Can you really help anyone in a single session of therapy?
Whatever your instincts tell you, the jury is out; current research doesn’t allow us to conclusively settle the question just yet. But single session therapy is now the subject of a clinical trial in the NHS via IAPT Hampshire. So don’t bet against it. And there is already clear evidence that clients like it. Our best guess is that in 5-10 years’ time, we’ll all be wondering why it took so long for providers of services and clinicians to embrace this approach.
Perhaps for now it still feels a bit new-fangled? Not so. Freud used one-off consultations, most famously with the composer Mahler. Later, Carl Rogers and others used a single session in the ‘Gloria films’ - which sought to demonstrate different forms of therapy to the public. As well as that long history, it has contemporary support too. Professor Mick Cooper has called it a profoundly client-centred approach. The previous Chair of the British Association for Counselling and Psychotherapy, Professor Andrew Reeves, says single session work is often exactly what clients need.
That support is perhaps not surprising given it’s surely better to see people at the point of need, rather than following an assessment interview, and then allocation to a waiting list. Imagine a situation in which psychological relief was provided in the same way that NHS walk-in centres immediately treat sprains, minor head injuries, burns or issue emergency contraception. Wouldn’t that be something? And yet single session therapy probably makes you nervous. You might even rail against the idea.
The primary objection can usually be summarised like this: what about ‘the alliance’... surely we can’t do anything useful in one session, before the relationship has properly formed? Or perhaps more frankly: have I really done four years of training for something that only takes an hour?”
Let’s look at two real life examples which contradict that assumption and suggest the opposite - valuable, therapeutic work, even life-changing work, is possible from the get-go:
A mother who two years prior had experienced the death of her infant daughter asked a therapist for help. She had one very specific request: she wanted to get rid of the memory of the pain on the face of her daughter as she held her in her arms during the final moments before her death. She was desperate. Here’s roughly what her therapist said: “I would never take that pain away from you. But you are only seeing the scene from your perspective. I want you to try see if from your daughter’s point of view. At the worst moment of your daughter’s life, she looked up and saw you. Do you know how many children die without their parents being present? Without a mum like you. The pain you are feeling is the price of love. No one can change that. No one should try. It has to be accepted".
Of course, that intervention did not take away all of the mother’s pain and grief. But it did begin to transform her experience. The therapist inserted something into the scene which had been missing: the daughter’s experience of her mother’s presence and love in her dying moments. In her grief, the mother had not been able to see this. Instead, she had become fused to a moment defined solely by pain and despair, as she looked down on her child she couldn’t save. New information inserted into the memory began to change that. Of course, it was still a memory of loss, still shot-through with pain, but it was now also reshaped as something profound and beautiful. Something that could now be accepted and, perhaps in time, even treasured.
No talk of attachment patterns, no clever interpretations, no months or years of working it through.
Let’s look at a more prosaic example, of a man who wanted to learn the guitar.
The client presented in a tentative manner and talked about his general malaise. After a time, the therapist asks him what he wants to accomplish in therapy. The client’s answer surprises him. He says that what he would really like to devote a year to studying guitar. He’s good, but hasn’t had any formal training and he’d really like to spend a year studying at a conservatory. He doesn't expect to go on to make a living as a professional musician - that’s not the point. He enjoys his current work, he just wants to take his guitar playing further. It’s his dream. His wife and family are supportive, but his wife’s salary won’t support the family, so he’d have to draw on scarce savings. And he’s worried he may not be able to find another executive position when he eventually returns to work. On the one hand, he doesn’t want to put his wife and children in a risky position; on the other, he remains preoccupied, distracted, and downcast all the while he can’t pursue his dream.
The therapist (in this case, Owen Renik) points out that he’s not really describing a choice he needs to make. Rather, he seems to be describing his reluctance to act on a choice that he’s already made. He can’t be happy without studying the guitar, and he can’t study the guitar without asking his wife and children to endure a degree of sacrifice and risk. The therapist points out that no amount of self-awareness or discussion is going to change the circumstances. Ultimately, he needs to do what he thinks best and live with the consequences, not all of which will be agreeable. The session ends. A month later, he’s in touch again to say he’s decided to take the plunge. A few years later, the therapist hears from him again - he’s back at work but also enjoying regular guitar playing and practice.
Working in this way relies on the therapist being willing and able to challenge. Willing and able to cut to the chase too - to frame choices and encourage decisions. Harder still perhaps, it requires a willingness to put aside our own, legitimate, needs for continued income. And hardest of all, it requires us to set aside our own need to feel needed.
Of course, a version of this kind of brief, solution-focused work has existed for decades. The solution-focused approach suggests that whatever problems you have, something is always working, and it can be built upon. Efficient therapy helps clients do more of what already works. A solution-focused approach asks clients to imagine life without the problem: suppose you achieved your hopes overnight (by miracle), what would you be doing tomorrow? The assumption that change can occur rapidly is supported by research. Solution-focused therapists help clients ‘think small’ - identifying incremental changes towards goals that are ‘good enough’. They are looking to keep therapy brief, aiming for each session to be the last by asking what needs to be done before the problem is solved and therapy can stop.
So, single session therapy appears to work, in certain circumstances at least. But it can only work if clients are ‘ready to take care of business now’, as Dryden, the driving force behind the method in the UK, puts it. That means clients must be realistic about what can be achieved in the session. They must be willing to focus on a particular problem, and only on the factors that are in their control. They need to accept that the solution or ‘bridge’ between their problem and their goal will need to be tested outside the session.
And there lies the rub. Not all clients are able to do that, or want to do that. There will be times they’ve had experiences which are so overwhelming that they can only speak of them with time and patient encouragement. There will also be occasions where they want someone in their corner, helping them manage complex ongoing problems, or working with them as they grapple with persistent, recurrent thoughts and behaviour. So, of course there are times when a single session won’t be the right treatment.
But if clients are ready, let’s not assume a single session is never enough or that useful work cannot be done. Not all clients want or need long-term therapy. Change works in different ways for different people. Clients don’t always need the deep relationship that therapists often seem to long for.
So, single session therapy is not a panacea for all problems. Right now it lacks a sufficiently robust evidence base to allow us to say how effective it is at helping with the kinds of problems seen in community mental health. There is too much variability between different studies, as well as methodological weaknesses within those studies. Nevertheless, in some research, up to 78% of participants reported satisfaction with one session, and 88% reported ‘improvement’ or ‘much improvement’ in their condition. Taken as a whole, the studies provide some support for the effectiveness of single session treatment, with most reviewers sharing the view that many people benefit from single session work, and with an emerging consensus on the high degree of client satisfaction.
For that reason, it is almost certainly part of the future. And be under no illusion, with the number of people seeking treatment for psychological distress on the rise, and mental health services increasingly over-stretched, this is an idea whose time has come. Commissioners will like it. Clients already appear to like it. And on that basis, therapists are probably going to have to learn to like it. Come along to our workshop to find out more.