Providing help at the point of need: insights from single-session therapy
University and College Counselling, May 2020

Introduction

When I trained in student counselling in the 1970s, university and college counselling (UCC) services did not face the challenges that they do today. Students, then, who sought counselling appointments, could usually have them when they needed them and could have as much counselling as they wanted. Professionally, counselling was differentiated from psychotherapy, and BACP was known as the British Association for Counselling (BAC). Counsellors saw their role as helping to promote clients’ self-development, while therapists saw their role as helping clients to address and deal with their disturbance. Today, these boundaries have largely become blurred.

Nowadays, if a student wants help with a self-development issue, and they are assessed for counselling, they will have to wait quite a long time to be seen, because students with more pressing problems will have greater priority. For the problems that students now seek counselling help with, seem to be more in the ‘disturbed’ range than in the ‘development’ range. Waiting lists for counselling currently pose both an acute and a chronic challenge to UCC services. There are several reasons for this. Students are facing greater pressures these days than they did in the mid 1970s, and need more help than hitherto. Students are now encouraged in mental health awareness campaigns to see that it is ‘OK’ (rather than shameful) to have problems, and that it is equally ‘OK’ to seek help for these problems. However, when they do come forward to seek help, they are faced with growing waiting lists in UCC services which are stretched to the limit.

One common way in which UCC services have tried to address the situation in which the demand for counselling services has outstripped the supply, is to offer everybody a ‘block’ of counselling sessions once they have been assessed and it has been decided that counselling is appropriate for them. However, the problem is that offering blocks of sessions does not really bring down waiting lists and does not take into account student behaviour when seeking and using help. An alternative to routinely offering students blocks of counselling comes from developments in single-session therapy (SST). As you will see later, SST has different names, but I will use the term ‘single-session therapy’ in this article as it is the term that is most commonly used in the literature. 

What is single-session therapy?

The term ‘single-session therapy’ seems to imply that the student is given one session of counselling and one session only. While there are times where students may be offered only one session of counselling, the situation is more complex than this. Thus, I define SST as: A purposeful endeavour where both parties set out with the intention of helping the client in one session, knowing that more help is available if needed.

I want to stress three points here:

1. SST is not imposed on the student. Students understand at the outset what they are being offered and they agree to it based on that understanding.
2. The counselling service that offers SST needs to engage with the task of disseminating what SST is and how students can access it.
3. More help is available if the student needs it.

One-at-a-time therapy

Some UCC services in the UK prefer the term ‘one-at-a-time therapy’ (OAATT) to ‘SST’ because it is more accurate, albeit less engaging. While, in fact, the two terms refer to the same phenomenon – the intention to help the person in one session while recognising that more help is available – the perceived emphasis is different. In SST, the professed emphasis is on a single session, while in OAATT, the emphasis is on providing more help, if needed. Given this latter emphasis, services which use the term OAATT
invite their clients, at the end of the first (and perhaps only) session, to engage in a five-part process, where they are encouraged to:

i) reflect on what they have learned from the session 
ii) digest this learning – perhaps making links between what they spoke about in the session and other problem areas
iii) act on their digested learning, where they put into practice what they have taken away from the session
iv) wait to see what happens, before they
v) decide whether or not to make another appointment.

Terminology

The above discussion shows that this kind of work can be referred to differently. My view is that if UCC services are going to incorporate the SST/OAATT mode of counselling delivery into their overall services, they need to be comfortable with the term that they employ, as do their stakeholders, including students. Some services are ambivalent about whether SST/OAATT is counselling (which is seen as a more ongoing mode of help) and prefer a term such as ‘single-session consultations’ to form a demarcation between single-session work (another term that has been used) and counselling. However, BACP recently revised its opinion that SST was not counselling and has now confirmed that provided a counsellor is offering contracted SST as part of a variety of interventions, which are offered on a needs-led basis to clients, SST does count as counselling and indeed, in this context, may – in conjunction with experience working across other types of counselling, including short and perhaps longer-term contracts – be acceptable as part of an application for service or individual accreditation.

The single-session mindset

Over the past year, I have received several requests to give a talk or workshop on the ‘single-session’ approach to counselling. While I can understand such requests, a simple presentation cannot encapsulate how the SST community conceptualises its work. SST is not an approach to counselling in the way that the person-centred approach or the cognitive-behavioural approaches to counselling are. Rather, it is an attitude to the work that can be adopted by counsellors from diverse orientations. It is also a way of delivering services. In this section, I will outline the single-session mindset, while in the following section, I will discuss the single-session mode of service delivery.

The single-session mindset is a collection of ideas that the person holds in mind and brings to the work. For the client to get the most out of the first (and perhaps only) counselling session, both therapist and client need to have a single-session mindset. I will focus on the therapist’s mindset in this article.

At the outset, let me make one point clear: I am not recommending that therapists interested in practising SST should surrender the way they currently think about their work and just adopt the single-session mindset. I think that it is possible and even desirable for therapists to have a variety of different mindsets and bring the most appropriate to the work that they are currently doing. So what follows is a collection of ideas that comprise the therapist’s single-session mindset.

Approaching the first session ‘as if’ it could be the last, irrespective of diagnosis, complexity or severity. As will be discussed shortly, SST can be practised when the person walks-in for help or when they make an appointment for help. What has been learned from walk-in counselling services is that anyone can benefit from a single session of counselling, irrespective of their diagnosis, the complexity of their problems or how severe their problems are.⁵

Holding that the best way of discovering who can benefit from a single session of counselling, is by giving the person a single session of counselling and seeing what happens. Following on from the above idea, the counsellor is freed from approaching the work with an assessment mindset, and instead focuses on discovering who can benefit from SST by providing it. What has also been learned from the practice of SST in walk-in settings is that help can be provided from the very first minute, with good results.⁵

Exploring what each client wants to walk away with at the end of the session at hand, rather than from a course of therapy. Most, but not all, counsellors will ask a client at the assessment stage what they want to achieve from counselling. However, given that SST may well only last for a single session, the single-session counsellor will ask what the person wants to achieve from that session.

Prioritising what to focus on – negotiated between client and counsellor, but largely client led. When I trained as a counsellor, much was made of the distinction between the client’s ‘presenting problem’ and their ‘real problem’. The term ‘presenting problem’ was a pejorative one which led counsellors to doubt the importance of the first problem the client chose to discuss. The single-session counsellor is much more likely to be client led in prioritising what to focus on in the session, although questions can be raised by the counsellor as part of the process of negotiating a focus for the session.

Checking in at various points throughout the session to ensure the work is on track. Once an agreed focus has been created, it is important to maintain it, as well as ensuring that it is still relevant. A focus may shift during the session, and the counsellor will want to ensure that the client is focusing on what is most useful to them and not on what the counsellor deems to be the most therapeutically relevant.

Identifying and utilising client strengths and environmental resources. The SST community assumes that clients have at their disposal internal strengths and external resources on which they can draw to benefit from the session. The point is made that when they come to counselling, clients are often in a demoralised state and have lost touch with these factors.⁶ By helping clients to focus on their internal strengths and external resources, counsellors can help restore their clients’ morale, and this general therapeutic factor can help in the later design and implementation of a solution. In addition, there is insufficient time to teach clients new skills in SST, so a reliance on pre-existing helpful factors is one that is pragmatically sound as well as therapeutically beneficial.

Negotiating a ‘solution’. By ‘solution’, I mean anything that helps the client to address a problematic issue and move towards a problemrelated goal. In selecting a solution, the client can draw from a number of sources: what has been helpful in the past; what they think might be helpful now; insights that the counsellor may have imparted in the session; their internal strengths as well as their external resources. Once the counsellor has helped the client to select a solution, they encourage them to rehearse it in the session and make any modifications to this selected solution based on that rehearsal.

Helping the client to develop a plan to implement the solution. It is important to help the client to develop a plan to implement the solution, ensuring that they can integrate the plan into their life and commit to implementing it.

Effecting closure and clarifying next steps. Single-session counsellors argue that it is important to end the session on a positive, encouraging note, and thus they strive to do this. An important part of this is that the client knows how and when they can access further help if required.

The SST mode of service delivery

There are a number of ways in which UCC services can offer SST.

SST by walk-in

As mentioned earlier, walk-in services offer a single session to anyone who ‘walks in’ and wants to see a counsellor. The client completes a form and sees somebody within the hour. Walk-in services are perhaps the most efficient way of providing help at the point of need; but, in my experience, UCC services are reluctant to introduce such services.

SST by appointment

The norm in UCC services who offer SST by appointment is to respond to students by doing some kind of assessment prior to an appointment being offered. It is important that such an appointment is offered quickly to take advantage of the therapeutic potency of SST, with its emphasis on help provided at the point of need rather than at the point of availability. So that time can be used well between the offer of an appointment and the session itself, the student is asked to complete a form designed to help them prepare for the session.

The importance of client choice

SST is a client-led mode of service delivery, and thus when a service offers a range of services, it should go along with the client’s choice and be able to refer the person to other services when deemed necessary. This is what happens in walk-in services and it is a practice that removes the time-consuming activity of assessing students on the basis of their suitability for SST, a problematic endeavour at the best of times.

SST as gateway

The Bouverie Centre in Victoria, Australia is a family-focused counselling agency which offers everyone who seeks help a quick appointment for SST. They know from experience that for about 40% to 50% of their clients, this will be sufficient, and for the rest, further help is offered, or referrals to specialised services within the agency are made.³ Here, then, SST is the central helping gateway. In my experience of running SST training in the UCC sector, it will take a significant shift in mindset for UCC services to take this route as a matter of course, since assessment is so rooted in the mindset of most services.

The goals of SST

I distinguish between outcome and process goals of SST.7 Here is an illustrative list of both:

Outcome goals in SST

• To help the client get ‘unstuck’
• To help the client take a few steps forward, which may help them to travel the rest of the journey without professional assistance.

These outcome goals show the realistic nature of what SST practitioners think they can achieve.

Process goals in SST

These are goals that counsellors strive to achieve in the service of helping clients to achieve session outcome goals:

• To help the client address a specific issue
• To give the client the space and opportunity to think and explore when needed. SST is considered to be highly focused, and it often is. However, for clients who welcome an opportunity to be heard and explore their concerns in the single session, such help can also be provided
• To help the client see that they have the wherewithal to achieve their goals
• To help the client select a possible solution
• To give the client the experience of the solution in the session, if possible
• To help the client develop an action plan
• To signpost the client to further help.

Good practice in SST

While the issue of what constitutes good practice warrants an article on its own, I do want to list therapeutic activities with which most SST practitioners would concur. Of course, not all of these activities are present in every session, and it is useful to think, by way of analogy, of a tradesperson who turns up for a job with a toolbox. They would not use every tool, but all tools are available if required. SST therapists seek to:

• Develop the working alliance at the outset and maintain it throughout
• Be clear with the client concerning the purpose of the session and what can and cannot be achieved
• Ask the client how they think they can best be helped and give them some alternatives if they cannot answer the question
• Elicit the client’s goal for the session, rather than from therapy
• Be focused and encourage the client to stay focused
• Use questions constructively
• Communicate with clarity
• Identify and encourage the client to use salient strengths
• Identify and encourage the client to use external resources
• Identify and make use of previous attempts to solve their problem
• Undertake solution-focused work if required
• Encourage the client to take away just one thing
• Get the client to summarise the session rather than the counsellor summarising it
• Help the client to develop an action plan
• Encourage the client to identify and problem-solve potential obstacles
• Identify and respond to the client’s doubts, reservations and objections
• Tie-up any loose ends
• Seek feedback from the client.

Conclusion

In conclusion, SST has much to offer UCC services who have unacceptable waiting lists. However, it has therapeutic potency far beyond this pragmatic consideration, as I hope I have made clear in this article. Early feedback from UCC services which have introduced SST as a mode of service delivery is that students value the opportunity to be seen quickly and at a time of their choosing. A lot of students have also said that they are glad that they can be helped in such a short period of time. Time will tell if this exciting innovation is more than a fad and can be integrated into counselling services to provide students with counselling help at the time of need, while at the same time ensuring that those who need more help can gain access to it.