Single Session Therapy(SST)

 

Single Session Therapy

 

Single session therapy (SST) dates as far back to Freud along with many other well-known therapists such as Donald Winnicott and Milton Erikson have all reported on single session work. However it was not until Moshe Talmon, clinical psychologist, reviewed the records of and followed up those clients who ceased treatment after one session, that single session therapy was noticed by therapeutic world (Young & Roycroft, 1997).

 

SST is essentially a form of open-ended therapy whereby the therapist and client treat each session as though it may be the last. It is based on the assumption that in many cases a single session of therapy will result in significant improvements in the clients (Cox & Campbell, 2003). Further clinical assistance is provided should the client and clinician agree on the need for more and so treatment is not restricted to just that initial session (Perkins, 2006). 

 

Through the analysis of his research, Talmon (1990) discovered that one is the most common number of sessions attended by clients with an average number of sessions being three. It was also revealed that a large percentage of subjects were satisfied with the outcome of their single session, therefore concluding that treatment in a single session is effective (Boyhan, 1996).

 

Since then, results form recent studies on the effectiveness and client satisfaction of single session therapy are congruent with that of Talmon’s analysis in that clients show clinically significant improvements following SST. Improvements are seen in studies such as those involving a two-hour session of solution- focused therapy with an SST approach on children and adolescents of a broad range of metal health problems. SST was successful based on parent and clinician measures showed that it was due to the fact that treatment was promptly delivered with minimal intrusiveness and its ability to empower the clients (Perkins, 2006).

 

Another study that also supports Talmon’s (1990) findings was at two Australian agencies with client stating satisfaction upon receiving a single session with the option of the open door policy (Boyhan, 1996). Interestingly clients who receive a single session do not rate therapy services differently from those who complete an entire course of treatment and a large proportion of these clients go on to report that presenting issues have since been resolved as research has indicated (Rosenbaum, 1994).

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More traditional forms of therapy have a tendency of focusing on assessment in early session with treatment and resolution of issues dealt with in later stages of therapy. SST differs in that from the beginning focus is on the key presenting issues and the strategies that can be taken to overcome or manage these (Perkins, 2006). It is an approach that enables clients to utilise their own resources to solve problems and requires them to be actively involved throughout the session (Campbell, 1999).

 

            The SST process has three major components; Intake, The Session and the Follow up, each involving several tasks and specific paperwork to be completed. Intake plays an important role as the first point of contact with clients having made the step in seeking help (Young & Roycroft, 1997). It is here that the process of SST is explained to the clients of aiming to gain the most out of the first session, whilst trying to obtain the needs of the client and explaining that decisions about what is needed will be determined by both the clinician and the client at the follow up call (Young & Roycroft, 1997). It is also at this stage that the clients are also notified about the ‘open door’ policy, which allows for and encourages clients to re-contact. At this point an appointment is made and a letter confirm is sent out, along with a questionnaire. This questionnaire, Pre-SSW Client Questionnaire, asks clients to record their main concerns, hopes for the therapy and questions they would like to address (Young & Roycroft, 1997).

 

The Session, involves being guided by the client while making the most of the time that is available. By reading the questionnaire completed by the clients, allows for finding a focus for the session, and to determine what the client have been able to achieve on their own. Seeing as it is a single session according to Talmon’s (1990) model, the clinician is to operate with partial knowledge of the client and avoiding therapeutic drift by checking in with the client whether appropriate territory is being covered (Boyhan, 1996).  In the later stages of the session involves reframing the problem, suggesting solutions and exploring last minute issues, allowing for enough time to address them. The use of time outs, sharing thoughts and feedbacks is also achieved here (Talmon, 1990).  The final stage of the session is where clarification of what the next and appropriate step is made, along with being open to the possibility of further work and scheduling of the follow up call is organised (Talmon, 1990).

 

            At Follow up call, made 1-3 weeks later, emphasis is on discovering the clients’ progress since the session and feedback about their experience, providing further assistance if appropriate. Also, a collaborative decision with the client about what further action is to be taken is made (Young & Roycroft, 1997). The worker completes the Post-SSW Client Questionnaire, during the phone call, which compares the scores from the pre-session questionnaire and the option of completing the Client Satisfaction Questionnaire, to be mailed to the client (Young & Roycroft, 1997).

 

            The therapeutic role and effect of the questionnaire in acknowledging the change that has often already begun when a client seeks professional help, and the effect of articulating difficulties, prioritising their problem and clarifying goals contribute to the positive outcomes of single session work (Bloom, 1992).  As mentioned at the intake phase of the therapy clients receive a questionnaire, Pre-SSW Client Questionnaire, encourages clients to focus on goals for the session and questions wanting to be addressed, whilst informing the clinician what the client requires and wants from the therapy (Price, 1994).

Questionnaires and scales used in SST vary according to context and organisation. In the present study, pre and post session questionnaires used for evaluation are based on those developed by SST members at Bouverie Family Therapy Centre (BFTC), Melbourne, modified to suit.                     

 

The two page Pre-SSW Client Questionnaire consists of two initial questions requiring the client to list their two greatest problems. Following this is a series of four sub questions pertaining to the presenting issues, which are rated by the client for the amount of worry, life interference and frequency of occurrence of the issues and the client’s perceived confidence in dealing with them (see Appendix 1).  Clients are asked to rate these questions using the 10 point Likert Scale found below each question, with 1=not at all and 10=as worried as I could possibly be, for question one and 1= not at all and 10=extremely, for questions two to four. Page two of the questionnaire consists of three additional questions in relation to clients’ motivation, positive factors and their available resources. It is from this questionnaire that the impact of the presenting issues on the client is revealed and clinician are able to make formulations and treatment plans as to which areas are of most importance to the client and require attention (Young & Roycroft, 1997; Price, 1994).

 

Just like the pre questionnaire, the Post-SSW Client Questionnaire includes both the initial presenting issue questions and the four Likert scale rated questions (See Appendix 2). Located on the bottom of the page is a comparison scale, which includes the four items, how upset, problem frequency, life interference and confidence. Beside each item is where scores pre and post session are recorded with a difference of the two scores also to be reported. It is from this comparison scale that the clinician can evaluate if the single session was effective and both client and clinician coming to an agreement as to where from this point. It is at this stage that consent is given by the client to receive the Client Satisfaction Questionnaire.

 

For the current study access to the satisfaction questionnaire was not possible as all evaluations were sent directly to the clinical coordinator anonymously and so evaluations of client used in current study could not be identified and not known if completed and so for this reason this questionnaire will be omitted from the evaluation.

The aim of the current study is to assess client progress and indication of change through the evaluation of the pre and post session questionnaires. Comparison of the two forms will be made in order to determine the effectiveness of SST and reliability of measures.

 

                                                        Method

                                        Participants

The participants in this study were clients that attended counselling at Plenty Valley Community Health. Clients were either self referred or directly referred via the police to NARRT. NARRT-Northern Assessment Referral and Treatment Team clients are those who require early intervention and is a crisis service targeting persons who have or have been offended and/or come to the attention of police. The current sample of ten subjects, consisted of four self referred generalist-counselling clients; five were NARTT referrals and one drug and alcohol client-self referred. Subjects were adults aged between 28 and 65. Of the ten participants five were male and five female with half attending just one session with a follow up call and three clients attending for a further three sessions. One client returned for four sessions whilst another attended a total of two (see Table 1 below).

Table 1: Presenting Issues, referral type and number of sessions attended by participants.

Client	Gender	Age	Referral Type	Presenting Issue	Number of Session Attended
1	Male	28	Counselling	Anger, relationship difficulties	3
2	Male	45	Drug & Alcohol	Drink driving offenses, depression	4
3	Male	30	NARTT	Anger, court cases	1
4	Male	37	Counselling	Domestic issues, intervention orders	1
5	Male	65	Counselling	Domestic issues-son	1
6	Female	32	NARTT	Domestic violence-assaulted	1
7	Female	35	NARTT	Behavioural issues-son	3
8	Female	44	NARTT	Intervention order-issues with sons	3
9	Female	42	NARTT	Relationship issues-husbands excessive drinking	2
10	Female	29	Counselling	Victim of home invasion	1

 

Materials

            The measures used in the present study to measure change in client psychopathology, clients’ were administered the Pre-SSW Client Questionnaire and the Post-SSW Client Questionnaire (Bouverie Centre, 2004). The Pre-SSW Client Questionnaire is completed at intake and brought into the initial session. It encourages clients to articulate goals for the session whilst informing the clinician what is hoped to be achieved from the session and specific questions to be addressed. The Pre-SSW Client Questionnaire uses written questions in identifying the two greatest problems the client is facing. This followed by a 10-point Likert Scale to determine the frequency and coping of the major presenting issues and its impact on daily life.  Problem frequency, interference and confidence with coping were measured with the scale (from 1 being ‘not at all’ to 10 being ‘extremely’) for responses to the items: ‘How often do these problems happen?’ ‘How much is it interfering with your life?’ and ‘How confident are you dealing with the problem(s)?’. A further three questions are used to identify positive and protective factors the client has access to with questions as: ‘What made you seek counselling at this time’, ‘Should counselling be successful, what would you be doing differently?’ and ‘What are the positives in our life you want to keep?’

            The Post-SSW Client Questionnaire, which is completed by the clinician during the follow up call, consists of the same four questions; (‘How worried are you about these questions?’, ‘How often doe they occur?’ ‘How much is it interfering with your life?’ and ‘How confident are you dealing with the problem?’) measured using the 10-point Likert Scale as the pre session questionnaire. Change in client psychopathology is measured here using the comparison scale by comparing pre and post session scores and noting the differences between the two.

                                                            Procedure

            At intake clients were sent the Pre-SSW Client Questionnaire, which was to be completed and brought to the session. This questionnaire encouraged clients to focus on what they wished to change as well as what they would like to maintain. At an interval of two weeks after the initial session, clients were contacted by the clinician, for a follow up, where the Post-SSW Client Questionnaire was completed. Upon completion of the questionnaires at follow up, the clinician addressed any issues raised by the client and the questionnaire and a decision made as to whether therapy would continue. If a single session was found to be sufficient by both parties, the clinician ensures that there is an understanding of the options available for future management, the ‘open door’ policy of returning for a further session, or ongoing therapy.   

            It is also important to note that all subjects were informed of the data collected from the questionnaires were to be used in this study for evaluation. Verbal consent was obtained from all clients and was notified that all identifying information would be omitted from the study.

 

 

 

 

 

 

Results

Scores from both the pre and post session questionnaires were gathered for comparison and evaluation of single session effectiveness and changes in client psychopathology. Comparisons of the 10-point Likert scale scores, from both pre and post session questionnaires are listed in Table 2 below.

Table 2. Comparison of scores pre and post session

Questions	Client         1			2		3		4		5
1 How upset  2ProblemFrequency 3 Life Interference 4 Confidence	Pre 10 8 10 10	Post 8 8 7 10		Pre 8.5 7 7 3	Post 7 5 6 6	Pre 9 5 9 10	Post 6 5 6 10	Pre 10 2 10 5	Post 7 2 7 8	Pre 10 5 10 5	Post 7 5 8 8
	6			7		8		9		10
	Pre 10 8 8 4		Post 8 6 6 7	Pre 6 6 6 7	Post 5 6 6 8	Pre 9 9 9.5 4.5	Post 8 6 8 7	Pre 10 9 9 8	Post 8 9 9 10	Pre 10 1 10 5	Post 8 1 8 8

 

Changes in emotional impact of the major presenting issues following SST

The comparison table showed positive changes in the amount of worry that the presenting problems were having on the client. The amount of worry decreased by two points for four out of the ten clients and three points lower for three of the ten clients. The remaining subjects’ worry had decreased by one point and so therefore indicating that SST was helpful in reducing client’s emotional reaction to presenting issues.

 

Changes in the frequency of the major presenting issues following SST

            Comparisons of pre and post questionnaires indicate that the frequency of the presenting issues occurring did not differ significantly from intake to follow up as many of the scores obtain in the pre session remained the same as seen with seven out of the ten clients. This lack of change occurred regardless of referral type and gender. Any changes in scores were reduced by two points, seen in clients two and six, with client eight lowering frequency by a total of three points. It should be noted that for those clients who exhibited no change explained that the issues that initially brought them to counselling had never occurred previously (for example like client 10) whereas clients two, six and eight who had reduced frequency stated that such issues had occurred in the past or have been experiencing such issues for some time.

 

Changes in amount of interference of major presenting issues following SST

            The results for the changes in scores of the amount of interference of presenting issues on life, between the first and second administration of questionnaires indicate improvement. All but two clients indicated a decrease of interference of between one to three points. So therefore results for this item suggesting that a single session was helpful to clients regardless of issue.

 

Changes in the amount of client confidence in dealing with presenting issues

            Following the initial session, there were significant increases in client confidence, with scores increases by two and three points. There were two clients whose score signified no change with ratings remaining constant from intake through to follow up. However, during the follow up call it was noted that both clients stated confusion with the scale. As for the previous three questions, a rating of ten was an indication of worry and difficulty whilst for the amount of confidence ten was defined as having ‘extreme’ confidence and so resulting in both clients scoring ten on both questionnaires indicating lack of confidence.

 

 

 

 

 

 

 

 

 

 

 

 

        Discussion

            The aim of the current study was to investigate the therapeutic impact of single session therapy on client progress. An indication of change was assessed through the evaluation of the questionnaires used and the reliability of these measures in developing treatment plans. Clients presented to the centre with a standard range of problems for the services provided. Two questionnaires were used to evaluate the effectiveness of SST, from intake through to follow up. The data revealed important positive changes surrounding the clients’ experience of the single session model. Also, the usefulness of the measures, in assisting in the formulation of treatment plans was verified.

 

            Firstly, all ten participants showed clinically significant improvements, relative to their initial responses to the Pre-SSW Client Questionnaire on all items of the questionnaire regardless of presenting issues, attendance total, gender and referral type. Also, no differences were found between scores of clients who had received treatment in the past and first timers. Secondly, improvements of clients from pre to post treatment were similar to changes in previous SST studies (e.g Perkins, 2006; Boyan, 1996). Clients from such studies showed improvement from initial sessions through to follow up’s with many clients satisfied with just a single session, as evidenced in this current study with half of the participants not requiring further sessions.

 

However, it is important to note that comparisons to other studies needs to be mindful of the use of different measures and larger sample sizes consisting of experimental and control groups. Also, most other research focused on results form evaluation questionnaires, which was not possible with the current study and so reliant on pre and post session questionnaires only. A main difference between this and other studies is that the administration of post questionnaires are usually completed months after the initial session as opposed to two weeks later as required with this study.

Through his analysis of past clients Talmon (1990), discovered that the most common number of session attended by clients is one with an average of three sessions attended in all. Although the number of sessions attended did not affect outcomes of results in this study, it is interesting to note however that half of the clients attended just the one session and three out of the ten returning for a total of three sessions.

 

Being a single session does not allow for an in depth formulation and diagnosis to be complete. Instead sessions focus on working through issues seen by the client as most important (Young & Roycroft, 1997). It is here where the reliability and usefulness of the questionnaires is verified as clients list the two most important issues they are facing, giving insight into what can be done differently and the available resources the client has, through the written questions required on the pre-session questionnaire.

 

It is from the comparison scales on the post-session questionnaire that the list of pending actions is revealed. It is also where the decision to continue treatment is made by both the clinician and client. Therefore the questionnaire giving insight into how the client is coping and how effective the treatment was (Talmon, 1990). 

 

 

            The small sample size and time restrictions placed limitations to this study. More appropriate testing would involve larger sample sizes and follow-ups at six weeks, six months and again after one year to identify whether clients sustain what the session gave and are able to continue to facilitate change in their lives.

 

In conclusion, evaluation of client responses, demonstrate clinically significant improvements in all ten clients. Improvements occurred across a wide range of presenting problems and age. Outcomes from this study indicate that SST can be used for various issues and although sessions are run as though it may be the last, SST encourages on going sessions as needed. Success of SST is in its ability to empower clients to manage problems themselves whilst increasing their confidence in doing so.