'It forced me to think in different ways about single-session therapy'

One of the first therapists who practised single-session therapy (SST) was Sigmund Freud. It is reported that the pioneer of long-term psychoanalysis carried out two well-known single-session treatments with Aurelia Öhm-Kronich ("Katharina") in 1893 (Freud & Breuer, 1895) and with the famous composer, Gustav Mahler in 1910 (Kuehn, 1965). While there are periodic references to single-session treatment in the literature from that time onwards, with well-known therapists like Alfred Adler, Milton Erickson and Albert Ellis pioneering the use of single therapy sessions often conducted in front of professional and lay audiences, it wasn't until 1990 that the field of SST began to cohere. This is when Moshe Talmon published a book which many, including myself, consider seminal and which marked the beginning of a growing interest in SST by appointment or by walk-in.

In the 1980s, Talmon left a comfortable private therapy practice in Israel to work at the world renowned public Kaiser Permanente clinic in Oakland, California. He discovered for the first time in his professional life that many patients that he saw in the clinic only attended for one session. Did he suddenly become a bad therapist with lots of 'drop-outs' to his name? While his professional pride was bruised, his curiosity was stronger and he took the step of telephoning 200 of his one-session patients to find that many of them been very satisfied with their session and did not feel the need for continuing therapy. From those early pioneering days, SST has challenged commonly-held ideas such as that psychological change occurs gradually and that treatment should only be initiated after a thorough case formulation has been undertaken.

Jeff Young (2018), a single-session family therapist from Australia, has recently reviewed three key research-based findings which are particularly challenging for what might be called established, longer-term approaches to psychological treatment:

1. The most common number of service contacts that clients attend, worldwide, is one, followed by two, followed by three. This is irrespective of diagnosis, complexity, or the severity of problem.
2. 70-80 per cent of people who attend only one session, across a range of therapies, report that the single session was adequate given their current circumstance.
3. It is impossible to accurately predict who will attend only one session and who will attend more. Given this, why not approach the first session 'as if' it might be the last?

This last point has led to something intriguing in the SST field. Single-session therapy is not therapy that lasts for one session and that is it. Rather, it is way of approaching therapy where therapist and client work together to see if they can help the latter get what they want from one session, but if not, more help is available. Paradoxically, it is knowing that more help is possible that enables the client to relax and get the most from the first and often only therapeutic encounter.

So why did I become interested in SST? Whenever I give a training course, I do a demonstration session of therapy and have done so for many years. I came to realise that these sessions were examples of SST and ones that took place in 30 minutes or less. Looking for a new challenge when I retired from my university post, I re-read Talmon's 1990 book and got enthused by the possibilities. Based on his and others' writings, I developed a single session-based approach to CBT which I called 'Single-Session Integrated CBT' (Dryden, 2017) which can be used in the NHS as well as in private practice. Indeed, my view is that if the NHS really wanted to improve access of psychological treatment then it would offer a nationwide set of walk-in clinics staffed by people keen to help people as quickly as possible at the point of need (an hour after attending a walk-in clinic) rather than (at present) at the point of availability, which is often months after a person has consulted their GP.

Against this backdrop, I spoke with Moshe Talmon about his views on the future of SST. 

What do you think have been the key developments in single-session therapy since 1990?
Well, there was quite a bit that happened since the publication of my first book in 1990. One development that was surprising to me was that, when we started the series of the SST studies at Kaiser Permanente Medical Group in 1986, we assumed that single-session therapy would suit mostly the so-called "worried well" and maybe a few of the adjustment disorders.

Since the publication of the book, both during training that I was invited to do all over the world and the research and publications done by other people around the world, it appears that single-session therapy can help people with much more complex and difficult problems than I originally assumed .

Initially, when people would call me to ask for training in SST, for example, those who were working with teenagers who live on the streets, with sexually and physically abused women, with cancer patients, with addicts of different kinds, etc. I would tell them that I know nothing about what can be done in a single session with people who clearly need much longer therapy, and they would keep telling me that this is the most common length of therapy with these clients, and therefore they would like to try and utilise single-session work with them.

So that was a surprising development that I'm glad to say today challenged me and forced me to think in different ways about single-session therapy.

The second development is the development of walk-in clinics where single-session therapy is actually the main modality that is used in the clinic, and what more recently we called the "one-at-a-time" model (Hoyt et al., 2018). These clinics had a much higher frequency of single-session therapy than we did. In our study of planned SST (Talmon, 1990) it was 58 per cent of the clients in our research sample, and in many of the walk-in clinics in Australia and Canada and the United States, it is up to 80 per cent of the clients. So that was a second development that was very interesting.

The third development is the use of single-session therapy in non-psychotherapy services – counselling services carried out by people who don't see themselves as psychotherapists; they see themselves as counsellors, they see themselves as coaches. In addition, I trained medical staff, primary care physicians family specialists and nurses in SST .

What are your predictions about how single-session therapy will develop in the future?
Well, I know that you indicated, in your book, that you were interested in the future of single session therapy, but in Hebrew we have a saying that I think you also know in English. It is that 'predictions are for fools'. So, I would prefer to talk about what are my hopes for the future of single-session therapy.

My first hope is that single-session therapy will be integrated with all services and with various approaches to therapy.

My second hope is that SST is utilised in what is called today 'advanced systems' such as the sharing economy and social media. In this way, everyone can help make therapy more accessible and more affordable, by combining, for example, artificial intelligence and social media. However, I think that, despite these technological developments, the importance of face-to-face interaction and human intuition and, the therapeutic alliance, in particular is still very vital. So I hope that the developments in artificial intelligence and in big data will make therapy more accessible, but that this is combined with the use of the face-to-face human interaction. So, both/and, not either/or.

My third hope is that while evidence-based therapy places a lot of importance on protocols, single-session therapy, while being evidence-based, will be individually tailored to each client rather than be protocol driven.

So it's important not to lose the human interaction, therapeutic alliance, sort of flesh and blood nature of the work.
Exactly. There is always the fear that artificial intelligence will exclude the human touch, but I think that, especially in psychological terms, everything that helps to create a therapeutic alliance, such as emotional intelligence and social intelligence, is not going to be replaced by artificial intelligence; indeed, to the contrary.

So, before we go onto your fears, your third hope is for what my good friend Arnold Lazarus (1981) used to call 'the bespoke nature of psychotherapy' in that SST would be individually tailored and would not fall foul of this current drive to protocol everything. So, although there are guidelines, of course, to practise single session therapy, the important thing is to utilise these guidelines and tailor them to the individual, rather than to fit the individual to the protocol.
Right. I hope that we will be flexible enough and versatile enough to meet each client at their place and time.

What about your fears for the future development of SST?
The main concern that I have is that powerful and big systems – be it governmental agencies, insurance companies or HMOs – will use the power and the effectiveness of single-session therapy to block access to populations that are in most need of psychotherapy. So, if single-session therapy is used, let's say, with poor people, single parents or people who live on the streets, and those controlling access to therapy say, 'OK, we will give you only one session, and you don't need more than that,' or, 'We will give you one individual session and then we will send you to group sessions,' then I think that it will be an abuse of single-session therapy. Is that clear?

Yes, and I agree with that entirely.
And one more concern, which I expressed also in the last chapter that I wrote on the subject (Talmon, 2018), I think that we have to be concerned that people will not use our findings and our successes with single-session therapy to narrow or flatten human struggle and human suffering into 'one size fits all'. That can be done by some people and it should be avoided.

Yes, I agree with that. Thank you, Moshe, for your time.

- Windy Dryden is one of the leading practitioners and trainers in the UK in the Cognitive Behaviour Therapy (CBT) tradition of psychotherapy. He is best known for his work in Rational-Emotive Cognitive Behaviour Therapy (RECBT), a leading CBT approach. He has been working in the field of counselling and psychotherapy since 1975 and was one of the first people in Britain to be trained in CBT.

He has published over 200 books and has trained therapists all over the world, in as diverse places as the UK, the USA, South Africa, Turkey and Israel.

He is Emeritus Professor of Psychotherapeutic Studies at Goldsmiths University of London.

- For more than 25 years Dr Moshe Talmon and his colleagues have been mentoring therapist all around the world in methods to provide efficient psychological therapy treatment. The goal is to help each patient receive an accessible treatment that is effective and affordable to the max.

References

Hoyt, M.F., Bobele, M., Slive, A., Young, J., & Talmon, M. (Eds.). (2018). Single-Session Therapy by Walk-In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-at-a Time Services. New York: Routledge.
Lazarus, A.A. (1981). The Practice of Multimodal Therapy. New York: McGraw-Hill.
Talmon, M. (1990). Single Session Therapy: Maximising the Effect of the First (and Often Only) Therapeutic Encounter. San Francisco: Jossey-Bass.
Talmon, M. (2018). The eternal now: On becoming and being a single-session therapist. In M.F. Hoyt, M. Bobele, A. Slive, J. Young, J., & M. Talmon, (Eds.), Single-Session Therapy by Walk-In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-at-a Time Services (pp. 149-154). New York: Routledge.