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\deflang1033\pard\qc\plain\f2\fs28\b SINGLE SESSION THERAPY, \plain\f2\fs28 by Moshe Talmon.
\par \pard\plain\f2\fs28 
\par \tab The average number of treatments in outpatient psychotherapy is 3-6. (p. xi)  Single Session Therapy is the most frequently used length of therapy.  (p. xv)The "founder" of SST was none other than Sigmund Freud.  (p. 3)
\par \tab In 1985 I was faced with the new reality of health care in America, with its surplus of providers and the growth of brief therapy in health maintenance organizations (HMOs), preferred provider organizations (PPOs), and employee assistance programs (EAPs).  (p.6)
\par \tab I learned from a review of the literature that the high frequency of SST has been well documented over a period of more than thirty years in a variety of settings.  [It ranges from 32% to 80%.]  (p. 8)  The therapeutic orientation of the therapists has no impact on the percentage of SSTs in their total practice.  (p. 7)  A follow-up of 200 patients showed that 78% said they got what they wanted out of the single session and felt better or much better about the problem that had led them to seek therapy.  (p. 9)
\par 
\par \tab \plain\f2\fs28\b INTAKE PROCEDURE:\plain\f2\fs28 
\par \tab Tamara Levy (1989) modified a standard telephone intake procedure... by adding a few questions such as: "Who else is involved with the family who could be helpful to counseling?"  She ended the conversation by saying, "Therapy is most effective if all of those involved come in at least for the first session.  Who will attend?"  The vast majority of callers are women, and an attempt to get other members of the family in the first session is often a struggle....  Levy found that using the above questions reduced the pretherapy dropout rate, increased [participation of family members and significant others, and altered the orientation of both therapist and patient so that they viewed the problem in a larger context.  (p. 20)
\par \tab Kauffman (1990)... requested that prior to the session the patient as well as others (like the referring source, personal physician, parent, teacher, or employee) submit in writing the answers to three questions:
\par \tab 1.  What are the central issues (or problems)?
\par \tab 2.  What are the factors or circumstances that seem related to 
\par the issue?
\par \tab 3.  What measures have been used so far in an attempt to solve the key issues?  (p. 20)
\par \tab With the initial phone call, what you choose not to ask is even more important than what you do ask.  Keep factual and history questions to a bare minimum, and avoid detours.  Try to get enough information to ask the following questions:
\par \tab 1.  Am I the right person for this patient?
\par \tab 2. Who is my customer?  In the initial session, therapists should try to include as many potential customers as they can.  Try asking, "Who else is concerned about this?, Who else has tried to help?, Who has the power to change the present situation?
\par \tab 3.  What is the hidden agenda, if any?  There's no point in trying to help someone who's trying to change someone else, get money or time from someone else, or get verification of an illness.
\par \tab 4.  How soon do you think the problem will be solved?
\par \tab 5.  How do you think therapy will help you?
\par \tab 6.  What made you decide that now is the right time for 
\par therapy?  Patients who answer I don't know to 4,5 or 6 are 
\par probably nonresponders.  (pp. 26-29)
\par \tab It is desirable to call the patient back within twenty-four hours of the initial call.  This is not only a matter of coutesy.  Between 30 and 40% of first appointments with mental health professionals are not kept.  (p. 19)
\par \tab In my work in a large busy medical center, I found that the rate of no-shows was greater among patients who were provided immediate appointments following emergency calls than among those who were scheduled for routine appointments (usually two to three weeks after the call).  In addition, those who waited for an appointment were more likely to show improvement than those who did not.  (p. 18)
\par \tab When an anxious patient called me and I wanted more information before the first session, I would say, "Between now and our first session, I want you to notice the things that happen to you that you would like to keep happening in the future." (p. 19)
\par 
\par \tab \plain\f2\fs28\b SESSION PROCEDURE:\plain\f2\fs28 
\par \tab Begin the session with a question about pretherapy changes.  (p. 34)  This conveys that the therapist expects changes, and helps the therapist pick up where the client is now, and helps the therapist identify any worsening problems.  (p. 36)
\par \tab A good opening is: "We have learned that one third of the people who come to therapy here do so for only one session and very often find it to be helpful and sufficient.  Yet I want you to know that if today or at any point in the future you and I find that further work is needed, I will be available and will be glad to see you for more sessions.  Is that OK with you?"  (p. 37)
\par \tab The therapist's next job is to find a focus for the session.  Patients often provide the focus in their own words.  It is rarely a deep-seated secret, so therapists shouldn't overlook the obvious.  Sometimes, however, patients are in so much pain, confusion and conflict that they are unable to sort it out.  (p. 38)
\par \tab A central task of the SST therapist is to construe the patient's difficulty in such a way that it can function as a pivot chord for change.  A pivot chord is an ambiguous chord that contains notes common to more than one key and so can facilitate the transition from one key to another.   (p. 38)
\par \tab Often the patient will describe how the presented symptom serves a role or a purpose in their family or with significant others.   (p. 40)
\par \tab A good focus can provide a leverage for a whole chain of changes.  (p. 41)
\par \tab The therapist can provide an opportunity for the airing of last-minute issues by asking, "Is there anything we did not cover at all today that you would like me to know about?  Are there any other questions you would like to ask me?"  These questions should be raised early enough in the session that there will be time to include them in the formulation of the solution and the conclusion of the session.  Often, only after these extra probes will patients come forward with the ultimate bottom-line question that brought them to 
\par seek help.   (p. 50)
\par \tab The final feedback usually includes four elements:
\par \tab 1.  Acknowledgment.  It is important to acknowledge the reason that brought the patient to the session.  The therapist should try in one or two sentences to emphatically connect with the emotional 
\par state of the patient.
\par \tab 2.  Compliments.  The therapist should underline the patient's positive qualities, so that the intervention can be presented as a small and natural step in the right direction.
\par \tab 3.  Diagnosis.  Assessment is presented as a reframing of the problem in solvable and autonomous terms.  A depressed patient might be told she's so loyal to her family that she sacrifices her own welfare.
\par \tab 4.  Prescription.  Present the patients with the smallest and simplest task that the therapist can come up with.  It takes a few years of humbling clinical practice to realize that the therapist's role is not to be smart or even right but rather to be helpful.   (pp. 50-52)
\par \tab During the final feedback, therapists can alternate among all four elements.   (p. 53)
\par \tab When concluding a potential SST, the therapist may ask whether the patient would like to make another appointment or would prefer to leave an open door to come back when necessary.  It is important to say that the therapist will be calling in three months for follow-up. (p. 54)
\par \tab On the whole, I realized that I had taken my interventions and my words much too seriously.  Patients reported following suggestions that I could not remember having made.  They created their own interpretations, which were sometimes quite different from what I recollected, and sometimes more creative and suitable versions of my suggestions.   (p. 60)  
\par \tab What does a therapist do when pathology prevails and the prognosis is poor?   (p. 63)  Remember that a considerable number of patients are capable of recovering "against all odds" in ways that are very difficult to explain using plausible and logical thinking within traditional theories.   (p. 65)
\par \tab Therapists should allow as much room as possible for spontaneous recovery or self-correcting and random solutions to take their course.  (p. 69)
\par \tab An important part of empowering is allowing their faith and belief systems to guide the healing process.  At the same time, one of the most difficult obstacles to overcome in trying to empower patients is their following a line that the therapist strongly opposes or, worse yet, considers to be gravely wrong.  (p. 70)
\par \tab Some patients can heal by first accepting their problem as 
\par illness and that one can become pwerful by first accepting one's helplessness.  This idea was beautifully expressed by Jullie, a young woman who developed blindness as a result of diabetes: "Blindness taught me to see, and death taught me to live" (Siegel, 1986, p. 145). (p. 71)
\par \tab \tab Siegel, B. S.  Love, Medicine and Miracles: Lessons Learned About Self-Healing from a Surgeon's Experience with Exceptionsl Patients.  New York: Harper & Row, 1986.
\par \tab The benefits of no treatment deserve more consideration than they generally receive.  (p. 71)  The Finnish physiiologist I. Kojo (1986) ... sees the placebo as a powerful tool in all medical treatments.  He suggests that the placebo effect can be more general and long-lasting than effects caused by more specific agents and proposes that imagery is the intermediary between suggestion and the placebo effect.  He concludes, "Thus placebo should be used intentionally together with treatments and drugs which have more direct physiological and pharmacological effects" (Kojo, 1989, p. 261).  (p. 72)
\par \tab \tab Kojo, I.  "The Mechanism of the Psychophysiological Effects of Placebo."  Medical Hypotheses, 1989, 27, 261-264.
\par \tab "A patient has a built-in drive to health, mental as well as physical.  His mental development and emotional development have been obstructed, and the therapist has only to remove the obstructions for the patient to grow naturally in his own direction.  The therapist does not cure anyone, he only treats him to the best of his ability, being careful not to injure, and waiting for nature to take its healing course" (Berne, 1966, p. 63).  (p. 72)
\par \tab \tab Berne, E.  Principles of Group Treatment.  New York: Oxford University Press, 1966.
\par \tab For those who are devoted to long-term private practice and want to avoid this kind of failure, the best bet would be to limit their practice to white, upper-middle-class educated and motivated patients who have already made a decision to commit a sizable amount of time and money to their treatment.  (p. 98)
\par \tab When many issues of independence and separation are unresolved, the patient is unlikely to perceive SST as sufficient.
\par \tab When the patient is unable to become targeted in the session and has multiple and vague complaints, more therapy is indicated.
\par \tab When the therapist is unable to reach clarity about the case or 
\par feels the patient should be seen by another professional, some form of therapy should be continued.  (p. 104)
\par \tab When patients come to "shop for the right therapist," it is best to focus the session on their expectations of the therapist and therapy rather than starting therapy right away.  In such cases, if therapists focus on the presenting problem, they are likely to fail.  (p. 105)
\par \tab With "experienced" patients, the therapist should find out early in the first session what they have got out of therapy so far and what their expectations are this time around.  (p. 105)
\par \tab When patients are referred to therapy by a third party (court, school, employer) or are in therapy in order to meet the needs of someone else (such as their parents), therapists may want to devote time to two questions: (1) what is the patient's hidden agenda (often hidden from the therapist but known to the patient) in coming to see the therapist now? (2) Is there a problem (perhaps a different one from the presenting problem) that can be targeted and that the patient 
\par is motivated to resolve?  (p. 106)
\par \tab The lack of correlation between the severity of the problem and the length of treatment also appears in other reports of psychotherapy practice (Knesper, Pagnucco, and Wheeler, 1985; Knesper, Belcher and Gross, 1987).  When some correlation is found, it is often negative-- that is, the young, verbal, functional and affluent receive much longer therapy than the dysfunctional, old and poor, and the longer the treatment, the lower the benefit.  (p. 107)
\par \tab \tab Knesper, D., Pagnucco, D., and Wheeler, R.  "Similarites and Differences Across Mental Health Services Providers and Practice Settings in the United States."  American Psychologist, 1985, 40, 1352-1369.
\par \tab \tab Knesper, D.,  Belcher, B., and Cross, G.  "Preliminary Production Function Describing Change in Mental Health Status."  Medical Care,1987, 25 (3), 222-237.
\par \tab In the first session, therapists should not try to reinvent the wheel or stir up fire and brimstone.  The spectacular is seldom necessary or productive.  It is often better to be a "constructive minimalist" and, rather than "uncommon therapy," (Haley, 1973), try to approach SST as "common therapy."  Most of the successful SSTs we have studied do not resemble the demonstrations of master 
\par therapists in conferences or books....  In most of the SST cases where patients reported particularly successful outcomes, the therapist appeared to have conducted a rather simple, almost dull session.  In fact, in many successful SSTs, it is the patient who appears in control and sets the pace for change.  (pp. 110-111)
\par \tab Therapists' attitudes are expressed in their first question in the initial session.  "Please tell me about yourself" and "Today I'd like to get to know you a little bit" are rather broad inquiries for information.  The session will naturally include gathering information on a broad variety of life issues.  Initial quesions like "What is the problem?" or "How can I help you?" communicate that the therapy is about problems and that the therapist is the helper.  On the other hand, an inquiry like "Between the time you called me and coming in today, what are the changes you have noticed?" communicates the therapist's interest in spontaneous changes occurring outside the session and focuses on here-and-now changes as the main area of exploration.   (p. 116)
\par \tab The attitude that more is better serves a competitive consumer society as well as the Judeo-Christian ethic of "trying harder."  This attitude has accommodated many a therapist's journey into the depths of the human mind and provided a good and stable income for private therapists working on a fee-for-service basis.   (p. 118)
\par \tab The advantages of adoptiing the attitude that a small change is sufficient are threefold: (1) It takes the pressure off both therapist and client, so niether falls over his or her feet in the process of trying too hard.  (2) The client is more likely to be willing to make a small change than a big one.  (3) Any kind of movement may suffice to ignite hope in the client (Rosenbaum, Hoyt and Talmon, 1990).  (pp. 119-120)
\par \tab \tab Rosenbaum, R., Hoyt, M., and Talmon, M.  "The Challenge of Single-Session Therapies: Creating Pivotal Moments."  In R. Wells and V. Giantetti (eds.), The Handbook of Brief Therapies.  New York: Plenum, 1990.  
\par \tab In the context of SST, the alternative attitude is not to ignore scientific findings or acquired knowledge but rather to keep them in reserve while leading the session with what a Zen master would call "a beginner's mind" by following patients' struggles to solve their problems and reduce their pain and the worry.  This attitude allows the therapist to be surprised and creative.  It means that an important part of the therapeutic process is the humble knowledge that we do not know everything and what we do know might or might not be useful for the individual client.  Therapists can assume that in nearly half of their cases, the problem will be solved spontaneously, and all the therapist needs to do is allow it to happen.  They can also safely assume that the majority of their clients either will not follow the therapist's instructions at all or will translate them into their own language.   (p. 122)
\par \tab Both clients and therapists ascribe meanings to their experiences.  The meanings one assigns may contribute to one's difficulties.  Therapists are often experts in adding heaviness and deep meanings to what might actually have been a chance fluctuation that got stuck as as people put excessive unproductive energies into solving it.  Many clients come to therapy in this state.  They are stuck with a problem to which they feel all attempted solutions have failed.  They are overwhelmed with the problem's size and view themselves or the problem in negative terms.  If the therapist's attitude is to expect a small change, to provide positive attributes, and to focus instead of broaden, the therapist is more likely to induce hope and lead to workable solutions.  This is a matter of approaching each hour with the openness that will best serve both therapist and patient in the pursuit of the unknown. (Langs, 1979) (p. 123)
\par \tab \tab Langs, R.  The Therapuetic Environment.  Northvale, N.J.: Aronson, 1979.
\par \tab Recent research (as cited in Siegel, 1986, 1989) as well as patients' personal accounts (Cousins, 1979, 1983) indicate that many times the troublemakers, those who challenge the doctors, question every decision, and burst out of the hospital in anger, are more likely to survive difficult illnesses such as cancer than are the compliant and passive patients who follow doctors' instructions faithfully.   (p. 125)
\par \tab \tab Siegel, B. S.  Love, Medicine, and Miracles: Lessons Learned About Self-Healing from a Surgeon's Experience with Exceptional Patients.  New York: Harper & Row, 1986.
\par \tab \tab Siegel, B. S.  Peace, Love and Healing: Body-Mind Communication and the Path to Self-Healing: An Exploration.  NewYork: Harper & Row, 1989.
\par \tab \tab Cousins, N.  Anatomy of an Illness as Perceived by the Patient: Reflections on Healing and Regeneration.  New York: Norton, 1979.
\par \tab \tab Cousins, N.  The Healing Heart.  New York: Norton, 1983.\plain\f2\fs24 
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\par \pard\plain\f2\fs28 \tab \plain\f2\fs28\b NO-SHOW PROCEDURE:\plain\f2\fs28 
\par \tab Therapists calling a no-show may say something like this: "Since we did not have the opportunity to meet last week, I am calling to find out how you are doing now and what you have found to be useful in solving the problem so far."   (p. 126)
\par }