5. History and the Hidden Narrative of Single Session Work (SSW)

Transcription

1 5. History and the Hidden Narrative of Single Session Work (SSW) Unplanned SSW: International Research and Evaluation Most therapists have experienced the occasional therapy which began with an assumption that work would be ongoing, but finished prematurely with mutual agreement that one session was sufficient to address the issues presented. A much more common phenomenon, however, is the single encounter which ends with the therapist planning for ongoing work and the client failing to return to therapy. Studies investigating this phenomenon show a consistently high frequency of unplanned single interview contacts across various service settings in the U.S., Israel and the U.K. Figures vary from 20% - 80% but a common finding is that about one third at least of all clients attend only once. Contexts include family service agencies - 56% of clients (Kogan, 1953); private prepaid non-profit health maintenance organisations - 39% of 6,708 clients (Spoerl, 1972); general psychiatric services 20% - 57% of clients (Baekland and Lundwall, 1975); and community mental health centres (Fiester and Rudestam, 1975). These unplanned single therapy sessions have been considered by and large to be therapeutic failures or "dropouts". However, studies which have followed up clients who chose not to attend more than one session consistently find a surprisingly high percentage of clients are satisfied with the outcome of the single session. Talmon himself reviewed the records of 100,000 outpatient contacts, and found that (i) the modal length of therapy for every therapist was one session, and (ii) that 30% of all clients chose to attend only once. Following up 200 of his own unplanned single session clients, Talmon found that more than three quarters reported that they were improved or much improved. He then resolved to investigate the possibilities inherent in planned single interviews. In 1990, Talmon and two colleagues, Michael Hoyt and Robert Rosenbaum, each following their different theoretical orientation and personal style, carried out planned S.S.T. with 60 clients. Of these clients, 58% decided they did not require further sessions and were happy to know that they could recontact the therapists if necessary. Furthermore, 88% of the 60 clients reported 'improvement" or "much improvement". Surprisingly, when compared to similar clients receiving longer term therapy, S.S.T. clients showed slightly more improvement and satisfaction. Also surprising, is that a number of other studies have found similar results, i.e., that single session clients evaluate their therapy experience just as highly as extended contact clients (Kaffman, 1990; Littlepage, 1976; Silverman & Beech, 1979). As Jerome Frank (1990) points out, if there is any merit in these findings, the fact that most clients drop out of therapy after very few sessions and yet report as much improvement as clients who complete a prescribed course of therapy, must provide a serious challenge to most models of therapy.

2 Unplanned Single Sessions (frequency) Author Clients Findings Kogan new clients in NY Family Services 56% cases closed after 1 session Bloom ,572 1st admission public & private US outpatients 32% cases for 1 session no diffs b/w client groups Spoerl ,708 private clients (prepaid) 39% cases for 1 session (despite coverage for 10) Lazare et al 1972 Retrospective review of outpatient groups 50% dropout rate after 1 session Baekland & Rudenstam 1975 Community mental health clients 37%-45% adult clientele dropout after 1-2 sessions Talmon clientele of Californian medical centre over 1 year Across multidicipline team modal numbers of sessions =1. 30% clientele chose 1 session Talmon ,000 outpatient appointments Californian medical centre As above

3 Unplanned Single Sessions (evaluation) Author Clients Findings Kogan single interviews 80% available for follow-up 66% clientele felt helped Malan Travistock clients "unplanned" single sessions 2-9 year follow-up 51% symptomatic improvement 54% psychodynamic improvement Littlepage et al former community mental health clients (treatment terminated in 1974) 1 session clients evaluated contact as highly as extended contact clients. Drop out clients valued as highly as clients who attended final scheduled therapy session Edwards et al 1977 Multi-modal therapy for 100 male alcoholics (1 advice group & 1 couple session group) 1 year follow-up, no sig. differences b/w group in alcohol intake, self-reported drinking problems & social adjustment Silverman & Beech 1979 Community mental health centre dropouts Follow-up evaluations rated services as highly as clients reaching normal termination Kaffman patients from child & family clinic in Israel 3-6 year follow-up of 1 session clientele who reported high improvements US research has shown that after 8 sessions, very little change occurs (Talmon, 1990). Although clients attending for one session is the most common form of therapy, these clients have usually been labelled "drop outs" and described in pejorative terms in the therapy literature (Talmon 1990), Baekeland and Lundwall (1975) reviewed 330 articles that mentioned "drop outs" in therapy and found that these clients were described as " apt to deny his (her) illness, to be resentful and distrustful, and to have sociopathic features" (p. 7 & 8). Therapists of "drop outs" (the most common type of client) were described as "less experienced, more ethnocentric, dislikes his (her) patient or finds him boring ' less personable, lacks warmth and was more likely to assign them a poor prognosis" (p761). "Therefore the most common type of therapeutic intervention, i.e., one-off sessions, have been viewed as pathological by the therapeutic field" (Jeff Young).

4 Note: We have used the title "Single Session Work" throughout this site to reflect the fact that not everyone who uses this framework would identify themselves as a "therapist". The possible applications of the ideas are much broader than therapy. However, we want to acknowledge that the origin of the ideas is embedded in the approach called "Single Session Therapy" as coined by Moshe Talmon (1990). The Hidden Narrative of Single Session Work It has been extremely hard for the therapeutic world to register the consistently positive results of single session research. In 1946, a psychoanalyst called Grotjahn described a successful single session "cure" of a forty-five year old depressed physician in a book called Psychoanalytic Therapy: Principles and Applications (Alexander and French 1946, reported in Talmon 1990). Grotjahn's report was greeted with disdain by the conservative American Psychoanalytic society and, because of the prevailing beliefs about therapy and change, this new information was not accepted. Despite the reaction Grotjahn's report received, a few other accounts of successful single session "cures" were reported in analytic journals. For example, Saul (1951, cited in Talmon 1990) described the symptomatic relief of a woman who suffered from hypochondriasis, following a single session of treatment. The first systematic evaluation of single sessions appears to have been carried out by the psychoanalytic psychotherapist, David Malan and his associates at the Tavistock Clinic in London. Malan followed up forty-five patients who were seen on only one occasion between 1962 and These subjects were described as "untreated neurotic clients", who either dropped out of therapy or were seen as unsuitable for psychodynamic therapy. When followed up after 2-9 years, Malan and his colleagues found that 51% had improved symptomatically and 24% had improved psychodynamically, leading Malan to warn that therapists should not automatically assign clients to long term psychotherapy because a " single dynamic interview may be all that is needed" (Malan and others 1975, p.110). None of these isolated but consistent reports were taken seriously. The possibilities of single session work, although clearly reported, could not be comprehended. Independent and isolated studies continued to report similar findings. For example, in 1981, Bernard Bloom, an analytic psychotherapist, undertook a small scale but uniquely prospective study of what he referred to as Focussed Single Session Therapy, in which 10 clients were seen for only a single 2 hour interview. At 2-month follow-up, all were doing well, and reported the intervention helpful. Only one client had gone on to seek help elsewhere. Still, it was only with Moshe Talmon's work (1990) that these findings began to be considered seriously. Why? It was not until the economic climate changed and created a pragmatic reason to consider the above data seriously, that the possibilities of SST were entertained more widely. The political context of therapy also was such by the 1990s that SST could be considered seriously. The postmodern revolution and the feminist critique had questioned and challenged the therapist role as central expert in client change, thus allowing for therapies that conceptualise the therapist as facilitative of rather than essential to client progress. As Harville Hendrix (1996, page viii) puts it, "Therapy is a healing process that requires a long time, but not necessarily a long time in formal therapy sessions". Hence, the economic rationalists, despite destroying much of the health system, helped us to see the SST data more objectively.

5 Single session work challenges many dearly held assumptions about therapy and about the role of therapists in people's lives. We have found that these challenges have greatly improved the way we provide all therapy: short and long term work. We are less interested in the economics of SST than in its capacity to provide timely, responsive and client-led health services.