coloured by how they feel right now.

Ecological momentary assessment, described in a 2008 review by Shiffman, Stone and Hufford, means "repeated sampling of subjects' current behaviors and experiences in real time, in subjects' natural environments". Its aim is to "minimize recall bias" and show how mood and behaviour shift across days and situations. Brief, regular check-ins borrow that idea: a few seconds recorded on Tuesday evening can be more accurate than a reconstruction of Tuesday made the following Monday.

There is also some evidence that noticing itself can help. In a 2012 randomised trial by Kauer and colleagues with 14 to 24 year olds attending GPs in Australia, young people who monitored their mood, stress and coping on their phones showed increased emotional self-awareness, which in turn was associated with fewer depressive symptoms. It was a modest trial (114 participants analysed), but the mechanism is plausible: putting a name to a feeling is a first step in doing something about it.

The risk of making it a burden

None of this works if people stop doing it. A 2018 systematic review by Dubad and colleagues of mood-monitoring apps for young people found that participation ranged from 30% to 99% across 25 studies. Young people generally viewed the apps positively, but the evidence base was thin, and the authors noted that adult studies suggest app use could, for some people, increase negativity and depressive symptoms. Self-monitoring is not automatically benign.

What predicts whether people keep going? A meta-analysis of 477 ecological momentary assessment studies by Wrzus and Neubauer, published in 2023, found average compliance of 79%. On average, studies prompted people six times a day for seven days. Interestingly, the number of prompts per day did not predict compliance or dropout. Financial incentives did, which is not an option for counselling services, and is a reminder that research compliance rates may flatter what happens in everyday use.

How to keep it light

The research above suggests a few working principles:

  • Ask for little, and make it quick. A daily mood rating or a short weekly questionnaire can be enough to show a trend.
  • Make the task meaningful. The Kazantzis findings suggest quality matters. One relevant task the student understands is better than several generic ones.
  • Agree it together. Between-session work that comes out of the session, in the student's own words, belongs to them rather than to the service.
  • Make it optional and forgiving. Missing a day should not feel like failing. Gaps are information too.
  • Watch for harm. If tracking makes someone ruminate or feel worse, stop or change it.
  • Close the loop. If a student records something, it should come up in the next session. Data that disappears into a void teaches people not to bother.

In practice

For counselling services, the question is less whether to involve the time between sessions, and more how to do it without adding weight.

Tools like Myndgard Share are designed around that idea: students already in counselling complete short check-ins and validated questionnaires in the app, and, with their consent, their counsellor sees the trends in a web portal before the next session. The aim is a clearer picture for the counsellor and a lighter load for the student, while the conversation, and the clinical judgement, stay in the room.

Whatever the tool, the principle is the same. Keep it small, make it relevant, and make sure someone is listening.

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