Before she was swinging a mallet and causing mayhem as Harley Quinn, Dr. Harleen Quinzel was a sharp, promising psychiatrist at Arkham Asylum. She wore her crisp white coat like armor, ready to protect herself from the emotional chaos of Gotham’s most dangerous criminals. But the real danger wasn’t the asylum’s bars or the Joker’s manipulations—it was her gradual loss of boundaries.

It started innocently enough, as it often does. A little extra time here, a blurred line there. Slowly, the boundary between therapist and patient dissolved, and Dr. Quinzel became Harley Quinn, plunging headfirst into the abyss of obsession and chaos. This is a cautionary tale for therapists everywhere: a story of how boundaries, particularly time boundaries, can be our greatest safeguard—if we hold them firm.

Time Boundaries: Your First Line of Defense

Imagine the scene: Dr. Quinzel, young and eager, sitting in a cold metal chair, her notebook resting on her lap as she listens to the Joker weave his twisted tales. Her watch ticks away, marking the steady passing of time. But she barely notices. She’s lost in the session, the intensity of the Joker’s words pulling her deeper. And then, without realizing it, she’s let the hour slip away, the floodgates of emotion wide open.

With each extra minute, Dr. Quinzel lost a piece of herself. What started as small concessions—just a few more minutes—quickly turned into full-blown emotional enmeshment. And this is where her armor cracked. The loss of boundaries led to the collapse of the very structure she needed to stay grounded, to stay Dr. Quinzel.

But she told herself it was for a good cause. After all, wasn’t she making progress with him? She convinced herself that these blurred boundaries were necessary to break through the Joker’s walls. Maybe, if she gave him more of herself—more time, more empathy—she could fix him.

Respecting the Therapeutic Container

In therapy, time boundaries are like the steel walls of Arkham Asylum—they keep the chaos in check. When we let sessions run over, even by just a few minutes, we risk letting the structure collapse. Emotions, thoughts, and everything that’s carefully held within the session can start to spill over. Those extra five minutes can turn into ten, and soon, you’ve crossed into dangerous territory—just as Harleen did.

Harleen’s first mistake? Letting those boundaries slip. The clock stopped being her ally, and she let the therapeutic container dissolve. What started as a professional relationship turned into something darker, blurring the lines between therapist and client. But in her mind, she justified it. I’m getting through to him, she thought. It’s worth it.

This is where many therapists can empathize. How often do we think, just five more minutes, I’m almost there, believing that a little extra time will push the session into breakthrough territory? But like Dr. Quinzel, we need to recognize that boundaries exist for a reason—to protect both the therapist and the client from losing themselves in the work.

Helpful Script for Ending on Time:  

“I know we’re getting into something deep here, but we’ll pick it back up next session. This gives you some time to process, and we can dive back in with fresh energy.”

Pacing: Slow and Steady Wins the Battle

As Dr. Quinzel fell deeper into the Joker’s web, she began rushing into emotional entanglements far too quickly. One moment she was observing from a safe distance, and the next, she was emotionally involved. Like sprinting into a battlefield without armor, she didn’t pace herself. And with each blurred boundary, she convinced herself it was worth it, that progress was just around the corner. But the deeper she got, the more she began losing her own sense of identity, swallowed by the chaotic emotions she was supposed to help contain.

This is where many therapists falter—when the lines between empathy and overextension blur. It feels good to help, to give more, but it also risks leading therapists into emotional burnout or unhealthy dynamics.

The Importance of Pacing Therapy Work

Think of therapy like exploring the dark hallways of Arkham Asylum. It’s a place full of hidden traumas and shadows. Rushing through can lead to getting lost, overwhelmed, or—like poor Harleen—captured by forces beyond your control. The Joker didn’t just happen overnight; he crept in, slowly unraveling the good doctor’s sense of self.

Therapy requires pacing—a deliberate, mindful journey through a client’s inner world. Rushing through difficult emotions or letting a session extend without boundaries can overwhelm both therapist and client. By resisting the urge to extend sessions or schedule too many in a week, you’re giving clients the space to sit with their emotions, to reflect on what’s been unearthed, and to gain strength for the next step.

Just as Harleen should have slowed down and protected herself from getting emotionally entangled, therapists must pace the work carefully to avoid boundary blurring. She thought she was helping by pushing harder, but instead, she was unraveling her own stability.

Helpful Script for Pacing Work:  

“I know you’re eager to keep going, and I love your enthusiasm for the work. But therapy is like planting seeds—we need to give them time to take root between sessions for them to grow properly.”

Reflection Question:  

How do I currently pace my therapy sessions? Are there moments where I could slow down or provide more space for processing between sessions?

The Temptation of the Session Extension

In that dimly lit room at Arkham, Dr. Quinzel sat across from the Joker, her pen tapping against her notebook, her heart beating faster. The Joker smiled, his gaze piercing through her, and for a moment, she considered staying longer—just a few more minutes, just to get to the heart of things. She had been telling herself, he’s finally opening up, I can’t stop now. 

And therein lies the temptation.

“Can We Extend to 120 Minutes?”

We all know that look—the client who’s about to have a breakthrough, eyes wide with realization, just as the clock ticks down to the end of the session. They ask, “Can we go a little longer?” And there it is, the temptation. The same temptation Harleen felt when she let the Joker pull her in deeper.

Extending a session can seem harmless in the moment, but it opens the door to more blurred boundaries, like Harleen crossing the threshold from doctor to victim. Therapy is a process—one that needs to unfold over time. By giving clients the space between sessions, you’re allowing them to reflect, process, and come back stronger.

In Harleen’s case, those extra moments weren’t about helping the Joker anymore. It became about her desire to prove something, to herself and to him—that she could be the one to save him. Many therapists might feel similarly, caught in the trap of wanting to fix everything in one go.

Helpful Script for Declining an Extension:  

“I hear you, and I understand this feels important, but let’s pause here and continue next time. Holding that space until next session will give you time to reflect and allow us to dive back in when we’re both fresh.”

Reflection Question:  

When was the last time I found myself extending a session? What were the factors at play, and how did it impact my energy and the therapeutic process?

Clinical Decision-Making: Scheduling an Additional Session

There are moments in therapy when scheduling an additional session in the week becomes essential to support a client through significant distress, a crisis, or a major life event. Unlike Dr. Quinzel’s hasty decisions based on emotional over-involvement, clinical decision-making should be thoughtful and strategic.

When to Schedule an Additional Session

An extra session may be appropriate when:

– The client is in crisis or experiencing intense emotional distress that requires immediate attention.

– A significant event—such as the death of a loved one, a trauma trigger, or a drastic life change—prompts the need for additional support.

– The client’s mental health symptoms have escalated, requiring more frequent check-ins to stabilize.

When making this decision, it’s crucial to ask: Is the client in a situation where they need urgent, short-term intervention to maintain their safety or well-being? The extra session should not create dependency but provide support to help the client navigate an acute phase.

Documenting the Extra Session

To align with clinical best practices, documentation is key. When scheduling an additional session, ensure you:

– Note the client’s distress or crisis in their file, describing why the extra session is necessary. This includes explaining the immediate need and how it connects to the client’s current treatment goals.

– Specify how the extra session fits into the treatment plan—for example, does it address an ongoing theme like trauma work or managing a mental health condition like anxiety?

– Ensure medical necessity by demonstrating in your notes that the additional session is part of the therapeutic intervention to address escalated symptoms or significant events.

Helpful Script for Scheduling an Extra Session:  

“I understand this week has been overwhelming, and we may need an extra session to address the heightened distress you’re feeling. Let’s focus on how this fits within your treatment goals to support you in getting through this period.”

Reflection Question:  

How do I make decisions about when to schedule extra sessions? Are these decisions clearly documented and tied to my client’s treatment plan and medical necessity?

The Costs and Benefits of Extending a Session or Allowing Two Sessions in One Week

While extending a session or allowing for two sessions in the same week can sometimes feel necessary, especially in moments of client distress or breakthrough, it’s important to weigh the costs and benefits carefully.

Benefits of Extending or Adding Sessions

– Increased Support During Crisis: During moments of heightened distress, crises, or significant life changes, offering additional time or another session in the same week can provide the client with much-needed support. It can prevent escalation and help stabilize emotions more quickly.

– Deeper Processing: Sometimes, a longer or additional session allows the client to dig deeper into their emotional landscape without feeling rushed. This can lead to important insights and breakthroughs that may not occur in shorter, more time-pressured sessions.

– Reinforcing Therapeutic Progress: When a client is making significant progress, an extra session may help sustain momentum, particularly when managing acute symptoms of anxiety, trauma, or other intense conditions.

Costs of Extending or Adding Sessions

– Therapist Burnout: The therapist’s energy and emotional well-being are finite. Extending a session or doubling up in a week can drain the therapist’s resources, especially if done frequently. This could lead to emotional fatigue, reduced effectiveness, and potentially even burnout.

– Client Dependency: While providing extra support can be beneficial in moments of crisis, repeated extensions or frequent double sessions may foster dependency. The client could come to rely on having extra time or multiple sessions as a coping mechanism rather than learning to manage distress between sessions.

– Blurring Boundaries: Regularly allowing extended or extra sessions may blur the professional boundaries between therapist and client. This can lead to feelings of resentment or over-investment from the therapist and may interfere with the client’s understanding of the therapeutic relationship’s structure.

– Financial and Insurance Complications: From a logistical standpoint, extending sessions may cause issues with insurance billing, especially if the extra time is not documented properly or justified within the treatment plan. Furthermore, multiple sessions in one week may not be covered by insurance policies, creating potential financial stress for the client or the practice.

Finding the Balance

Ultimately, the decision to extend a session or add an extra one in the same week should be made thoughtfully, ensuring that it is driven by the client’s clinical needs and that it aligns with the overall treatment plan. Balancing the short-term benefits with long-term sustainability for both the client and therapist is key.

Helpful Script for Addressing Client Requests:  

“I understand things feel intense right now, and I want to support you through this. Let’s discuss whether extending the session or scheduling an extra one aligns with your goals and overall progress, and how we can best navigate this period within the structure we’ve set.”

Documenting Clinical Justification for 90837 Sessions

When billing for extended therapy sessions (90837 or 53+ minutes), it’s essential to provide clear clinical justification to support the additional time spent with the client. The justification should not only reflect the need for the extended session but also connect to the client’s presenting issues, treatment goals, and clinical outcomes. Here are some key factors to document to ensure medical necessity:

Common Reasons to Justify 90837 Sessions

When documenting the use of 90837, consider these clinically relevant reasons, ensuring that the rationale is tied to the client’s current situation:

– Client is unable to share with others due to the nature of the problem: The client’s issues may require more time because they are unable to address these problems with anyone else, making therapy their primary outlet.

– Life stressors impacting multiple domains of life: Clients experiencing stressors across various areas such as work, home, and relationships may require additional time to process the complexity of their issues.

– Client presenting with acute issues or in crisis: When a client is facing a crisis or acute emotional distress, additional time may be needed to help de-escalate and stabilize symptoms.

– Multiple life stressors: The presence of several stressors at once may necessitate extended sessions to ensure that each issue is adequately addressed within the therapeutic container.

– Limited healthy support network: If the client lacks a support system outside of therapy, additional time may be required to provide the emotional containment that is otherwise unavailable to them.

– Time needed to address and contain intense emotions: When the session involves processing severe emotional content, extra time is needed to safely explore these emotions and return to a more balanced state before concluding.

– Severity of diagnosis and intensity of clinical presentation: Clients with severe or complex mental health conditions often require longer sessions to manage their symptoms and ensure a comprehensive therapeutic response.

– Monthly sessions to maintain acquired skills: If the client attends monthly maintenance sessions to retain progress, an extended session may be warranted to review and reinforce coping mechanisms.

– Prevent escalation to a higher level of care: When therapy acts as a preventative measure to avoid hospitalization or intensive treatment, documenting the need for additional time is essential to show the importance of longer sessions.

How to Include Justification in Your Notes

In your clinical notes, clearly outline why the extended session was necessary. Here’s a checklist of elements you may include to provide justification for using 90837:

– Client’s presenting issues: Highlight acute symptoms, crisis situations, or the complexity of multiple stressors.

– Clinical goals: Connect the extended time to specific therapeutic goals or interventions being utilized, such as trauma processing or symptom stabilization.

– Functional impairment: Document how the client’s symptoms are affecting their daily functioning in areas such as work, social life, or self-care, and how the extended time helped address this.

– Treatment modality used: If the session required additional time due to a specific intervention like EMDR or processing trauma, note the modality and its necessity.

– Preventative measures: Mention if the extended session was aimed at preventing further deterioration or escalation of the client’s condition (e.g., preventing hospitalization or intensive care).

Example Documentation:  

“The client is currently experiencing multiple life stressors and presented with intense emotional content related to a significant trauma trigger. Due to the severity of symptoms and limited external support, an extended session was needed to fully process the emotions and prevent further escalation. The additional time allowed for grounding techniques and containment to stabilize the client.”  

Focus on Medical Necessity

When using 90837, the key is to always link the extended time to medical necessity. This means demonstrating that without the extra time, the client’s therapeutic goals would be compromised or their safety may be at risk. Always ensure your documentation clearly shows how the extra session time aligns with the client’s treatment plan and current clinical needs.

When a Client Requests a Second Session in the Same Week

As the Joker tightened his grip on Dr. Quinzel’s mind, she began to lose herself in him. It started with little things—extra sessions, longer hours, blurring the line between therapist and…something else. But what Harleen didn’t realize was that the more she gave, the less of herself remained.

Flexibility vs. Boundaries: Don’t Lose Yourself Like Harley Did

Therapists often face this dilemma: a client requests a second session in the same week, and it feels like an emergency. You want to help, to be flexible, to offer support. But like Harley, if you give too much, you can lose yourself in the process.

Is the Client in Crisis?

Sometimes clients genuinely need extra support, but not always. Like Harleen, who let the Joker twist her mind by giving too much too soon, therapists need to ask themselves: Is this an actual crisis, or is this part of a pattern? Doubling up on sessions too often can foster dependence, just as Harleen became emotionally dependent on the Joker.

Helpful Script for Managing Requests for Extra Sessions:  

“I understand things feel intense right now, and I want to support you through this. Let’s talk about some strategies you can use between sessions to help manage this. If we need to schedule an extra session in the future, we can explore that based on your treatment plan.”

Example Documentation for an Additional Session (Two in One Week)

“Client is experiencing heightened distress related to a recent significant life event (e.g., the loss of a family member), which has triggered intense emotional reactions and a relapse in anxiety symptoms. Due to the severity of the client’s current mental health symptoms and their expressed need for immediate support, an additional session was scheduled within the same week to provide crisis intervention and emotional stabilization. The extra session aligns with the treatment goals of managing acute distress, preventing further deterioration, and avoiding escalation to a higher level of care. The need for this additional session was discussed and agreed upon with the client to ensure continuity of care.”

Important Considerations for Insurance-Based Clients

Imagine Harley trying to navigate the Joker’s manipulation while also dealing with the tedious paperwork of insurance claims. Luckily for her, she didn’t have to—but we do.

Time is Money (And So Are Boundaries)

Holding time boundaries with insurance-based clients isn’t just about maintaining emotional well-being—it’s about compliance and protecting your practice from financial headaches. 

Billing for the Correct Time

Insurance companies demand strict adherence to time. If a session runs over without proper documentation, it’s not just a breach of boundaries—it’s a billing nightmare. Harleen let her boundaries slip without consequence, but we can’t afford to do that. Hold the line on time, and ensure both you and your clients know the limits.

Helpful Script for Insurance-Based Boundaries:  

“I’d love to be able to offer more time, but unfortunately, your insurance limits us to a certain amount per session. Let’s make the most of the time we have, and if we need more frequent sessions in the future, we can explore how that fits with your coverage.”

Handling Therapist Guilt (Harley Should Have Listened to Herself)

Therapist guilt is a powerful thing, and it’s what ultimately led to Dr. Quinzel’s undoing. She felt guilty for keeping her emotional distance, for holding firm. In trying to help, she lost herself. As therapists, we often feel the pull to go above and beyond, especially when a client is in distress, but the truth is, boundaries are part of the therapy.

Helpful Script for Easing Guilt:  

“I can see you’re feeling a lot right now, and that’s important. Let’s end here today, so you have some time to sit with these feelings, and we’ll work through them together next session.”

Reflection Question:  

How does holding time boundaries affect my own emotional well-being as a therapist?

Therapist Tools for Holding Boundaries

While Dr. Quinzel didn’t have the right tools to hold her boundaries, you do. Here’s a quick list to keep yourself grounded and maintain healthy boundaries with clients:

– Time Tracker: Use a clock or timer to help you stay aware of when to end the session.

– Pacing Prompts: Ask reflective questions throughout the session to slow things down and avoid rushing.

– Boundaries Reminders: Keep a personal mantra or affirmation about boundaries at your desk (e.g., “Boundaries are kindness”).

– Energy Check-In: Before each session, take a moment to check in with your emotional state—this helps prevent giving too much when you’re already feeling drained.

Boundaries Are Your Armor

At the end of the day, Dr. Harleen Quinzel became Harley Quinn because she didn’t hold her boundaries. She let the Joker in—little by little—until he took over completely. As therapists, we don’t need to swing a mallet or fight off supervillains, but we do need to guard our emotional and professional boundaries just as fiercely.

Boundaries aren’t just about saying no—they’re about protecting both therapist and client. Time boundaries, in particular, are your first line of defense. So next time a client asks for an extension or an extra session, take a breath, hold the line, and remember—you’re not just holding boundaries, you’re safeguarding the entire therapeutic process.

Key Takeaways:

– Time boundaries create safety and structure in therapy, much like the walls of Arkham Asylum.

– Pacing therapy allows for deeper processing between sessions, protecting both client and therapist.

– Responding to client requests for extended or additional sessions with care and boundaries models healthy emotional management.

– Compliance with session lengths and insurance requirements is crucial to avoid financial and emotional pitfalls.

– When scheduling an additional session, ensure it is clinically justified and fits within the treatment plan to align with medical necessity.

Call to Action:

Boundaries are your armor—so, how are you protecting yourself? Take a moment after reading this post to review your own boundaries with clients. Are there any areas where you’re giving too much? How can you start reinforcing your own version of Arkham’s walls to keep your practice—and yourself—safe?

Written by Jen Hyatt, a licensed psychotherapist at Storm Haven, Counseling & Wellness in Temecula, California. 

Disclaimer: This blog post references fictional characters and stories to illustrate professional points. Dr. Harleen Quinzel, Harley Quinn, and the Joker are intellectual properties of DC Comics. The examples in this post are for educational purposes and are not intended to diagnose, treat, or replace therapeutic relationships.

Additionally, this post includes an affiliate link for the TimeQube time tracker, a tool recommended for tracking time during therapy sessions. If you choose to make a purchase through this link, I may earn a small commission at no extra cost to you.